Malvina Hoxha1*
Mariagrazia Abbasciano2,3
Giuseppina Avantaggiato3Bruno Zappacosta4
Domenico Tricarico3- 1Department for Chemical-Toxicological and Pharmacological Evaluation of Drugs, Faculty of Pharmacy, Catholic University Our Lady of Good Counsel, Tirana, Albania
- 2Institute of Sciences of Food Production (ISPA), National Research Council (CNR), Bari, Italy
- 3Department of Pharmacy and Pharmaceutical Sciences, University of Bari “Aldo Moro”, Bari, Italy
- 4Department of Biomedical Sciences, Faculty of Medicine, Catholic University Our Lady of Good Counsel, Tirana, Albania
1 Introduction
In recent years, there has been a growing interest in assessing the role of mycotoxins in different diseases, especially in neurological disorders, and neuropsychiatric symptoms (Ratnaseelan et al., 2018; Nguyen et al., 2021; Abia et al., 2025; Ehsanifar et al., 2023). Mycotoxins are secondary metabolites produced by mold or fungi that contaminate food, and are responsible of biochemical and pathological changes in animals and humans. They can be found especially in cereals, wheat, coffee beans, maize, dried fruits (nuts, almonds, peanuts), dry-cured meat products, spices, rice, and crude vegetable oils (Pleadin et al., 2019). Mycotoxins can also be present in food even in the absence of visible molds, and industrial processing has little effect on their reduction. Moisture content, temperature, humidity, pH, physical damage of the food, are some of the factors that affect the mycotoxin biosynthesis (Richard, 2007). Their elimination from the body depends on the mycotoxin type, and varies from days to years. Controlling every step and condition during food production and storage process is essential in reducing the impact of these food safety hazard in human health. Ochratoxin A (OTA), patulin (PAT), aflatoxins, zearalenone (ZEA), trichothecenes, fumonisins are some of the most common mycotoxins found in food that can be involved in neuropsychiatric symptoms, and in neurological disorders (Von Tobel et al., 2014; Brand et al., 2019; Dai et al., 2024; Kowalska et al., 2016; Feuerstein et al., 2017; Chen et al., 2021).
Refugee populations, a group of individuals that cross the international border, and often live in refugee camps, temporary shelters in host countries, or urban areas, are more vulnerable to mycotoxins exposure. Refugees often rely on humanitarian aid for food, and often face resource constraints. In refugee settlements, humanitarian agencies consistently assess for major mycotoxins, such as ochratoxins, aflatoxins, and fumonisins, and reject crops with unsafe levels to protect refugees from exposure. Nevertheless, not all food lots can be tested due to resource limitations, and mycotoxins levels can increase after testing. This may occur during transit or storage, particularly under suboptimal conditions, before the food is prepared for meals. These challenges reveal the need for enhanced monitoring systems, better storage techniques, and robust protocols to ensure food safety throughout the supply chain. By addressing these challenges and implementing practical solutions, humanitarian agencies can more securely safeguard the wellbeing of refugee populations, reducing the risk of neuropsychiatric symptoms associated with exposure to mycotoxins.
The aim of this opinion paper is to discuss the potential role of mycotoxins in neuropsychiatric symptoms in vulnerable populations, such as refugees, who are particularly susceptible to food contamination and prolonged exposure to humid environments—factors that promote mold growth and mycotoxin production. Despite evidence linking mycotoxins to neuropsychiatric symptoms, research on their impact in refugee populations are deficient. This study addresses this gap by evaluating the potential role of mycotoxins exposure in refugees population, their neurological and psychiatric effects, and potential mitigation strategies. Different studies should be conducted to prove this hypothesis, taking in consideration also many confounding factors, such trauma, malnutrition, and chronic stress that might exacerbate the neuropsychiatric consequences of mycotoxin exposure.
2 Mycotoxins and neuropsychiatric symptoms
Exposure to mycotoxins is associated with a higher risk of cognitive impairment, depression, anxiety, and other neuropsychiatric symptoms (Ratnaseelan et al., 2018). Different studies have reported many neurological symptoms mycotoxin-associated, such as short-term memory loss, alteration of blink-reflex latency, color discrimination issues (Kilburn, 2003). In a study carried out in 182 subjects exposed to mold, moderate to severe levels of depression, and other physical, cognitive and emotional problems were reported. Patients were characterized by a hypoactivation in the frontal cortex (Crago et al., 2003). The presence of mold was also associated with emotional distress and depression in other studies (Hyndman, 1990; Packer et al., 1994).
The depletion of dopamine in mice treated with the OTA mycotoxin may also contribute to an increased risk of anxiety and depression (Pei et al., 2021). In addition, OTA can impair the hippocampal neurogenesis in vivo leading to cognitive impairment, difficulty in learning and concentration, and memory loss. Different studies report that OTA contributes to neurodegenerative disorders through DNA damage, oxidative stress, and mitochondrial dysfunction (Pei et al., 2021; Yoon et al., 2009; Zhang et al., 2009; Mateo et al., 2022). Long-term exposure to OTA can reduce cognitive function and cause attention deficits (Mateo et al., 2022).
In addition, fumonisin B1 (FB1) has been shown to have neurotoxic effects, inhibiting neurodevelopment, with increased levels observed in children with neural tube defects (NTD) and autism spectrum disorder (ASD) (Stockmann-Juvala and Savolainen, 2008; Ratnaseelan et al., 2018; Missmer et al., 2006; Yli-Mattila and Sundheim, 2022b). FB1 also suppresses the immune system, increasing the susceptibility to pathogens, and changing the expression of cytokine (Bulder et al., 2012; Wild et al., 2015). A chronic exposure to FB1can bring to different psychotic symptoms, such as memory disorders, and hallucinations (Chen et al., 2021).
PAT is a mycotoxin primarily found in apples and apple products, but also present in moldy fruits like grapes and pears, and has demonstrated neurotoxicity in various animal models (Song et al., 2014; Sabater Vilar et al., 2004). Furthermore, PAT is associated with nerve cell damage, irritability, confusion, alteration of communication between neurons, and uncoordinated movement (Pal et al., 2017; Brand et al., 2019).
Aflatoxins are one of the most important classes of mycotoxins, found in agricultural crops and comprising 21 members, all of which are capable of disrupting the blood-brain barrier. Alfatoxin B1 (AFB1) the most toxic member of the family, that has been involved in neurotoxicity, can cause depression, anxiety, memory deficit, and learning disorders (Dai et al., 2024; Qureshi et al., 2015). Animal models have shown that AFB1 affects neurotransmitter and neuropeptide regulation, leading to neurobehavioral abnormalities.
ZEA is another mycotoxin, that resembles estrogen and disrupts the hormone balance leading to irritability, and fluctuating mood (Kowalska et al., 2016).
Citrinin (CIT) is a mycotoxin found in wheat, rice, cheese, fermented sausages that can cause neurotoxic effects associated with damage in brain cells. Sleep deprivation, and anxiety are some of the symptoms that CIT can cause (Zargar and Wani, 2023a; Zargar and Wani, 2023b).
Trichothecenes are another class of mycotoxins that can cause neuroinflammation, leading to symptoms such as depression and headaches (Feuerstein et al., 2017). In particular, T-2 toxin, which is a member of trichothecene involved in the changes in neurotransmitters levels, can lead to cognitive impairment and increased irritability (Zhang et al., 2020a; Zhang et al., 2020b).
3 Discussion
Many studies have reported the role of mycotoxins in low- and middle-income countries, highlighting the need to evaluate intervention measures to prevent fatalities from acute mycotoxin intoxication, as well as the long-term effects from sub-acute exposure. In light of the above mentioned findings, mycotoxins can increase the vulnerability of neuropsychiatric symptoms in patients with already a higher risk, by accelerating the underlying neurologic, or pathologic processes (Empting, 2009).
Emotional distress, anxiety and depression, are also some of the neuropsychiatric symptoms frequent in special vulnerable populations, with particular need for help, such as in refugee populations. FB1 and ZEA levels were reported to be associated with drought stress in South Eastern Africa, sub-Saharan Africa, regions that host significant refugee populations (Yli-Mattila and Sundheim, 2022a; Pestka, et al., 1987; Ren et al., 2016a; Ren et al., 2016b; Ratnaseelan et al., 2018). Although the number of studies on mycotoxin levels and their effects on health has rapidly increased in recent years, there is a lack of research and review articles in current literature databases regarding mycotoxin serum and urine levels in refugee populations worldwide. In this context, measuring the levels of mycotoxins in different refugees populations around the world, such as in Africa, Middle East, or Southeast Asia would be of great interest, not only for studying their effects on health, but especially in neuropsychiatric disorders. Considering the pivotal role of mycotoxins in the high levels of stunting in children, we believe it would be of great public health interest to study their levels in these vulnerable populations as well.
We must also consider the numerous challenges, including the diversity of refugee populations, cultural contexts, national laws, and the lack of country-specific resources and data. It is also important to acknowledge the significant role of malnutrition, dietary deficiencies, psychological trauma, and post-traumatic stress disorder (PTSD) in contributing to neuropsychiatric symptoms in refugee populations. Deficiencies in vitamins (particularly vitamin B12), omega-3 fatty acids, and minerals, resulting from restricted access to adequate nutrition, are another contributing factor to neuropsychiatric symptoms in refugee populations, including mood disorders, anxiety, depression, and cognitive decline (Ogbu et al., 2022; Mason et al., 2012). In addition, many displaced individuals go through loss, violence, and experience an extreme emotional stress, or PTSD, which brings to manifestations of mental health disorders, including emotional instability, and social disengagement (Peconga and Høgh Thøgersen, 2020). Thus, it is essential to consider how trauma, PTSD, and malnutrition, may intersect with the role of mycotoxin exposure in neuropsychiatric outcomes.
Moreover, environmental pollutants like heavy metals (mercury, arsenic, lead) and pesticides may worsen neuropsychiatric symptoms in refugee populations, as they often live in areas with improper waste handling, and exposure to industrial pollutants that contaminate air, water, and food sources. The role of heavy metals in emotional disturbances, increased risk of depression and anxiety is widely acknowledged (Daher et al., 2025). On the other hand, in refugee populations, due to adjacency to farming activities, the exposure to pesticides combined with trauma and malnutrition, can exacerbate mental health issues (Richardson et al., 2019; Blackmore et al., 2020; Kamel et al., 2004).
Adapting monitoring campaigns to identify the most efficient and cost-effective strategies for assessing and reducing mycotoxin exposure in refugee populations is crucial. Efforts such as improving food storage, diversifying diets, and utilizing biomarkers of exposure can significantly reduce mycotoxin-related risks. These measures are essential for reducing neuropsychiatric symptoms associated with mycotoxin exposure and alleviating the suffering of affected populations.
Through this “opinion” study we propose an investigation of the levels of mycotoxins in these special populations, that will bring to further recommendations for the governmental and nongovernmental organizations, for either monitoring the prevalence of mycotoxins levels in neuropsychiatric symptoms in refugee populations, or for implementing various strategies to reduce mycotoxins exposure and contamination.
Author contributions
MH: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing–original draft, Writing–review and editing. MA: Writing–review and editing. GA: Writing–review and editing. BZ: Writing–review and editing. DT: Writing–review and editing.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. We would like to thank the Catholic University Our Lady of Good Counsel, for the financial support for the publication of this research paper.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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References
Abia, W. A., Foupouapouognigni, Y., Nfombouot, H. P. N., Ngoungoure, L. V. N., Ntungwe, E. N., Salah-Abbès, J. B., et al. (2025). A scoping review on mycotoxin-induced neurotoxicity. Discov. Toxicol. 2 (1), 1. doi:10.1007/s44339-024-00013-7
Blackmore, R., Boyle, J. A., Fazel, M., Ranasinha, S., Gray, K. M., Fitzgerald, G., et al. (2020). The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med. 17 (9), e1003337. doi:10.1371/journal.pmed.1003337
Brand, B., Stoye, N. M., dos Santos Guilherme, M., Nguyen, V. T. T., Baumgaertner, J. C., Schüffler, A., et al. (2019). Identification of Patulin from Penicillium coprobium as a toxin for enteric neurons. Molecules 24 (2776), 2776. doi:10.3390/molecules24152776
Bulder, A. S., Arcella, D., Bolger, M., Carrington, C., Kpodo, K., Resnik, S., et al. (2012). “Fumonisins (addendum),” in Safety evaluation of certain food additives and contaminants: prepared by the seventy-fourth meeting of the Joint FAO/WHO Expert Committee on Food Additives (JECFA) (Geneva, Switzerland), 325–794.
Chen, J., Wen, J., Tang, Y., Shi, J., Mu, G., Yan, R., et al. (2021). Research progress on fumonisin B1 contamination and toxicity: a review. Molecules 26 (17), 5238. doi:10.3390/molecules26175238
Crago, B. R., Gray, M. R., Nelson, L. A., Davis, M., Arnold, L., and Thrasher, J. D. (2003). Psychological, neuropsychological, and electrocortical effects of mixed mold exposure. Arch. Environ. Health 58, 452–463. doi:10.3200/AEOH.58.8.452-463
Daher, S., Ziade, F., and Baroudi, M. (2025). Dietary exposure to Arsenic, Cadmium, and lead amongst under-five Syrian refugee and Lebanese children in rural Lebanon. Food Chemistry Advances 6, 100909. doi:10.1016/j.focha.2025.100909
Dai, C., Tian, E., Li, H., Gupta, S. D., Hao, Z., Wang, Z., et al. (2024). Molecular mechanisms of aflatoxin neurotoxicity and potential neuroprotective agents. Food Sci. Hum. Wellness 13 (5), 2445–2455. doi:10.26599/fshw.2022.9250201
Ehsanifar, M., Rajati, R., Gholami, A., and Reiss, J. P. (2023). Mold and mycotoxin exposure and brain disorders. J. Integr. Neurosci. 22 (6), 137. doi:10.31083/j.jin2206137
Empting, L. D. (2009). Neurologic and neuropsychiatric syndrome features of mold and mycotoxin exposure. Toxicol. Ind. Health 25 (9-10), 577–581. doi:10.1177/0748233709348393
Feuerstein, G., Lorenzana, R. M., and Beasley, V. R. (2017). “Effects of trichothecene mycotoxins on the nervous system,” Trichothecene Mycotoxicosis Pathophysiol. Eff., 2 111–122. doi:10.1201/9781315121260
Hyndman, S. J. (1990). Housing dampness and health amongst British bengalis in East london. Soc. Sci. Med. 30, 131–141. doi:10.1016/0277-9536(90)90336-q
Kamel, F., and Hoppin, J. A. (2004). Association of pesticide exposure with neurologic dysfunction and disease. Environ Health Perspect. 112 (9), 950–958. doi:10.1289/ehp.7135
Kilburn, K. H. (2003). Indoor mold exposure associated with neurobehavioral and pulmonary impairment: a preliminary report. Arch. Environ. Health 58, 390–398. doi:10.1080/00039896.2003.11879139
Kowalska, K., Habrowska-Górczyńska, D. E., and Piastowska-Ciesielska, A. W. (2016). Zearalenone as an endocrine disruptor in humans. Environ. Toxicol. Pharmacol. 48, 141–149. doi:10.1016/j.etap.2016.10.015
Mason, J. B., White, J. M., Heron, L., Carter, J., Wilkinson, C., and Spiegel, P. (2012). Child acute malnutrition and mortality in populations affected by displacement in the Horn of Africa, 1997-2009. Int. J. Environ. Res. public health 9 (3), 791–806. doi:10.3390/ijerph9030791
Mateo, E., Tonino, R. P. B., Canto, A., Monroy Noyola, A., Miranda, M., Soria, J. M., et al. (2022). The neurotoxic effect of ochratoxin-A on the hippocampal neurogenic niche of adult mouse brain. Toxins (Basel) 14 (9), 624. doi:10.3390/toxins14090624
Missmer, S. A., Suarez, L., Felkner, M., Wang, E., Merrill, A. H., Rothman, K. J., et al. (2006). Exposure to fumonisins and the occurrence of neural tube defects along the Texas-Mexico border. Environ. Health Perspect. 114 (2), 237–241. doi:10.1289/ehp.8221
Nguyen, V. T. T., König, S., Eggert, S., Endres, K., and Kins, S. (2021). The role of mycotoxins in neurodegenerative diseases: current state of the art and future perspectives of research. Biol. Chem. 403 (1), 3–26. doi:10.1515/hsz-2021-0214
Ogbu, T. J., Scales, S. E., de Almeida, M. M., van Loenhout, J. A. F., Speybroeck, N., and Guha-Sapir, D. (2022). Predictors of exceeding emergency under-five mortality thresholds using small-scale survey data from humanitarian settings (1999 - 2020): considerations for measles vaccination, malnutrition, and displacement status. Archives public health = Archives belges de sante publique 80 (1), 160. doi:10.1186/s13690-022-00916-0
Packer, C. N., Stewart-Brown, S., and Fowle, S. E. (1994). Damp housing and adult health: results from a lifestyle study in Worcester, England. J. Epidemiol. Community Health 48, 555–559. doi:10.1136/jech.48.6.555
Pal, S., Singh, N., and Ansari, K. M. (2017). Toxicological effects of patulin mycotoxin on the mammalian system: an overview. Toxicol. Res. (Camb) 6 (6), 764–771. doi:10.1039/c7tx00138j
Peconga, E. K., and Høgh Thøgersen, M. (2020). Post-traumatic stress disorder, depression, and anxiety in adult Syrian refugees: what do we know? Scand. J. public health 48 (7), 677–687. doi:10.1177/1403494819882137
Pei, X., Zhang, W., Jiang, H., Liu, D., Liu, X., Li, L., et al. (2021). Food-origin mycotoxin-induced neurotoxicity: intend to break the rules of neuroglia cells. Oxid. Med. Cell. Longev. 2021, 9967334. doi:10.1155/2021/9967334
Pestka, J. J., Tai, J. H., Witt, M. F., Dixon, D. E., and Forsell, J. H. (1987). Suppression of immune response in the B6C3F1 mouse after dietary exposure to the Fusarium mycotoxins deoxynivalenol (vomitoxin) and zearalenone. Food Chem. Toxicol. 25, 297–304. doi:10.1016/0278-6915(87)90126-8
Pleadin, J., Frece, J., and Markov, K. (2019). Mycotoxins in food and feed. Adv. Food Nutr. Res. 89, 297–345. doi:10.1016/bs.afnr.2019.02.007
Qureshi, H., Hamid, S. S., Ali, S. S., Anwar, J., Siddiqui, A. A., and Khan, N. A. (2015). Cytotoxic effects of aflatoxin B1 on human brain microvascular endothelial cells of the blood-brain barrier. Med. Mycol. 53 (4), 409–416. doi:10.1093/mmy/myv010
Ratnaseelan, A. M., Tsilioni, I., and Theoharides, T. C. (2018). Effects of mycotoxins on neuropsychiatric symptoms and immune processes. Clin. Ther. 40 (6), 903–917. doi:10.1016/j.clinthera.2018.05.004
Ren, Z. H., Deng, H. D., Deng, Y. T., Deng, J. L., Zuo, Z. C., Yu, S. M., et al. (2016b). Effect of the Fusarium toxins, zearalenone and deoxynivalenol, on the mouse brain. Environ. Toxicol. Pharmacol. 46, 62–70. doi:10.1016/j.etap.2016.06.028
Ren, Z. H., Deng, H. D., Wang, Y. C., Deng, J. L., Zuo, Z. C., Wang, Y., et al. (2016a). The Fusarium toxin zearalenone and deoxynivalenol affect murine splenic antioxidant functions, interferon levels, and T-cell subsets. Environ. Toxicol. Pharmacol. 41, 195–200. doi:10.1016/j.etap.2015.12.007
Richard, J. L. (2007). Some major mycotoxins and their mycotoxicoses—an overview. Int. J. Food Microbiol. 119, 3–10. doi:10.1016/j.ijfoodmicro.2007.07.019
Richardson, J. R., Fitsanakis, V., Westerink, R. H. S., and Kanthasamy, A. G. (2019) Neurotoxicity of pesticides. Acta Neuropathol. 138 (3), 343–362. doi:10.1007/s00401-019-02033-9
Sabater-Vilar, M., Maas, R. F., De Bosschere, H., Ducatelle, R., and Fink-Gremmels, J. (2004). Patulin produced by an Aspergillus clavatus isolated from feed containing malting residues associated with a lethal neurotoxicosis in cattle. Mycopathologia 158 (4), 419–426. doi:10.1007/s11046-005-2877-x
Song, E., Su, C., Fu, J., Xia, X., Yang, S., Xiao, C., et al. (2014). Selenium supplementation shows protective effects against patulin-induced brain damage in mice via increases in GSH-related enzyme activity and expression. Life Sci. 109 (1), 37–43. doi:10.1016/j.lfs.2014.05.022
Stockmann-Juvala, H., and Savolainen, K. (2008). A review of the toxic effects and mechanisms of action of fumonisin B1. Human & experimental toxicology, 27 (11), 799–809. doi:10.1177/0960327108099525
von Tobel, J. S., Antinori, P., Zurich, M. G., Rosset, R., Aschner, M., Glück, F., et al. (2014). Repeated exposure to ochratoxin A generates a neuroinflammatory response, characterized by neurodegenerative M1 microglial phenotype. Neurotoxicology 44, 61–70. doi:10.1016/j.neuro.2014.04.005
C. P. Wild, J. D. Miller, and J. D. Groopman (2015). Mycotoxin control in low-and middle-income countries. Lyon, France: International Agency for Research on Cancer.
Yli-Mattila, T., and Sundheim, L. (2022a). Fumonisins in african countries. Toxins (Basel) 14 (6), 419. doi:10.3390/toxins14060419
Yli-Mattila, T., and Sundheim, L. (2022b). Fumonisins in african countries. Toxins (Basel) 14 (6), 419. doi:10.3390/toxins14060419
Yoon, S., Cong, W. T., Bang, Y., Lee, S. N., Yoon, C. S., Kwack, S. J., et al. (2009). Proteome response to ochratoxin A-induced apoptotic cell death in mouse hippocampal HT22 cells. Neurotoxicology 30, 666–676. doi:10.1016/j.neuro.2009.04.013
Zargar, S., and Wani, T. A. (2023a). Food toxicity of mycotoxin citrinin and molecular mechanisms of its potential toxicity effects through the implicated targets predicted by computer-aided multidimensional data analysis. Life 13 (880), 880. doi:10.3390/life13040880
Zargar, S., and Wani, T. A. (2023b). Food toxicity of mycotoxin citrinin and molecular mechanisms of its potential toxicity effects through the implicated targets predicted by computer-aided multidimensional data analysis. Life 13, 880. doi:10.3390/life13040880
Zhang, J., You, L., Wu, W., Wang, X., Chrienova, Z., Nepovimova, E., et al. (2020a). The neurotoxicity of trichothecenes T-2 toxin and deoxynivalenol (DON): current status and future perspectives. Food Chem. Toxicol. 145, 111676. doi:10.1016/j.fct.2020.111676
Zhang, J., You, L., Wu, W., Wang, X., Chrienova, Z., Nepovimova, E., et al. (2020b). The neurotoxicity of trichothecenes T-2 toxin and deoxynivalenol (DON): current status and future perspectives. Food Chem. Toxicol. 145, 111676. doi:10.1016/j.fct.2020.111676
Keywords: refugee populations, mycotoxins, neuropsychiatric symptoms, depression, anxiety
Citation: Hoxha M, Abbasciano M, Avantaggiato G, Zappacosta B and Tricarico D (2025) Mycotoxins and neuropsychiatric symptoms: possible role in special refugee populations. Front. Pharmacol. 16:1524152. doi: 10.3389/fphar.2025.1524152
Received: 07 November 2024; Accepted: 03 March 2025;
Published: 19 March 2025.
Edited by:
Ahmed Noah Badr, National Research Centre, EgyptReviewed by:
Alejandro Ortega-Beltran, International Institute of Tropical Agriculture (IITA), NigeriaCopyright © 2025 Hoxha, Abbasciano, Avantaggiato, Zappacosta and Tricarico. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Malvina Hoxha, bS5ob3hoYUB1bml6a20uYWw=