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Hegde M, Girisa S, Aswani BS, Alqahtani MS, Abbas M, Sethi G, Kunnumakkara AB. Harnessing potential role of gangliosides in immunomodulation and cancer therapeutics. Life Sci 2024; 351:122786. [PMID: 38848944 DOI: 10.1016/j.lfs.2024.122786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 05/01/2024] [Accepted: 06/04/2024] [Indexed: 06/09/2024]
Abstract
Gangliosides represent glycolipids containing sialic acid residues, present on the cell membrane with glycan residues exposed to the extracellular matrix (ECM), while the ceramides are anchored within the membrane. These molecules play a critical role in pathophysiological processes such as host-pathogen interactions, cell-cell recognition, signal transduction, cell adhesion, motility, and immunomodulation. Accumulated evidence suggests the overexpression of gangliosides on tumor tissues in comparison to healthy human tissues. These tumor-associated gangliosides have been implicated in various facets of tumor biology, including cell motility, differentiation, signaling, immunosuppression, angiogenesis, and metastasis. Consequently, these entities emerge as attractive targets for immunotherapeutic interventions. Notably, the administration of antibodies targeting gangliosides has demonstrated cytotoxic effects on cancer cells that exhibit an overexpression of these glycolipids. Passive immunotherapy approaches utilizing murine or murine/human chimeric anti-ganglioside antibodies have been explored as potential treatments for diverse cancer types. Additionally, vaccination strategies employing tumor-associated gangliosides in conjunction with adjuvants have entered the realm of promising techniques currently undergoing clinical trials. The present comprehensive review encapsulates the multifaceted roles of gangliosides in tumor initiation, progression, immunosuppression, and metastasis. Further, an overview is provided of the correlation between the expression status of gangliosides in normal and tumor cells and its impact on cancer patient survival. Furthermore, the discussion extends to ongoing and completed clinical trials employing diverse strategies to target gangliosides, elucidating their effectiveness in treating cancers. This emerging discipline is expected to supply substantial impetus for the establishment of novel therapeutic strategies.
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Affiliation(s)
- Mangala Hegde
- Cancer Biology Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati (IITG), Guwahati, Assam 781039, India
| | - Sosmitha Girisa
- Cancer Biology Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati (IITG), Guwahati, Assam 781039, India
| | - Babu Santha Aswani
- Cancer Biology Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati (IITG), Guwahati, Assam 781039, India
| | - Mohammed S Alqahtani
- Radiological Sciences Department, College of Applied Medical Sciences, King Khalid University, Abha 61421, Saudi Arabia; BioImaging Unit, Space Research Centre, Michael Atiyah Building, University of Leicester, Leicester LE1 7RH, UK
| | - Mohamed Abbas
- Electrical Engineering Department, College of Engineering, King Khalid University, Abha 61421, Saudi Arabia
| | - Gautam Sethi
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore; NUS Center for Cancer Research, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117699, Singapore.
| | - Ajaikumar B Kunnumakkara
- Cancer Biology Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati (IITG), Guwahati, Assam 781039, India.
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Jiang Y, Zhang S, Pan L, Leng J, Zhou T, Liu M, Li L, Zhao W. β-Glucan-based superabsorbent hydrogel acts as a gastrointestinal exoskeleton enhancing satiety and interfering fat hydrolysis. Int J Biol Macromol 2024:133333. [PMID: 38945724 DOI: 10.1016/j.ijbiomac.2024.133333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
Fat and its hydrolysis products, fatty acids, are indispensable nutritional components; however, prolonged excessive fat consumption, particularly in western diets, contributes to the onset of obesity and multiple metabolic disorders. In this study, we propose a daily-ingestible hydrogel (denoted as βC-MA hydrogel) composed of natural β-glucan and sodium carboxymethylcellulose crosslinked by malic acid at 120 °C. This hydrogel exhibits rapid swelling performance, up to 24-fold within 1 min and 176-fold after 1 h in deionized water. It also lengthens gastric retention and increases endogenous satiety signal levels, potentially controlling appetite and reducing food intake. Furthermore, βC-MA hydrogels that enter the small intestine can effectively inhibit fat hydrolysis and decrease triglyceride synthesis and transport. Specifically, the hydrogels inhibit the release of free fatty acids (FFAs) by approximately 50 % during digestion, influence the translocation of triglycerides and FFAs across the intestinal epithelium, and reduce the serum triglyceride levels by 22.2 %. These findings suggest that βC-MA hydrogels could serve as a noninvasive gastrointestinal device for weight control, with the advantage of reducing food intake and restoring lipid metabolism homeostasis.
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Affiliation(s)
- Yiming Jiang
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Shiqi Zhang
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Linfan Pan
- School of Design, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Juncai Leng
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Tingyi Zhou
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Mingxuan Liu
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Li Li
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Wei Zhao
- State Key Laboratory of Food Science and Resources, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China.
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Cheung IY, Mauguen A, Modak S, Basu EM, Feng Y, Kushner BH, Cheung NK. Long Prime-Boost Interval and Heightened Anti-GD2 Antibody Response to Carbohydrate Cancer Vaccine. Vaccines (Basel) 2024; 12:587. [PMID: 38932316 PMCID: PMC11209353 DOI: 10.3390/vaccines12060587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
The carbohydrate ganglioside GD2/GD3 cancer vaccine adjuvanted by β-glucan stimulates anti-GD2 IgG1 antibodies that strongly correlate with improved progression-free survival (PFS) and overall survival (OS) among patients with high-risk neuroblastoma. Thirty-two patients who relapsed on the vaccine (first enrollment) were re-treated on the same vaccine protocol (re-enrollment). Titers during the first enrollment peaked by week 32 at 751 ± 270 ng/mL, which plateaued despite vaccine boosts at 1.2-4.5 month intervals. After a median wash-out interval of 16.1 months from the last vaccine dose during the first enrollment to the first vaccine dose during re-enrollment, the anti-GD2 IgG1 antibody rose to a peak of 4066 ± 813 ng/mL by week 3 following re-enrollment (p < 0.0001 by the Wilcoxon matched-pairs signed-rank test). Yet, these peaks dropped sharply and continually despite repeated boosts at 1.2-4.5 month intervals, before leveling off by week 20 to the first enrollment peak levels. Despite higher antibody titers, patients experienced no pain or neuropathic side effects, which were typically associated with immunotherapy using monoclonal anti-GD2 antibodies. By the Kaplan-Meier method, PFS was estimated to be 51%, and OS was 81%. The association between IgG1 titer during re-enrollment and β-glucan receptor dectin-1 SNP rs3901533 was significant (p = 0.01). A longer prime-boost interval could significantly improve antibody responses in patients treated with ganglioside conjugate cancer vaccines.
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Affiliation(s)
- Irene Y. Cheung
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
| | - Audrey Mauguen
- Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Shakeel Modak
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
| | - Ellen M. Basu
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
| | - Yi Feng
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
| | - Brian H. Kushner
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
| | - Nai Kong Cheung
- Departments of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (S.M.); (E.M.B.); (Y.F.); (B.H.K.); (N.K.C.)
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Viana JPM, Costa FF, Dias TG, Mendes PM, Copeland GB, Nascimento WS, Mendes SSN, Figueiredo IFS, Fernandes ES, Bocca AL, Maciel MCG. Glucans: A Therapeutic Alternative for Sepsis Treatment. J Immunol Res 2024; 2024:6876247. [PMID: 38939744 PMCID: PMC11208795 DOI: 10.1155/2024/6876247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 04/30/2024] [Accepted: 05/10/2024] [Indexed: 06/29/2024] Open
Abstract
Sepsis treatment is a challenging condition due to its complexity, which involves host inflammatory responses to a severe and potentially fatal infection, associated with organ dysfunction. The aim of this study was to analyze the scientific literature on the immunomodulatory effects of glucans in a murine model of systemic infection induced by cecal ligation and puncture. This study comprises an integrative literature review based on systematic steps, with searches carried out in the PubMed, ScienceDirect, Scopus, Web of Science, and Embase databases. In most studies, the main type of glucan investigated was β-glucan, at 50 mg/kg, and a reduction of inflammatory responses was identified, minimizing the occurrence of tissue damage leading to increased animal survival. Based on the data obtained and discussed in this review, glucans represent a promising biotechnological alternative to modulate the immune response and could potentially be used in the clinical management of septic individuals.
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Affiliation(s)
- Jesse P. M. Viana
- Departamento de Biologia CelularInstituto de Ciências BiológicasPrograma de Pós Graduação em Ciências Biológicas (Biologia Molecular)Laboratório de Imunologia AplicadaUniversidade de Brasília (UnB), Brasília, Brazil
| | - Fernanda F. Costa
- Programa de Pós-graduação em Saúde e TecnologiaUniversidade Federal do Maranhão, São Luís, Brazil
| | - Tatielle G. Dias
- Programa de Pós-graduação em Ciências da SaúdeUniversidade Federal do Maranhão, São Luís, Brazil
| | - Priscila M. Mendes
- Programa de Pós-graduação em Ciências da SaúdeUniversidade Federal do Maranhão, São Luís, Brazil
| | - Gabriel B. Copeland
- Laboratório de Imunologia AplicadaUniversidade de Brasília (UnB), Brasília, Brazil
| | | | - Sofia S. N. Mendes
- Laboratório de Imunologia AplicadaUniversidade de Brasília (UnB), Brasília, Brazil
| | - Isabella F. S. Figueiredo
- Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente—Faculdades Pequeno PríncipeInstituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Elizabeth S. Fernandes
- Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente—Faculdades Pequeno PríncipeInstituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Anamelia L. Bocca
- Departamento de Biologia CelularInstituto de Ciências BiológicasPrograma de Pós Graduação em Ciências Biológicas (Biologia Molecular)Laboratório de Imunologia AplicadaUniversidade de Brasília (UnB), Brasília, Brazil
- Plataforma Bi-Institucional de Pesquisa Translacional—Fiocruz/SP, São Paulo, Brazil
| | - Márcia C. G. Maciel
- Departamento de Biologia CelularInstituto de Ciências BiológicasPrograma de Pós Graduação em Ciências Biológicas (Biologia Molecular)Laboratório de Imunologia AplicadaUniversidade de Brasília (UnB), Brasília, Brazil
- Programa de Pós-graduação em Saúde e TecnologiaUniversidade Federal do Maranhão, São Luís, Brazil
- Programa de Pós-graduação em Ciências da SaúdeUniversidade Federal do Maranhão, São Luís, Brazil
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Mora J, Modak S, Kinsey J, Ragsdale CE, Lazarus HM. GM-CSF, G-CSF or no cytokine therapy with anti-GD2 immunotherapy for high-risk neuroblastoma. Int J Cancer 2024; 154:1340-1364. [PMID: 38108214 DOI: 10.1002/ijc.34815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/17/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023]
Abstract
Colony-stimulating factors have been shown to improve anti-disialoganglioside 2 (anti-GD2) monoclonal antibody response in high-risk neuroblastoma by enhancing antibody-dependent cell-mediated cytotoxicity (ADCC). A substantial amount of research has focused on recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) as an adjuvant to anti-GD2 monoclonal antibodies. There may be a disparity in care among patients as access to GM-CSF therapy and anti-GD2 monoclonal antibodies is not uniform. Only select countries have approved these agents for use, and even with regulatory approvals, access to these agents can be complex and cost prohibitive. This comprehensive review summarizes clinical data regarding efficacy and safety of GM-CSF, recombinant human granulocyte colony-stimulating factor (G-CSF) or no cytokine in combination with anti-GD2 monoclonal antibodies (ie, dinutuximab, dinutuximab beta or naxitamab) for immunotherapy of patients with high-risk neuroblastoma. A substantial body of clinical data support the immunotherapy combination of anti-GD2 monoclonal antibodies and GM-CSF. In contrast, clinical data supporting the use of G-CSF are limited. No formal comparison between GM-CSF, G-CSF and no cytokine has been identified. The treatment of high-risk neuroblastoma with anti-GD2 therapy plus GM-CSF is well established. Suboptimal efficacy outcomes with G-CSF raise concerns about its suitability as an alternative to GM-CSF as an adjuvant in immunotherapy for patients with high-risk neuroblastoma. While programs exist to facilitate obtaining GM-CSF and anti-GD2 monoclonal antibodies in regions where they are not commercially available, continued work is needed to ensure equitable therapeutic options are available globally.
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Affiliation(s)
- Jaume Mora
- Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Shakeel Modak
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joyce Kinsey
- Partner Therapeutics, Inc, Lexington, Massachusetts, USA
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Bhargavi G, Subbian S. The causes and consequences of trained immunity in myeloid cells. Front Immunol 2024; 15:1365127. [PMID: 38665915 PMCID: PMC11043514 DOI: 10.3389/fimmu.2024.1365127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
Conventionally, immunity in humans has been classified as innate and adaptive, with the concept that only the latter type has an immunological memory/recall response against specific antigens or pathogens. Recently, a new concept of trained immunity (a.k.a. innate memory response) has emerged. According to this concept, innate immune cells can exhibit enhanced responsiveness to subsequent challenges, after initial stimulation with antigen/pathogen. Thus, trained immunity enables the innate immune cells to respond robustly and non-specifically through exposure or re-exposure to antigens/infections or vaccines, providing enhanced resistance to unrelated pathogens or reduced infection severity. For example, individuals vaccinated with BCG to protect against tuberculosis were also protected from malaria and SARS-CoV-2 infections. Epigenetic modifications such as histone acetylation and metabolic reprogramming (e.g. shift towards glycolysis) and their inter-linked regulations are the key factors underpinning the immune activation of trained cells. The integrated metabolic and epigenetic rewiring generates sufficient metabolic intermediates, which is crucial to meet the energy demand required to produce proinflammatory and antimicrobial responses by the trained cells. These factors also determine the efficacy and durability of trained immunity. Importantly, the signaling pathways and regulatory molecules of trained immunity can be harnessed as potential targets for developing novel intervention strategies, such as better vaccines and immunotherapies against infectious (e.g., sepsis) and non-infectious (e.g., cancer) diseases. However, aberrant inflammation caused by inappropriate onset of trained immunity can lead to severe autoimmune pathological consequences, (e.g., systemic sclerosis and granulomatosis). In this review, we provide an overview of conventional innate and adaptive immunity and summarize various mechanistic factors associated with the onset and regulation of trained immunity, focusing on immunologic, metabolic, and epigenetic changes in myeloid cells. This review underscores the transformative potential of trained immunity in immunology, paving the way for developing novel therapeutic strategies for various infectious and non-infectious diseases that leverage innate immune memory.
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Affiliation(s)
| | - Selvakumar Subbian
- Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ, United States
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Nordin AH, Husna SMN, Ahmad Z, Nordin ML, Ilyas RA, Azemi AK, Ismail N, Siti NH, Ngadi N, Azami MSM, Mohamad Norpi AS, Reduan MFH, Osman AY, Pratama DAOA, Nabgan W, Shaari R. Natural Polymeric Composites Derived from Animals, Plants, and Microbes for Vaccine Delivery and Adjuvant Applications: A Review. Gels 2023; 9:227. [PMID: 36975676 PMCID: PMC10048722 DOI: 10.3390/gels9030227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
A key element in ensuring successful immunization is the efficient delivery of vaccines. However, poor immunogenicity and adverse inflammatory immunogenic reactions make the establishment of an efficient vaccine delivery method a challenging task. The delivery of vaccines has been performed via a variety of delivery methods, including natural-polymer-based carriers that are relatively biocompatible and have low toxicity. The incorporation of adjuvants or antigens into biomaterial-based immunizations has demonstrated better immune response than formulations that just contain the antigen. This system may enable antigen-mediated immunogenicity and shelter and transport the cargo vaccine or antigen to the appropriate target organ. In this regard, this work reviews the recent applications of natural polymer composites from different sources, such as animals, plants, and microbes, in vaccine delivery systems.
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Affiliation(s)
- Abu Hassan Nordin
- Faculty of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Johor, Malaysia
- Faculty of Applied Sciences, Universiti Teknologi MARA (UiTM), Arau 02600, Perlis, Malaysia
| | - Siti Muhamad Nur Husna
- Faculty of Applied Sciences, Universiti Teknologi MARA (UiTM), Arau 02600, Perlis, Malaysia
| | - Zuliahani Ahmad
- Faculty of Applied Sciences, Universiti Teknologi MARA (UiTM), Arau 02600, Perlis, Malaysia
| | - Muhammad Luqman Nordin
- Department of Clinical Studies, Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu 16100, Kelantan, Malaysia
- Centre for Veterinary Vaccinology (VetVaCC), Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu 16100, Kelantan, Malaysia
| | - Rushdan Ahmad Ilyas
- Faculty of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Johor, Malaysia
- Centre for Advanced Composite Materials (CACM), Universiti Teknologi Malaysia (UTM), Skudai 81310, Johor, Malaysia
| | - Ahmad Khusairi Azemi
- Institute of Marine Biotechnology, Universiti Malaysia Terengganu, Kuala Terengganu 21030, Terengganu, Malaysia
| | - Noraznawati Ismail
- Institute of Marine Biotechnology, Universiti Malaysia Terengganu, Kuala Terengganu 21030, Terengganu, Malaysia
| | - Nordin Hawa Siti
- Pharmacology Unit, School of Basic Medical Sciences, Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu 20400, Terengganu, Malaysia
| | - Norzita Ngadi
- Faculty of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Johor, Malaysia
| | | | - Abdin Shakirin Mohamad Norpi
- Faculty Pharmacy and Health Sciences, Universiti Kuala Lumpur Royal College of Medicine Perak, Ipoh 30450, Perak, Malaysia
| | - Mohd Farhan Hanif Reduan
- Department of Clinical Studies, Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu 16100, Kelantan, Malaysia
- Centre for Veterinary Vaccinology (VetVaCC), Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu 16100, Kelantan, Malaysia
| | - Abdinasir Yusuf Osman
- The Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hatfield AL9 7TA, Hertfordshire, UK
- National Institutes of Health (NIH), Ministry of Health, Corso Somalia Street, Shingani, Mogadishu P.O. Box 22, Somalia
| | | | - Walid Nabgan
- Departament d’Enginyeria Química, Universitat Rovira I Virgili, Av. Països Catalans 26, 43007 Tarragona, Spain
| | - Rumaizi Shaari
- Department of Clinical Studies, Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu 16100, Kelantan, Malaysia
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