1
|
Joó JG, Sulyok E, Bódis J, Kornya L. Disrupted Balance of the Oxidant-Antioxidant System in the Pathophysiology of Female Reproduction: Oxidative Stress and Adverse Pregnancy Outcomes. Curr Issues Mol Biol 2023; 45:8091-8111. [PMID: 37886954 PMCID: PMC10605220 DOI: 10.3390/cimb45100511] [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: 09/12/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/28/2023] Open
Abstract
The significance of oxidative stress in the pathophysiology of male reproductive processes has been closely studied in the last two decades. Recently, it has become clear that oxidative stress can lead to numerous pathological conditions during female reproductive processes as well, contributing to the development of endometriosis, polycystic ovary syndrome and various forms of infertility. During pregnancy, physiological generation of reactive oxygen species (ROS) occurs in association with several developmental processes including oocyte maturation and implantation. An overproduction of ROS can lead to disturbances in fetal development and increases the risk for missed abortion, intrauterine growth restriction, pre-eclampsia, premature delivery and gestational diabetes. Our review focuses on the etiological role of the disrupted oxidant-antioxidant system during human gestation as it relates to adverse pregnancy outcomes.
Collapse
Affiliation(s)
- József Gábor Joó
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary
| | - Endre Sulyok
- Faculty of Health Sciences, University of Pécs, 7621 Pécs, Hungary
| | - József Bódis
- Faculty of Health Sciences, University of Pécs, 7621 Pécs, Hungary
| | - László Kornya
- Central Hospital of South Pest National Institute of Hematology and Infectious Diseases, 1476 Budapest, Hungary
| |
Collapse
|
2
|
Hannah W, Bhavadharini B, Beks H, Deepa M, Anjana RM, Uma R, Martin E, McNamara K, Versace V, Saravanan P, Mohan V. Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review. Acta Diabetol 2022; 59:403-427. [PMID: 34743219 DOI: 10.1007/s00592-021-01800-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/07/2021] [Indexed: 01/02/2023]
Abstract
AIMS Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia. METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized. RESULTS Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed. CONCLUSIONS There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.
Collapse
Affiliation(s)
- Wesley Hannah
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
- Deakin University, Geelong, Australia
| | | | | | - Mohan Deepa
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
| | - Ranjit Mohan Anjana
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
| | - Ram Uma
- Seethapathy Clinic & Hospital, Chennai, India
| | | | | | | | - Ponnusamy Saravanan
- Populations, Evidence and Technologies, Warwick Medical School, Gibbet Hill, Division of Health Sciences, University of Warwick, Coventry, UK
- Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital NHS Trust, Nunetaon, UK
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India.
| |
Collapse
|
3
|
Phoswa WN, Khaliq OP. The Role of Oxidative Stress in Hypertensive Disorders of Pregnancy (Preeclampsia, Gestational Hypertension) and Metabolic Disorder of Pregnancy (Gestational Diabetes Mellitus). OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:5581570. [PMID: 34194606 PMCID: PMC8184326 DOI: 10.1155/2021/5581570] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/25/2021] [Indexed: 11/17/2022]
Abstract
Purpose of the Review.To highlight the role of oxidative stress in hypertensive disorders of pregnancy (HDP) and metabolic disorders of pregnancy (gestational diabetes mellitus). Recent Findings. In both preeclampsia (PE) and gestational hypertension (GH), oxidative stress leads to inadequate placental perfusion thus resulting in a hypoxic placenta, which generally leads to the activation of maternal systemic inflammatory response. In PE, this causes inflammation in the kidneys and leads to proteinuria. A proteinuria marker known as urinary 8-oxoGuo excretion is expressed in preeclampsia. In GDM, oxidative stress plays a role in the pathogenesis of the disease, as a result of over secretion of insulin during pregnancy. This uncontrolled secretion of insulin results in the production of lipid peroxidation factors that also mask the secretion of antioxidants. Therefore, ROS becomes abundant at cellular level and prevents the cells from transporting glucose to body tissues. Summary. There is a need for more research investigating the role of oxidative stress, especially in obstetrics-related conditions. More studies are required in order to understand the difference between the pathogenesis and pathophysiology of PE versus GH since investigations on the differences in genetic aspects of each condition are lacking. Furthermore, research to improve diagnostic procedures for GDM in pregnancy is needed.
Collapse
Affiliation(s)
- Wendy N. Phoswa
- Department of Life and Consumer Sciences, University of South Africa (UNISA), Science Campus, Private Bag X6, Florida, Roodepoort 1710, South Africa
| | - Olive P. Khaliq
- Department of Obstetrics and Gynaecology and Women's Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
4
|
Shiqiao H, Bei X, Yini Z, Lei J. Risk factors of gestational diabetes mellitus during assisted reproductive technology procedures. Gynecol Endocrinol 2020; 36:318-321. [PMID: 31432718 DOI: 10.1080/09513590.2019.1648418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
To investigate risk factors of gestational diabetes mellitus (GDM) during assisted reproductive technology (ART) procedures. A total of 1022 patients were included in this retrospective cohort study from January 1, 2014 to August 31, 2017. While patients were divided into two groups: the non- GDM group and the GDM group. There was no significant difference in basal FSH, AFC, infertility years, gestational age, number of fetus, method of fertilization, and reason of infertility between the two groups. However, age, BMI, and fresh cycle were verified to be association with GDM by using logistic regression model. During the process of controlled ovarian hyperstimulation (COH), estradiol (E2) was significantly lower in the GDM group. The incidence of GDM was highest when E2 level less than 200 pg/mL of per oocyte. Our study showed maternal fundamental factors had greater impacts on subsequent GDM.
Collapse
Affiliation(s)
- Hu Shiqiao
- Reroductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Xu Bei
- Reroductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Zhang Yini
- Reroductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Jin Lei
- Reroductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| |
Collapse
|
5
|
Quaresima P, Visconti F, Chiefari E, Mirabelli M, Borelli M, Caroleo P, Foti D, Puccio L, Venturella R, Di Carlo C, Brunetti A. Appropriate Timing of Gestational Diabetes Mellitus Diagnosis in Medium- and Low-Risk Women: Effectiveness of the Italian NHS Recommendations in Preventing Fetal Macrosomia. J Diabetes Res 2020; 2020:5393952. [PMID: 33015192 PMCID: PMC7520011 DOI: 10.1155/2020/5393952] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Screening strategies for gestational diabetes mellitus (GDM) earlier than 24-28 weeks of gestation should be considered to prevent adverse pregnancy outcomes. Nonetheless, there is uncertainty about which women would benefit most from early screening and which screening strategies should be offered to women with GDM. The Italian National Healthcare Service (NHS) recommendations on selective screening for GDM at 16-18 weeks of gestation are effective in preventing fetal macrosomia in high-risk (HR) women, but the appropriateness of timing and effectiveness of these recommendations in medium- (MR) and low-risk (LR) women are still controversial. Patients and Methods. We retrospectively enrolled 769 consecutive singleton pregnant women who underwent both anomaly scan at 19-21 weeks of gestation and screening for GDM at 16-18 and/or 24-28 weeks of gestation, in agreement with the NHS recommendations and risk stratification criteria. Comparison of maternal characteristics, fetal biometric parameters at anomaly scan (head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), estimated fetal weight (EFW)), and neonatal birth weight (BW) percentile among risk groups was examined. RESULTS 219 (28.5%) women were diagnosed with GDM, while 550 (71.5%) were normal glucose-tolerant women. Out of 164 HR women, only 62 (37.8%) underwent the recommended early screening for GDM at 16-18 weeks of gestation. AC and EFW percentiles, as well as neonates' BW percentiles, were significantly higher in HR women diagnosed with GDM at 24-28 weeks of gestation with respect to normal glucose-tolerant women, as well as MR and LR women who tested positive for GDM. Comparative analysis between MR and LR women with GDM and women with normal glucose tolerance revealed significant differences in both AC and EFW percentiles (P < 0.05), while there was no significant difference in neonatal BW percentiles. CONCLUSION In MR and LR women with GDM, a mild acceleration of fetal growth can be detected at the time of anomaly scan. However, in these at-risk categories, the NHS recommendations for screening and treatment of GDM at 24-28 weeks of gestation are still effective in normalizing BW and preventing fetal macrosomia, thus supporting a risk factor-based selective screening program for GDM.
Collapse
Affiliation(s)
- Paola Quaresima
- Unit of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Federica Visconti
- Unit of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Eusebio Chiefari
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Massimo Borelli
- UMG School of PhD Programmes Life Sciences and Technologies, University “Magna Græcia” of Catanzaro, Italy
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Italy
| | - Patrizia Caroleo
- Complex Operative Structure Endocrinology-Diabetology, Hospital Pugliese-Ciaccio, Viale Pio X, 88100 Catanzaro, Italy
| | - Daniela Foti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Luigi Puccio
- Complex Operative Structure Endocrinology-Diabetology, Hospital Pugliese-Ciaccio, Viale Pio X, 88100 Catanzaro, Italy
| | - Roberta Venturella
- Unit of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Costantino Di Carlo
- Unit of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Antonio Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| |
Collapse
|
6
|
Lobo TF, Torloni MR, Mattar R, Nakamura MU, Alexandre SM, Daher S. Adipokine levels in overweight women with early-onset gestational diabetes mellitus. J Endocrinol Invest 2019; 42:149-156. [PMID: 29696612 DOI: 10.1007/s40618-018-0894-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 04/19/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE The study of adipokines in overweight women with early-onset (diagnosed before 20 weeks) gestational diabetes mellitus (GDM) could help to understand the ethiopathological mechanisms of this disorder. Our aim was to assess adipokine levels in overweight pregnant women with early-onset GDM compared to patients with standard-onset (diagnosed at 24-28 weeks) GDM and to glucose-tolerant women at the same gestational ages. METHODS This nested case-control study included 133 overweight pregnant women: 33 with early-onset (diagnosed < 20 weeks) GDM; 40 with standard-onset (diagnosed ≥ 24 weeks) GDM and 60 glucose-tolerant (normal oral glucose tolerance tests < 20 and ≥ 24 weeks). Adiponectin, leptin, resistin, visfatin and ghrelin serum levels were measured by ELISA. RESULTS Adiponectin serum levels were significantly lower in early-onset GDM women than in standard-onset GDM patients or controls matched for gestational age. Leptin serum levels were significantly higher in women with early-onset GDM than in controls. Women with early-onset GDM had lower adiponectin/leptin ratio than those with standard-onset GDM. There were no significant differences in resistin, ghrelin and visfatin serum levels among the participants. CONCLUSIONS Our results suggest that, compared to overweight glucose-tolerant women and patients with standard-onset GDM, overweight women with early-onset GDM have unbalanced adipokine levels, suggesting that they have a more inflammatory profile.
Collapse
Affiliation(s)
- T F Lobo
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - M R Torloni
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - R Mattar
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - M U Nakamura
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - S M Alexandre
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - S Daher
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, Brazil.
| |
Collapse
|
7
|
Tang XW, Qin QX. miR-335-5p induces insulin resistance and pancreatic islet β-cell secretion in gestational diabetes mellitus mice through VASH1-mediated TGF-β signaling pathway. J Cell Physiol 2018; 234:6654-6666. [PMID: 30341900 DOI: 10.1002/jcp.27406] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/21/2018] [Indexed: 12/25/2022]
Abstract
Multiple studies have reported different methods in treating gestational diabetes mellitus (GDM); however, the relationship between miR-335-5p and GDM still remains unclear. Here, this study explores the effect of miR-335-5p on insulin resistance and pancreatic islet β-cell secretion via activation of the TGFβ signaling pathway by downregulating VASH1 expression in GDM mice. The GDM mouse model was established and mainly treated with miR-335-5p mimic, miR-335-5p inhibitor, si-VASH1, and miR-335-5p inhibitor + si-VASH1. Oral glucose tolerance test (OGTT) was conducted to detect fasting blood glucose (FBG) fasting insulin (FINS). The OGTT was also used to calculate a homeostasis model assessment of insulin resistance (HOMA-IR). A hyperglycemic clamp was performed to measure the glucose infusion rate (GIR), which estimated β-cell function. Expressions of miR-335-5p, VASH1, TGF-β1, and c-Myc in pancreatic islet β-cells were determined by RT-qPCR, western blot analysis, and insulin release by ELISA. The miR-335-5p mimic and si-VASH1 groups showed elevated blood glucose levels, glucose area under the curve (GAUC), and HOMA-IR, but a reduced GIR and positive expression of VASH1. Overexpression of miR-335-5p and inhibition of VASH1 contributed to activated TGFβ1 pathway, higher c-Myc, and lower VASH1 expressions, in addition to downregulated insulin and insulin release levels. These findings provided evidence that miR-335-5p enhanced insulin resistance and suppressed pancreatic islet β-cell secretion by inhibiting VASH1, eventually activating the TGF-β pathway in GDM mice, which provides more clinical insight on the GDM treatment.
Collapse
Affiliation(s)
- Xu-Wen Tang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center Affiliated to, Guangzhou Medical University, Guangzhou, China
| | - Qing-Xin Qin
- Department of Endocrinology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
8
|
Guo W, Wang H, Liu Q, Yuan Y, Jing Y, Yang X. Analysis of the correlation of gestational diabetes mellitus and peripheral ferritin with iron levels in early pregnancy. MINERVA ENDOCRINOL 2018; 44:91-96. [PMID: 29442476 DOI: 10.23736/s0391-1977.18.02734-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to investigate the relationship of serum iron and ferritin concentrations in early pregnancy with gestational diabetes mellitus (GDM) complicated in pregnant metaphase through detecting the serum iron and ferritin concentrations in early pregnancy of normal pregnant women, so as to provide new ideas for the early detection and prevention of GDM. METHODS Spontaneously pregnant women with single fetus receiving prenatal routine examination in our hospital from December 2014 to October 2016 were selected. They were in good health before with normal fasting blood-glucose in early pregnancy without anemia during pregnancy and any medication history. The serum iron and ferritin concentrations were measured at 12 gestational weeks, the fasting blood-glucose was detected at 12 weeks of pregnancy, and 75g oral glucose tolerance test was performed at 24-26 weeks. According to the results of oral glucose tolerance test, the pregnant women were divided into GDM group (N.=52) and normal control group (N.=310). The detection results of pregnant women in the two groups were statistically analyzed. RESULTS The serum ferritin and iron levels at 12 gestational weeks in GDM group were higher than those in normal pregnancy group (P<0.05). The cut-off values of serum ferritin and iron at 12 gestational weeks in the prediction of GDM were 67.8 μg/L and 52.9 mmol/L. CONCLUSIONS The high concentrations of serum iron and ferritin in early pregnancy have a certain correlation with the incidence of GDM, and the early detection of serum iron and ferritin levels can improve the detection rate of GDM in pregnant metaphase.
Collapse
Affiliation(s)
- Wenchen Guo
- Department of Clinical Laboratory, People's Hospital of Weifang, Weifang, China
| | - Hongyan Wang
- Department of Obstetrics, People's Hospital of Zhangqiu Distric, Jinan, China
| | - Qi Liu
- Department of Endocrinology, People's Hospital of Zhangqiu Distric, Jinan, China
| | - Yuchao Yuan
- Department of Obstetrics and Gynecology, People's Hospital of Zhangqiu Distric, Jinan, China
| | - Yanyan Jing
- Department of Obstetrics, People's Hospital of Zhangqiu Distric, Jinan, China
| | - Xiaoju Yang
- Department of Obstetrics and Gynecology, East Hospital of Tongji University, Shanghai, China -
| |
Collapse
|
9
|
Immanuel J, Simmons D. Screening and Treatment for Early-Onset Gestational Diabetes Mellitus: a Systematic Review and Meta-analysis. Curr Diab Rep 2017; 17:115. [PMID: 28971305 DOI: 10.1007/s11892-017-0943-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We conducted a systematic review to evaluate the current evidence for screening and treatment for early-onset gestational diabetes mellitus (GDM) RECENT FINDINGS: Many of the women with early GDM in the first trimester do not have evidence of hyperglycemia at 24-28 weeks' gestation. A high proportion (15-70%) of women with GDM can be detected early in pregnancy depending on the setting, criteria used and screening strategy. However, there remains no good evidence for any of the diagnostic criteria for early-onset GDM. In a meta-analysis of 13 cohort studies, perinatal mortality (relative risk (RR) 3.58 [1.91, 6.71]), neonatal hypoglycemia (RR 1.61 [1.02, 2.55]), and insulin use (RR 1.71 [1.45, 2.03]) were greater among early-onset GDM women compared to late-onset GDM women, despite treatment. Considering the high likelihood of benefit from treatment, there is an urgent need for randomized controlled trials that investigate any benefits and possible harms of treatment of early-onset GDM.
Collapse
Affiliation(s)
- Jincy Immanuel
- School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown, NSW, 2751, Australia
| | - David Simmons
- School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown, NSW, 2751, Australia.
| |
Collapse
|