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Geryk M, Kucerova V, Velganova-Veghova M, Foltenova H, Bouchalova K, Karasek D, Radvansky M, Karaskova E. Association of selected adipokines with vitamin D deficiency in children with inflammatory bowel disease. BMC Pediatr 2024; 24:426. [PMID: 38961351 PMCID: PMC11223338 DOI: 10.1186/s12887-024-04890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 06/19/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Adipose tissue is significantly involved in inflammatory bowel disease (IBD). Vitamin D can affect both adipogenesis and inflammation. The aim of this study was to compare the production of selected adipokines, potentially involved in the pathogenesis of IBD - adiponectin, resistin, retinol binding protein 4 (RBP-4), adipocyte fatty acid binding protein and nesfatin-1 in children with IBD according to the presence of 25-hydroxyvitamin D (25(OH)D) deficiency. METHODS The study was conducted as a case-control study in pediatric patients with IBD and healthy children of the same sex and age. In addition to adipokines and 25(OH)D, anthropometric parameters, markers of inflammation and disease activity were assessed in all participants. RESULTS Children with IBD had significantly higher resistin levels regardless of 25(OH)D levels. IBD patients with 25(OH)D deficiency only had significantly lower RBP-4 compared to healthy controls and also compared to IBD patients without 25(OH)D deficiency. No other significant differences in adipokines were found in children with IBD with or without 25(OH)D deficiency. 25(OH)D levels in IBD patients corelated with RBP-4 only, and did not correlate with other adipokines. CONCLUSIONS Whether the lower RBP-4 levels in the 25(OH)D-deficient group of IBD patients directly reflect vitamin D deficiency remains uncertain. The production of other adipokines does not appear to be directly related to vitamin D deficiency.
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Affiliation(s)
- Milos Geryk
- Department of Pediatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry Palacky University Olomouc, Olomouc, Czech Republic
| | - Veronika Kucerova
- Department of Clinical Biochemistry, University Hospital Olomouc, Olomouc, Czech Republic
| | - Maria Velganova-Veghova
- Department of Pediatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry Palacky University Olomouc, Olomouc, Czech Republic
| | - Hana Foltenova
- Department of Pediatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry Palacky University Olomouc, Olomouc, Czech Republic
| | - Katerina Bouchalova
- Department of Pediatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry Palacky University Olomouc, Olomouc, Czech Republic
| | - David Karasek
- 3rd Department of Internal Medicine - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Martin Radvansky
- Department of Computer Science, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava - Poruba, Czech Republic
| | - Eva Karaskova
- Department of Pediatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry Palacky University Olomouc, Olomouc, Czech Republic.
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Vitamin D Deficiency Is Inversely Associated with Homeostatic Model Assessment of Insulin Resistance. Nutrients 2021; 13:nu13124358. [PMID: 34959910 PMCID: PMC8705502 DOI: 10.3390/nu13124358] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 01/08/2023] Open
Abstract
The study was conducted to comprehensively assess the association of the concentration of vitamin D in the blood and insulin resistance in non-diabetic subjects. The objective was to pool the results from all observational studies from the beginning of 1980 to August 2021. PubMed, Medline and Embase were systematically searched for the observational studies. Filters were used for more focused results. A total of 2248 articles were found after raw search which were narrowed down to 32 articles by the systematic selection of related articles. Homeostatic Model Assessment of Insulin Resistance (HOMAIR) was used as the measure of insulin resistance and correlation coefficient was used as a measure of the relationship between vitamin D levels and the insulin resistance. Risk of bias tables and summary plots were built using Revman software version 5.3 while Comprehensive meta-analysis version 3 was used for the construction of forest plot. The results showed an inverse association between the status of vitamin D and insulin resistance (r = -0.217; 95% CI = -0.161 to -0.272; p = 0.000). A supplement of vitamin D can help reduce the risk of insulin resistance; however further studies, like randomized controlled trials are needed to confirm the results.
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Rafiq S, Jeppesen PB. Insulin Resistance Is Inversely Associated with the Status of Vitamin D in Both Diabetic and Non-Diabetic Populations. Nutrients 2021; 13:1742. [PMID: 34063822 PMCID: PMC8224049 DOI: 10.3390/nu13061742] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
Vitamin D has been implicated in the regulation of glucose metabolism and insulin resistance. We designed this study to provide evidence that insulin resistance is dependent on the concentration of vitamin D in the body. Forty observational studies of both type 2 diabetes mellitus patients and healthy subjects were included in this meta-analysis. Related articles were searched from Embase, PubMed, and Medline through January 2021. Filters for search were used to obtain more focused results. We used Comprehensive Meta-Analysis Version 3 for the construction of forest plots. RevMan software version 5.3 was used to build the risk of bias tables and summary plots. The observational studies included in this systematic review and meta-analysis showed an inverse relationship of insulin resistance with the status of vitamin D both in non-diabetic (r = -0.188; 95% CI = -0.141 to -0.234; p = 0.000) and diabetic (r = -0.255; 95% CI = -0.392 to -0.107, p = 0.001) populations. From the meta-analysis we concluded that hypovitaminosis D is related to increased levels of insulin resistance in both type 2 diabetes patients and the healthy population all over the world.
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Affiliation(s)
- Shamaila Rafiq
- Department of Clinical Medicine, Aarhus University, Aarhus N, 8200 Aarhus, Denmark;
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Demirkol ME, Tamam L, Çakmak S, Yeşiloğlu C. Şizofreni tanılı hastalarda metabolik sendrom ve D vitamini düzeyleri ilişkisi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.569373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Makariou SE, Elisaf M, Challa A, Tellis CC, Tselepis AD, Liberopoulos EN. No effect of vitamin D administration plus dietary intervention on emerging cardiovascular risk factors in patients with metabolic syndrome. JOURNAL OF NUTRITION & INTERMEDIARY METABOLISM 2019. [DOI: 10.1016/j.jnim.2019.100093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Is the association between vitamin D, adiponectin, and insulin resistance present in normal weight or obese? A pilot study. CLINICAL NUTRITION EXPERIMENTAL 2019. [DOI: 10.1016/j.yclnex.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kocot J, Dziemidok P, Kiełczykowska M, Kurzepa J, Szcześniak G, Musik I. Is There Any Relationship between Plasma 25-Hydroxyvitamin D₃, Adipokine Profiles and Excessive Body Weight in Type 2 Diabetic Patients? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 15:E19. [PMID: 29295491 PMCID: PMC5800119 DOI: 10.3390/ijerph15010019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/17/2017] [Accepted: 12/20/2017] [Indexed: 12/16/2022]
Abstract
A growing interest in the role of vitamin D in metabolic diseases led us to study the relationships between 25-hydroxyvitamin D₃ (25(OH)D₃) and the profiles of selected adipokines in type 2 diabetic (T2DM) patients. The study comprised 92 type 2 diabetics divided into quartiles regarding 25(OH)D₃ concentration. Each group was divided into male and female subgroups. All the studied patients had their anthropometric and biochemical parameters determined. Plasma 25-hydroxyvitamin D₃ concentration was determined by HPLC, while the selected adipokines (leptin, adiponectin, resistin and visfatin) by ELISA methods. The ratio of leptin to adiponectin (L/A) was calculated for all the patients. In 85.3% of diabetics a full (<20 ng/mL) or moderate (20-30 ng/mL) vitamin D deficit was found. Irrespective of sex, plasma leptin concentration decreased across increasing quartiles of 25(OH)D₃ level. In women, 25(OH)D₃ was negatively correlated with BMI, leptin level as well as L/A ratio, and positively with adiponectin concentration. In men, 25(OH)D₃ was positively correlated with HDL and negatively with systolic blood pressure (SBP), leptin level and L/A ratio. Considering all the patients, there ocurred a significant negative correlation between 25(OH)D₃ and SBP, BMI, WHR, TG, leptin and L/A ratio and positive ones between 25(OH)D₃ and both adiponectin and HDL. The results of the study support the existence of the relationship among vitamin D, obesity and leptin in type 2 diabetic patients.
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Affiliation(s)
- Joanna Kocot
- Chair and Department of Medical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland; (M.K.); (J.K.); (I.M.)
| | - Piotr Dziemidok
- Diabetology Ward, Institute of Rural Health, Jaczewskiego 2, 20-090 Lublin, Poland; (P.D.); (G.S.)
- Institute of Public Health, Pope John Paul II State School of Higher Education, Sidorska 95/97, 21-500 Biała Podlaska, Poland
| | - Małgorzata Kiełczykowska
- Chair and Department of Medical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland; (M.K.); (J.K.); (I.M.)
| | - Jacek Kurzepa
- Chair and Department of Medical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland; (M.K.); (J.K.); (I.M.)
| | - Grzegorz Szcześniak
- Diabetology Ward, Institute of Rural Health, Jaczewskiego 2, 20-090 Lublin, Poland; (P.D.); (G.S.)
| | - Irena Musik
- Chair and Department of Medical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland; (M.K.); (J.K.); (I.M.)
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Rutkowski JM, Pastor J, Sun K, Park SK, Bobulescu IA, Chen CT, Moe OW, Scherer PE. Adiponectin alters renal calcium and phosphate excretion through regulation of klotho expression. Kidney Int 2017; 91:324-337. [PMID: 27914707 PMCID: PMC5237401 DOI: 10.1016/j.kint.2016.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 08/16/2016] [Accepted: 09/08/2016] [Indexed: 12/29/2022]
Abstract
The kidney controls systemic calcium and phosphate levels and disturbances of its control mechanisms can lead to a variety of diseases. The insulin-sensitizing adipokine adiponectin is renoprotective and accelerates functional recovery following renal injury. However, unlike other adipokines, adiponectin is reduced in obesity. High adiponectin levels are also correlated with bone loss, suggestive of an additional action in mineral metabolism. Using knockout, wild-type, and adiponectin-overexpressing transgenic mice, we sought to identify the mechanistic basis for adiponectin's ability to regulate calcium and phosphate balance at the level of the kidney. Adiponectin knockout mice exhibited lower serum calcium, lower urinary calcium excretion, and markedly lower serum fibroblast growth factor 23 (FGF23) levels, although circulating klotho concentrations were significantly higher than in wild-type littermates. The transgenic mice exhibited lower bone mass and strength, particularly compared to adiponectin knockout mice. The transgenic mice were hyper-responsive to a 2% phosphate-enriched diet, exhibiting 2-fold higher serum FGF23 and concomitantly higher fractional phosphate excretion. These mice also excreted more calcium with calcium-enriched diet and had less renal klotho protein expression. In contrast, the knockout mice exhibited a smaller increase in FGF23 and maintained elevated klotho levels on both mineral challenges. Kidney-specific adiponectin expression in doxycycline-inducible adiponectin mice and adiponectin addition in vitro confirmed adiponectin's ability to reduce tubular epithelial cell klotho secretion. Thus, adiponectin alters calcium and phosphate balance and renal mineral excretion, in part, through klotho. This work highlights the profound effects of adipose tissue on renal function and has identified a new mechanism by which adiponectin may regulate bone mass.
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Affiliation(s)
- Joseph M Rutkowski
- Touchstone Diabetes Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanne Pastor
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kai Sun
- Touchstone Diabetes Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sun K Park
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - I Alexandru Bobulescu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher T Chen
- The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orson W Moe
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Physiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philipp E Scherer
- Touchstone Diabetes Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Sharifi N, Amani R, Hajiani E, Cheraghian B. Women may respond different from men to vitamin D supplementation regarding cardiometabolic biomarkers. Exp Biol Med (Maywood) 2016; 241:830-8. [PMID: 26811103 DOI: 10.1177/1535370216629009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/28/2015] [Indexed: 01/10/2023] Open
Abstract
Evidence has revealed that vitamin D status is associated with the cardiometabolic risk factors. Moreover, few gender-specific analyses have been performed in the clinical trials regarding vitamin D supplementation. As a result, assessing gender differences regarding the effects of vitamin D supplementation on some cardiometabolic biomarkers in patients with non-alcoholic fatty liver disease (NAFLD) was the aim of present study. We conducted a post hoc subgroup analysis of a double blind placebo controlled study. Patients with NAFLD randomly allocated to receive one oral pearl consisting of 50,000 IU vitamin D3 (n = 27, 13 men and 14 women) or a placebo (n = 26, 13 men and 13 women) every 14 days for four months. Serum lipid profiles, aminotransferases, high-sensitive C-reactive protein (hs-CRP), adiponectin as well as insulin resistance and dietary intakes were assessed pre- and post-study. In both genders, serum 25(OH) D3 increased significantly (P < 0.001). This increase was accompanied by significant decrease in serum total cholesterol (TC) (% of change: -7% in vitamin D vs. + 0.4% in placebo, P = 0.04) and LDL-C (%of change: -9.6% in vitamin D vs. -4% in placebo, P = 0.006) in women. However, in men, vitamin D supplementation increased the levels of serum TC (% of change: +9.2% in vitamin D vs. -10% in placebo, P = 0.02) with no significant effects on LDL-C. Moreover, vitamin D significantly reduced serum hs-CRP in women. The median daily calcium intake in both genders was well below the dietary reference intake for adults. In conclusion, improved vitamin D status might decrease serum TC and LDL-C levels as well as hs-CRP in women with NAFLD. However, it might increase serum TC in men who have low daily calcium intake. Further studies with larger sample sizes are needed to confirm these results.
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Affiliation(s)
- Nasrin Sharifi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan 87159-88141, Iran Research Institute for Infectious Diseases of Digestive System, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Reza Amani
- Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Eskandar Hajiani
- Research Institute for Infectious Diseases of Digestive System, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Bahman Cheraghian
- Department of Epidemiology and Biostatistics, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
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Fisher L, Srikusalanukul W, Fisher A, Smith P. Liver function parameters in hip fracture patients: relations to age, adipokines, comorbidities and outcomes. Int J Med Sci 2015; 12:100-15. [PMID: 25589886 PMCID: PMC4293175 DOI: 10.7150/ijms.10696] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/11/2014] [Indexed: 02/07/2023] Open
Abstract
AIM To asses liver markers in older patients with hip fracture (HF) in relation to age, comorbidities, metabolic characteristics and short-term outcomes. METHODS In 294 patients with HF (mean age 82.0±7.9 years, 72.1% women) serum alanine aminotransferase (ALT), gammaglutamyltransferase (GGT), alkaline phosphatase (ALP), albumin, bilirubin, 25(OH)vitaminD, PTH, calcium, phosphate, magnesium, adiponectin, leptin, resistin, thyroid function and cardiac troponin I were measured. RESULTS Elevated ALT, GGT, ALP or bilirubin levels on admission were observed in 1.7%-9.9% of patients. With age GGT, ALT and leptin decrease, while PTH and adiponectin concentrations increase. Higher GGT (>30 U/L, median level) was associated with coronary artery disease (CAD), diabetes mellitus (DM), and alcohol overuse; lower ALT (≤20 U/L, median level) with dementia; total bilirubin>20 μmol/L with CAD and alcohol overuse; and albumin>33 g/L with CAD. Multivariate adjusted regression analyses revealed ALT, ALP, adiponectin, alcohol overuse and DM as independent and significant determinants of GGT (as continuous or categorical variable); GGT for each other liver marker; and PTH for adiponectin. The risk of prolonged hospital stay (>20 days) was about two times higher in patients with GGT>30 U/L or adiponectin>17.14 ng/L (median level) and 4.7 times higher if both conditions coexisted. The risk of in-hospital death was 3 times higher if albumin was <33 g/L. CONCLUSIONS In older HF patients liver markers even within the normal range are associated with age-related disorders and outcomes. Adiponectin (but not 25(OH)vitaminD, PTH, leptin or resistin) is an independent contributor to higher GGT. Serum GGT and albumin predict prolonged hospital stay and in-hospital death, respectively. A unifying hypothesis of the findings presented.
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Affiliation(s)
- Leon Fisher
- 1. Department of Gastroenterology, The Canberra Hospital, Canberra, ACT, Australia
| | - Wichat Srikusalanukul
- 2. Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia
| | - Alexander Fisher
- 2. Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia ; 4. Australian National University Medical School, Canberra, ACT, Australia
| | - Paul Smith
- 3. Department of Orthopaedic Surgery, The Canberra Hospital, Canberra, ACT, Australia ; 4. Australian National University Medical School, Canberra, ACT, Australia
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Gandhe MB, Jain K, Gandhe SM. Evaluation of 25(OH) Vitamin D3 with Reference to Magnesium Status and Insulin Resistance in T2DM. J Clin Diagn Res 2013; 7:2438-41. [PMID: 24392366 DOI: 10.7860/jcdr/2013/6578.3568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/03/2013] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Calcium is a recognized second messenger implicated in insulin secretion. Vitamin D (1,25-dihydroxycholecalciferol, Calcitriol) plays a role in calcium metabolism. This explains the indirect role of Vitamin D in insulin secretion and insulin sensitivity. Hence, low Vitamin D levels are implicated in decreased insulin secretion and increased insulin resistance. In this study, we tried to find out the probable association of Vitamin D3, calcium and magnesium with reference to insulin resistance in type 2 diabetes mellitus (T2DM) cases. It is well documented that measurement of circulating 25-Hydroxycholecalciferol {25 (OH)Vitamin D3} is a marker of total Vitamin D status. METHODOLOGY We measured 25(OH) Vitamin D3 levels in thirty T2DM subjects with thirty age and sex matched healthy controls. We estimated Vitamin D status, calcium and magnesium levels in the light of insulin resistance. Insulin resistance was measured by homeostasis model assessment of insulin resistance (HOMA-IR). RESULTS Twenty five (OH) Vitamin-D3 level was significantly low among T2DM cases (12.29+2.32ng/ml) in comparison to healthy controls (19.55+0.50ng/ml) (p<0.01). The levels of calcium and magnesium were also significantly low in T2DM cases as compared to healthy controls (p<0.01). There was significant negative correlation between Vitamin D status and insulin levels, and insulin resistance (p<0.01). IMPLICATION A significant negative correlation between Vitamin D status and insulin levels suggest that the supplementation of Vitamin D has the potential to increase insulin sensitivity and lower the risk of developing type 2 diabetes mellitus.
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Affiliation(s)
- Mahendra Bhauraoji Gandhe
- Assistant Professor, Department of Biochemistry, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - Keerthi Jain
- Intern, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
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