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Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Vojdani A, Maes M. Increased IgA-mediated responses to the gut paracellular pathway and blood-brain barrier proteins predict delirium due to hip fracture in older adults. Front Neurol 2024; 15:1294689. [PMID: 38379706 PMCID: PMC10876854 DOI: 10.3389/fneur.2024.1294689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Delirium is accompanied by immune response system activation, which may, in theory, cause a breakdown of the gut barrier and blood-brain barrier (BBB). Some results suggest that the BBB is compromised in delirium, but there is no data regarding the gut barrier. This study investigates whether delirium is associated with impaired BBB and gut barriers in elderly adults undergoing hip fracture surgery. Methods We recruited 59 older adults and measured peak Delirium Rating Scale (DRS) scores 2-3 days after surgery, and assessed plasma IgG/IgA levels (using ELISA techniques) for zonulin, occludin, claudin-6, β-catenin, actin (indicating damage to the gut paracellular pathway), claudin-5 and S100B (reflecting BBB damage), bacterial cytolethal distending toxin (CDT), LPS-binding protein (LBP), lipopolysaccharides (LPS), Porphyromonas gingivalis, and Helicobacter pylori. Results Results from univariate analyses showed that delirium is linked to increased IgA responses to all the self-epitopes and antigens listed above, except for LPS. Part of the variance (between 45-48.3%) in the peak DRS score measured 2-3 days post-surgery was explained by independent effects of IgA directed to LPS and LBP (or bacterial CDT), baseline DRS scores, and previous mild stroke. Increased IgA reactivity to the paracellular pathway and BBB proteins and bacterial antigens is significantly associated with the activation of M1 macrophage, T helper-1, and 17 cytokine profiles. Conclusion Heightened bacterial translocation, disruption of the tight and adherens junctions of the gut and BBB barriers, elevated CDT and LPS load in the bloodstream, and aberrations in cell-cell interactions may be risk factors for delirium.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aristo Vojdani
- Immunosciences Lab Inc., Los Angeles, CA, United States
- Cyrex Labs LLC, Phoenix, AZ, United States
| | - Michael Maes
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
- Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria
- Research Institute, Medical University of Plovdiv, Plovdiv, Bulgaria
- Kyung Hee University, Seoul, Republic of Korea
- Cognitive Impairment and Dementia Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Shu LZ, Ding YD, Xue QM, Cai W, Deng H. Direct and indirect effects of pathogenic bacteria on the integrity of intestinal barrier. Therap Adv Gastroenterol 2023; 16:17562848231176427. [PMID: 37274298 PMCID: PMC10233627 DOI: 10.1177/17562848231176427] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/01/2023] [Indexed: 06/06/2023] Open
Abstract
Bacterial translocation is a pathological process involving migration of pathogenic bacteria across the intestinal barrier to enter the systemic circulation and gain access to distant organs. This phenomenon has been linked to a diverse range of diseases including inflammatory bowel disease, pancreatitis, and cancer. The intestinal barrier is an innate structure that maintains intestinal homeostasis. Pathogenic infections and dysbiosis can disrupt the integrity of the intestinal barrier, increasing its permeability, and thereby facilitating pathogen translocation. As translocation represents an essential step in pathogenesis, a clear understanding of how barrier integrity is disrupted and how this disruption facilitates bacterial translocation could identify new routes to effective prophylaxis and therapy. In this comprehensive review, we provide an in-depth analysis of bacterial translocation and intestinal barrier function. We discuss currently understood mechanisms of bacterial-enterocyte interactions, with a focus on tight junctions and endocytosis. We also discuss the emerging concept of bidirectional communication between the intestinal microbiota and other body systems. The intestinal tract has established 'axes' with various organs. Among our regulatory systems, the nervous, immune, and endocrine systems have been shown to play pivotal roles in barrier regulation. A mechanistic understanding of intestinal barrier regulation is crucial for the development of personalized management strategies for patients with bacterial translocation-related disorders. Advancing our knowledge of barrier regulation will pave the way for future research in this field and novel clinical intervention strategies.
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Affiliation(s)
- Lin-Zhen Shu
- Medical College, Nanchang University, Nanchang,
Jiangxi Province, China
| | - Yi-Dan Ding
- Medical College, Nanchang University, Nanchang,
Jiangxi Province, China
| | - Qing-Ming Xue
- Medical College, Nanchang University, Nanchang,
Jiangxi Province, China
| | - Wei Cai
- Medical College, Nanchang University, Nanchang,
Jiangxi Province, China
- Department of Pathology, the Fourth Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Huan Deng
- Department of Pathology, The Fourth Affiliated
Hospital of Nanchang University, No. 133 South Guangchang Road, Nanchang
330003, Jiangxi Province, China
- Tumor Immunology Institute, Nanchang
University, Nanchang, China
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Cui S, Li J, Liu Y, Yao G, Wu Y, Liu Z, Sun L, Sun L, Liu H. Correlation of systemic immune-inflammation index and moderate/major depression in patients with depressive disorders: a large sample cross-sectional study. Front Psychiatry 2023; 14:1159889. [PMID: 37275977 PMCID: PMC10232846 DOI: 10.3389/fpsyt.2023.1159889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/02/2023] [Indexed: 06/07/2023] Open
Abstract
Objective To evaluate the clinical value of systemic immune-inflammation index (SII) based on peripheral blood neutrophil, lymphocyte, and platelet count in evaluating the subtype and severity of depression in patients with depressive disorder. Methods This retrospective cohort study was conducted in the Third People's Hospital of Fuyang City from January 1, 2020 to December 31, 2022. The data included sociodemographic information at admission, clinical data, discharge diagnosis and inflammatory markers. Patients were divided into low SII group and high SII group according to the optimal threshold of SII determined by receiver operating characteristic curve (ROC curve). Binary logistic regression was used to analyze the correlation between moderate/major depression and SII level. Results Compared to the low SII group, the high SII group had a higher age level (χ2 = 7.663, p = 0.006), more smokers (χ2 = 9.458, p = 0.002), more moderate/major depression patients (χ2 = 45.645, p < 0.001), and a higher proportion of patients with accompanying somatic symptoms (χ2 = 14.867, p < 0.001). In the final logistic regression model, after controlling for confounding factors, SII at admission was significantly associated with moderate/major depression [β =1.285, p < 0.001; odds ratio (95% confidence intervals) = 3.614 (2.693-4.850)]. Patients with high SII scores were 3.614 times more likely to have moderate/severe depression than those with low SII scores. We propose a cut-off value of SII =540.78 (sensitivity = 36.4% and specificity = 80.3%) according to the maximum Youden index. Conclusion Our research indicates that SII may be a useful, repeatable, convenient, and affordable index to identify moderate/major depression in depressive disorder.
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Affiliation(s)
- Shu Cui
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Juanjuan Li
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Yun Liu
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Gaofeng Yao
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Yanhai Wu
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Zhiwei Liu
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
| | - Liang Sun
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
- Department of Psychiatry, Chaohu Hospital Affiliated to Anhui Medical University, Hefei, Anhui, China
| | - Longlong Sun
- Department of Psychiatry, Third People’s Hospital of Fuyang, Fuyang, Anhui, China
- Department of Psychiatry, Chaohu Hospital Affiliated to Anhui Medical University, Hefei, Anhui, China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital Affiliated to Anhui Medical University, Hefei, Anhui, China
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui, China
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Maes M, Vasupanrajit A, Jirakran K, Klomkliew P, Chanchaem P, Tunvirachaisakul C, Payungporn S. Exploration of the Gut Microbiome in Thai Patients with Major Depressive Disorder Shows a Specific Bacterial Profile with Depletion of the Ruminococcus Genus as a Putative Biomarker. Cells 2023; 12:cells12091240. [PMID: 37174640 PMCID: PMC10177051 DOI: 10.3390/cells12091240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
Maes et al. (2008) published the first paper demonstrating that major depressive disorder (MDD) is accompanied by abnormalities in the microbiota-gut-brain axis, as evidenced by elevated serum IgM/IgA to lipopolysaccharides (LPS) of Gram-negative bacteria, such as Morganella morganii and Klebsiella Pneumoniae. The latter aberrations, which point to increased gut permeability (leaky gut), are linked to activated neuro-immune and oxidative pathways in MDD. To delineate the profile and composition of the gut microbiome in Thai patients with MDD, we examined fecal samples of 32 MDD patients and 37 controls using 16S rDNA sequencing, analyzed α- (Chao1 and Shannon indices) and β-diversity (Bray-Curtis dissimilarity), and conducted linear discriminant analysis (LDA) effect size (LEfSe) analysis. Neither α- nor β-diversity differed significantly between MDD and controls. Rhodospirillaceae, Hungatella, Clostridium bolteae, Hungatella hathewayi, and Clostridium propionicum were significantly enriched in MDD, while Gracillibacteraceae family, Lutispora, and Ruminococcus genus, Ruminococcus callidus, Desulfovibrio piger, Coprococcus comes, and Gemmiger were enriched in controls. Contradictory results have been reported for all these taxa, with the exception of Ruminococcus, which is depleted in six different MDD studies (one study showed increased abundance), many medical disorders that show comorbidities with MDD, and animal MDD models. Our results may suggest a specific profile of compositional gut dysbiosis in Thai MDD patients, with increases in some pathobionts and depletion of some beneficial microbiota. The results suggest that depletion of Ruminococcus may be a more universal biomarker of MDD that may contribute to increased enteral LPS load, LPS translocation, and gut-brain axis abnormalities.
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Affiliation(s)
- Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
- Department of Psychiatry, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
- Research Institute, Medical University Plovdiv, 4002 Plovdiv, Bulgaria
- Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea
| | - Asara Vasupanrajit
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Ketsupar Jirakran
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
- Maximizing Thai Children's Developmental Potential Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Pavit Klomkliew
- Center of Excellence in Systems Microbiology, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Prangwalai Chanchaem
- Center of Excellence in Systems Microbiology, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Chavit Tunvirachaisakul
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Sunchai Payungporn
- Center of Excellence in Systems Microbiology, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Ji N, Lei M, Chen Y, Tian S, Li C, Zhang B. How Oxidative Stress Induces Depression? ASN Neuro 2023; 15:17590914231181037. [PMID: 37331994 DOI: 10.1177/17590914231181037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
Depression increasingly affects a wide range and a large number of people worldwide, both physically and psychologically, which makes it a social problem requiring prompt attention and management. Accumulating clinical and animal studies have provided us with substantial insights of disease pathogenesis, especially central monoamine deficiency, which considerably promotes antidepressant research and clinical treatment. The first-line antidepressants mainly target the monoamine system, whose drawbacks mainly include slow action and treatment resistant. The novel antidepressant esketamine, targeting on central glutamatergic system, rapidly and robustly alleviates depression (including treatment-resistant depression), whose efficiency is shadowed by potential addictive and psychotomimetic side effects. Thus, exploring novel depression pathogenesis is necessary, for seeking more safe and effective therapeutic methods. Emerging evidence has revealed vital involvement of oxidative stress (OS) in depression, which inspires us to pursue antioxidant pathway for depression prevention and treatment. Fully uncovering the underlying mechanisms of OS-induced depression is the first step towards the avenue, thus we summarize and expound possible downstream pathways of OS, including mitochondrial impairment and related ATP deficiency, neuroinflammation, central glutamate excitotoxicity, brain-derived neurotrophic factor/tyrosine receptor kinase B dysfunction and serotonin deficiency, the microbiota-gut-brain axis disturbance and hypothalamic-pituitary-adrenocortical axis dysregulation. We also elaborate on the intricate interactions between the multiple aspects, and molecular mechanisms mediating the interplay. Through reviewing the related research progress in the field, we hope to depict an integral overview of how OS induces depression, in order to provide fresh ideas and novel targets for the final goal of efficient treatment of the disease.
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Affiliation(s)
- Na Ji
- The School of Public Health, Faculty of Basic Medical Sciences, Guangxi Key Laboratory of Brain and Cognitive Neuroscience, Guilin Medical University, Guilin Guangxi, China
| | - Mengzhu Lei
- The School of Public Health, Faculty of Basic Medical Sciences, Guangxi Key Laboratory of Brain and Cognitive Neuroscience, Guilin Medical University, Guilin Guangxi, China
| | - Yating Chen
- The School of Public Health, Faculty of Basic Medical Sciences, Guangxi Key Laboratory of Brain and Cognitive Neuroscience, Guilin Medical University, Guilin Guangxi, China
| | - Shaowen Tian
- The School of Public Health, Faculty of Basic Medical Sciences, Guangxi Key Laboratory of Brain and Cognitive Neuroscience, Guilin Medical University, Guilin Guangxi, China
| | - Chuanyu Li
- The School of Public Health, Faculty of Basic Medical Sciences, Guilin Medical University, Guilin Guangxi, China
| | - Bo Zhang
- The School of Public Health, Faculty of Basic Medical Sciences, Guangxi Key Laboratory of Brain and Cognitive Neuroscience, Guilin Medical University, Guilin Guangxi, China
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Yoshikawa S, Taniguchi K, Sawamura H, Ikeda Y, Tsuji A, Matsuda S. A New Concept of Associations between Gut Microbiota, Immunity and Central Nervous System for the Innovative Treatment of Neurodegenerative Disorders. Metabolites 2022; 12:1052. [PMID: 36355135 PMCID: PMC9692629 DOI: 10.3390/metabo12111052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/20/2022] [Accepted: 10/31/2022] [Indexed: 07/30/2023] Open
Abstract
Nerve cell death accounts for various neurodegenerative disorders, in which altered immunity to the integrated central nervous system (CNS) might have destructive consequences. This undesirable immune response often affects the progressive neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, schizophrenia and/or amyotrophic lateral sclerosis (ALS). It has been shown that commensal gut microbiota could influence the brain and/or several machineries of immune function. In other words, neurodegenerative disorders may be connected to the gut-brain-immune correlational system. The engrams in the brain could retain the information of a certain inflammation in the body which might be involved in the pathogenesis of neurodegenerative disorders. Tactics involving the use of probiotics and/or fecal microbiota transplantation (FMT) are now evolving as the most promising and/or valuable for the modification of the gut-brain-immune axis. More deliberation of this concept and the roles of gut microbiota would lead to the development of stupendous treatments for the prevention of, and/or therapeutics for, various intractable diseases including several neurodegenerative disorders.
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Monoamine Neurotransmitters Control Basic Emotions and Affect Major Depressive Disorders. Pharmaceuticals (Basel) 2022; 15:ph15101203. [PMID: 36297314 PMCID: PMC9611768 DOI: 10.3390/ph15101203] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Major depressive disorder (MDD) is a common and complex mental disorder, that adversely impacts an individual’s quality of life, but its diagnosis and treatment are not accurately executed and a symptom-based approach is utilized in most cases, due to the lack of precise knowledge regarding the pathophysiology. So far, the first-line treatments are still based on monoamine neurotransmitters. Even though there is a lot of progress in this field, the mechanisms seem to get more and more confusing, and the treatment is also getting more and more controversial. In this study, we try to review the broad advances of monoamine neurotransmitters in the field of MDD, and update its effects in many advanced neuroscience studies. We still propose the monoamine hypothesis but paid special attention to their effects on the new pathways for MDD, such as inflammation, oxidative stress, neurotrophins, and neurogenesis, especially in the glial cells, which have recently been found to play an important role in many neurodegenerative disorders, including MDD. In addition, we will extend the monoamine hypothesis to basic emotions; as suggested in our previous reports, the three monoamine neurotransmitters play different roles in emotions: dopamine—joy, norepinephrine—fear (anger), serotonins—disgust (sadness). Above all, this paper tries to give a full picture of the relationship between the MDD and the monoamine neurotransmitters such as DA, NE, and 5-HT, as well as their contributions to the Three Primary Color Model of Basic Emotions (joy, fear, and disgust). This is done by explaining the contribution of the monoamine from many sides for MDD, such the digestive tract, astrocytes, microglial, and others, and very briefly addressing the potential of monoamine neurotransmitters as a therapeutic approach for MDD patients and also the reasons for its limited clinical efficacy, side effects, and delayed onset of action. We hope this review might offer new pharmacological management of MDD.
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Maes MHJ, Stoyanov D. False dogmas in mood disorders research: Towards a nomothetic network approach. World J Psychiatry 2022; 12:651-667. [PMID: 35663296 PMCID: PMC9150032 DOI: 10.5498/wjp.v12.i5.651] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/07/2021] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
The current understanding of major depressive disorder (MDD) and bipolar disorder (BD) is plagued by a cacophony of controversies as evidenced by competing schools to understand MDD/BD. The DSM/ICD taxonomies have cemented their status as the gold standard for diagnosing MDD/BD. The aim of this review is to discuss the false dogmas that reign in current MDD/BD research with respect to the new, data-driven, machine learning method to model psychiatric illness, namely nomothetic network psychiatry (NNP). This review discusses many false dogmas including: MDD/BD are mind-brain disorders that are best conceptualized using a bio-psycho-social model or mind-brain interactions; mood disorders due to medical disease are attributable to psychosocial stress or chemical imbalances; DSM/ICD are the gold standards to make the MDD/BD diagnosis; severity of illness should be measured using rating scales; clinical remission should be defined using threshold values on rating scale scores; existing diagnostic BD boundaries are too restrictive; and mood disorder spectra are the rule. In contrast, our NNP models show that MDD/BD are not mind-brain or psycho-social but systemic medical disorders; the DSM/ICD taxonomies are counterproductive; a shared core, namely the reoccurrence of illness (ROI), underpins the intertwined recurrence of depressive and manic episodes and suicidal behaviors; mood disorders should be ROI-defined; ROI mediates the effects of nitro-oxidative stress pathways and early lifetime trauma on the phenome of mood disorders; severity of illness and treatment response should be delineated using the NNP-derived causome, pathway, ROI and integrated phenome scores; and MDD and BD are the same illness.
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Affiliation(s)
- Michael HJ Maes
- Department of Psychiatry, Chulalongkorn University, Bangkok 10330, Thailand
| | - Drozdstoy Stoyanov
- Department of Psychiatry, Medical University Plovdiv, Plovdiv 4000, Bulgaria
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Abstract
Curcumin is the major biologically active polyphenolic constituent in the turmeric plant (Curcuma longa) that has been shown to have antioxidant, anti-inflammatory, neuroprotective, anticancer, antimicrobial, and cardioprotective effects. Interest in curcumin as a treatment for mental health conditions has increased and there is an expanding body of preclinical and clinical research examining its antidepressant and anxiolytic effects. In this narrative review, human trials investigating the effects of curcumin for the treatment of depression or depressive symptoms are summarised. Using findings from in vitro, animal, and human trials, possible biological mechanisms associated with the antidepressant effects of curcumin are also explored. To increase the understanding of curcumin for the treatment of depression, directions for future research are proposed.
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Affiliation(s)
- Adrian L Lopresti
- Clinical Research Australia, 38 Arnisdale Rd, Duncraig, Perth, WA, 6023, Australia.
- College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, 6150, Australia.
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