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Sharma A, Khurana P, Venkatraman A, Gupta M. Subsume Pediatric Headaches in Psychiatric Disorders? Critiques on Delphic Nosology, Diagnostic Conundrums, and Variability in the Interventions. Curr Pain Headache Rep 2024:10.1007/s11916-024-01225-7. [PMID: 38367199 DOI: 10.1007/s11916-024-01225-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE OF REVIEW Tension-type headache (TTH) continues to be the most prevalent type of headache across all age groups worldwide, and the global burden of migraine and TTH together account for 7% of all-cause years lived with disability (YLDs). TTH has been shown to have a prevalence of up to 80% in several studies and presents a wide range and high variability in clinical settings. The aim of this review is to identify gaps in diagnostics, nosology, and variability in the treatment of children and adolescents who present with headaches without an identifiable etiology. RECENT FINDINGS Migraine and TTH have been debated to have more similarities than distinctions, increasing chances of misdiagnosis and leading to significant cases diagnosed as probable TTH or probable migraine. The lack of specificity and sensitivity for TTH classification often leads to the diagnosis being made by negating associated migraine symptoms. Although pathology is not well understood, some studies have suggested a neurological basis for TTH, in need of further validation. Some research indicates that nitric oxide signaling plays an integral part in the pain mechanisms related to TTH. Analgesics and non-steroidal anti-inflammatories are usually the first lines of treatment for children with recurring headaches, and additional treatment options include medication and behavioral therapies. With high prevalence and socioeconomic burden among children and adolescents, it's essential to further study Tension-type headaches and secondary headaches without known cause and potential interventions. Treatment studies involving randomized controlled trials are also needed to test the efficacy of various treatments further.
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Affiliation(s)
- Aditya Sharma
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Priyal Khurana
- Department of Psychology, Christ University, Delhi, NCR, India
| | - Akila Venkatraman
- Department of Pediatric Neurology, Geisinger Health System, Danville, PA, USA
| | - Mayank Gupta
- Southwood Psychiatric Hospital, Pittsburgh, PA, USA.
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Onofri A, Pensato U, Rosignoli C, Wells-Gatnik W, Stanyer E, Ornello R, Chen HZ, De Santis F, Torrente A, Mikulenka P, Monte G, Marschollek K, Waliszewska-Prosół M, Wiels W, Boucherie DM, Onan D, Farham F, Al-Hassany L, Sacco S. Primary headache epidemiology in children and adolescents: a systematic review and meta-analysis. J Headache Pain 2023; 24:8. [PMID: 36782182 PMCID: PMC9926688 DOI: 10.1186/s10194-023-01541-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
INTRODUCTION Headache is the most prevalent neurological manifestation in adults and one of the leading causes of disability worldwide. In children and adolescents, headaches are arguably responsible for a remarkable impact on physical and psychological issues, yet high-quality evidence is scarce. MATERIAL AND METHODS We searched cross-sectional and cohort studies in Embase, Medline, Web of Science, and Cochrane databases from January 1988 to June 2022 to identify the prevalence of headaches in 8-18 years old individuals. The risk of bias was examined with the Joanna Briggs Institute (JBI) scale. A random-effects model was used to estimate the pooled prevalence of pediatric headache. Subgroup analyses based on headache subtypes were also conducted. RESULTS Out of 5,486 papers retrieved electronically, we identified 48 studies that fulfilled our inclusion criteria. The pooled prevalence of primary headaches was 11% for migraine overall [95%CI: 9-14%], 8% for migraine without aura (MwoA) [95%CI: 5-12%], 3% for migraine with aura (MwA) [95%CI:2-4%] and 17% for tension-type headache (TTH) [95% CI: 12-23%]. The pooled prevalence of overall primary headache in children and adolescents was 62% [95% CI: 53-70%], with prevalence in females and males of 38% [95% CI: 16-66%] and 27% [95% CI: 11-53%] respectively. After the removal of studies ranked as low-quality according to the JBI scale, prevalence rates were not substantially different. Epidemiological data on less common primary headaches, such as trigeminal autonomic cephalalgias, were lacking. CONCLUSION We found an overall remarkably high prevalence of primary headaches in children and adolescents, even if flawed by a high degree of heterogeneity. Further up-to-date studies are warranted to complete the picture of pediatric headache-related burden to enhance specific public interventions.
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Affiliation(s)
- Agnese Onofri
- grid.158820.60000 0004 1757 2611Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Umberto Pensato
- grid.417728.f0000 0004 1756 8807Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy ,grid.452490.eHumanitas University, Pieve Emanuele, Milan, Italy
| | - Chiara Rosignoli
- grid.158820.60000 0004 1757 2611Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - William Wells-Gatnik
- grid.7841.aDepartment of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Emily Stanyer
- grid.13097.3c0000 0001 2322 6764Wolfson Centre for Age Related Diseases, King’s College London, London, UK
| | - Raffaele Ornello
- grid.158820.60000 0004 1757 2611Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Hui Zhou Chen
- grid.13097.3c0000 0001 2322 6764Wolfson Centre for Age Related Diseases, King’s College London, London, UK
| | - Federico De Santis
- grid.158820.60000 0004 1757 2611Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Angelo Torrente
- grid.10776.370000 0004 1762 5517Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Petr Mikulenka
- grid.412819.70000 0004 0611 1895Department of Neurology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Gabriele Monte
- grid.414125.70000 0001 0727 6809Department of Neuroscience, Neurology Unit, Bambino Gesù Children’s Hospital, Istituto Di Ricovero E Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Karol Marschollek
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wroclaw, Poland
| | - Marta Waliszewska-Prosół
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wroclaw, Poland
| | - Wietse Wiels
- grid.8767.e0000 0001 2290 8069Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Deirdre M. Boucherie
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Dilara Onan
- grid.14442.370000 0001 2342 7339Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Fatemeh Farham
- grid.411705.60000 0001 0166 0922Department of Headache, Iranian Center of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Linda Al-Hassany
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L'Aquila, L'Aquila, Italy.
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Kaltseis K, Frank F, Bernar B, Kiechl S, Winder B, Kiechl-Kohlendorfer U, Knoflach M, Broessner G. Primary headache disorders in adolescents in North- and South-Tyrol: Findings of the EVA-Tyrol-Study. Cephalalgia 2022; 42:993-1004. [PMID: 35331020 PMCID: PMC9442274 DOI: 10.1177/03331024221088997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assessment of the prevalence of primary headache disorders, associated risk factors and use of acute/preventive medication in a representative large sample of adolescents. METHODS Within the EVA-Tyrol project, a community-based non-randomized controlled cross-sectional study, data was collected from adolescents aged 14-19 years from 45 sites across North-, East- and South Tyrol. Headaches were classified according to the latest ICHD-3 and assessed by headache specialists in face-to-face interviews. FINDINGS Of 1923 participants 930 (48.4%) reported having headaches. Female to male ratio was 2:1. Migraine, tension-type headache and other headache were diagnosed in 10%, 30.2% and 8.2% respectively. Medication overuse was diagnosed in 3.4%, increasing up to 21.7% in participants with chronic headache. The use of preventative medication was not reported by any adolescent. Sleep disturbances (p < 0.05), alcohol consumption (p < 0.05), low physical activity (p < 0.01) and high screen time exposure (p < 0.01) were associated with an increased risk of headaches. CONCLUSION We report high prevalence of primary headache disorders and medication overuse in a large community-based sample of teenagers. Acute and preventive non-drug and pharmacological treatments are not established due to lack of paediatric headache outpatient clinics. Promoting health education in teenagers and encouraging public awareness, including that of health care providers is pivotal.Trial registration: EVA-Tyrol has been retrospectively registered at clinicaltrials.gov under https://clinicaltrials.gov/ct2/show/NCT03929692 since April 29, 2019.
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Affiliation(s)
- Katharina Kaltseis
- Department of Neurology, Medical University of Innsbruck,
Innsbruck, Austria
| | - Florian Frank
- Department of Neurology, Medical University of Innsbruck,
Innsbruck, Austria
| | - Benoît Bernar
- Department of Paediatrics I, Medical University of Innsbruck,
Innsbruck, Austria
| | - Sophia Kiechl
- Department of Neurology, Medical University of Innsbruck,
Innsbruck, Austria,VASCage, Research Centre on Vascular Ageing and Stroke,
Innsbruck, Austria
| | - Bernhard Winder
- VASCage, Research Centre on Vascular Ageing and Stroke,
Innsbruck, Austria,Department of Paediatrics II, Medical University of Innsbruck,
Innsbruck, Austria
| | - Ursula Kiechl-Kohlendorfer
- VASCage, Research Centre on Vascular Ageing and Stroke,
Innsbruck, Austria,Department of Paediatrics II, Medical University of Innsbruck,
Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck,
Innsbruck, Austria,VASCage, Research Centre on Vascular Ageing and Stroke,
Innsbruck, Austria
| | - Gregor Broessner
- Department of Neurology, Medical University of Innsbruck,
Innsbruck, Austria,Gregor Broessner, Department of Neurology,
Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Arruda MA, Arruda R, Landeira-Fernandez J, Anunciação L, Bigal ME. Resilience and vulnerability in adolescents with primary headaches: A cross-sectional population-based study. Headache 2021; 61:546-557. [PMID: 33720394 DOI: 10.1111/head.14078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND A scarcity of studies on the role of resilience resources (RRs) and vulnerability risk (VR) in children and adolescents with primary headache hampers the development of a risk-resilience model for pediatric headaches. OBJECTIVE To examine the extent to which headache frequency and diagnosis are associated with RRs and VR and explore possible predictors of low RRs and high VR in a cross-sectional population-based study in adolescents. METHODS This is a cross-sectional population study conducted in a small city in Brazil (Delfinópolis). Consents and analyzable data were obtained from 339/378 adolescents (89.7%). RRs and VR were assessed using the validated Brazilian version of the Resiliency Scales for Children and Adolescents, completed by the adolescents. Parents filled a structured questionnaire assessing sociodemographic and headache characteristics, as well as the Brazilian-validated version of the Strengths and Difficulties Questionnaire added to the impact supplement to evaluate the adolescent's psychosocial adjustment skills. Teachers completed a structured questionnaire about the students' school performance. RESULTS A higher frequency of headache was associated with lower RRs (F3,335 = 2.99, p = 0.031) and higher VR (F3,335 = 4.05, p = 0.007). Headache diagnosis did not significantly influence the risk of having lower RRs or higher VR. In the exploratory analyses, females (OR 3.07; 95% CI: 1.16-9.3) and individuals with psychosocial adjustment problems (OR 7.5; 95% CI: 2.51-22.4) were predictors of low RRs, and prenatal exposure to tobacco (OR 5.6; 95% CI: 1.57-20.9) was a predictor of high VR in adolescents with primary headache. CONCLUSIONS The risk of low RRs and high VR was associated with a higher headache frequency, but not with headache diagnosis. These findings may contribute to the development of a risk-resilience model of headaches in the pediatric population and help identify novel targets and develop effective resources for successful interventions.
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Affiliation(s)
| | - Renato Arruda
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - J Landeira-Fernandez
- Department of Psychology, Pontifical Catholic University, Rio de Janeiro, Brazil
| | - Luis Anunciação
- Department of Psychology, Pontifical Catholic University, Rio de Janeiro, Brazil
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Miller VE, Faurot KR, Palssson OS, MacIntosh BA, Suchindran C, Honvoh G, Gaylord S, Ramsden CE, Mann JD. Comparing prospective headache diary and retrospective four-week headache questionnaire over 20 weeks: Secondary data analysis from a randomized controlled trial. Cephalalgia 2020; 40:1523-1531. [PMID: 32799667 PMCID: PMC9060397 DOI: 10.1177/0333102420949180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Headache diaries and recall questionnaires are frequently used to assess headache frequency and severity in clinical and research settings. METHODS Using 20 weeks of data from an intervention trial with 182 participants, we evaluated concordance between an electronic headache diary administered on a daily basis and designed to capture the presence and severity of headaches on an hourly basis (the headache diary) and a recall questionnaire, with retrospective estimation of the number of headache days assessed on a monthly basis. We further examined whether the duration or severity of headaches assessed by the electronic diary impacted concordance between these two measures. RESULTS Over the course of four 28-day periods, people with migraine participating in a dietary intervention reported an average of 13.7 and 11.1 headache days in the headache diary and recall questionnaire, respectively. CONCLUSION Over time, the concordance between headache days reported in these two measures tended to increase; however, the recall questionnaire headache estimates were lower than the diary measures in all four periods. When analysis was restricted to headaches lasting 8 hours or more, the number of headache days was more closely aligned with days reported in the recall questionnaire, indicating that the accuracy of recall estimates is likely to be influenced by headache duration. Restriction of analyses to moderate-to-severe headaches did not change results as much as headache duration. The findings indicate that recall questionnaires administered on a monthly basis may underestimate headache frequency and therefore should not be used interchangeably with headache diaries.Clinical Trials.gov Identifier: NCT02012790.
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Affiliation(s)
- Vanessa E Miller
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Olafur S Palssson
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beth A MacIntosh
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chirayath Suchindran
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gilson Honvoh
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan Gaylord
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christopher E Ramsden
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Douglas Mann
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Abstract
PURPOSE OF REVIEW Headaches are not only responsible for restrictions in everyday life in adults. In children and adolescents, regular headaches lead also to reduced life quality and limitations in the social sphere, in school education, and in professional careers. Here, we provide an overview on the frequency of headache in children and adolescents with the aim of increasing awareness about this particular health issue. RECENT FINDINGS Overall, headache prevalence in children and adolescents has been increasing in recent years. From various regions worldwide, data describing headache, its forms, and consequences are growing. In addition, factors frequently correlated with headache are repeatedly investigated and named: besides genetic factors, psychosocial and behavioral factors are linked to the prevalence of headache. Increasing evidence indicates that headache is underestimated as a common disorder in children and adolescents. Accordingly, too little emphasis is placed by society on its prevention and treatment. Thus, the extent of the social and health economic burden of frequent headaches in children and adolescents needs to be better illustrated, worldwide. Furthermore, the data collected in this review should support the efforts to improve outpatient therapy paths for young headache patients. Factors correlating with headache in pupils can draw our attention to unmet needs of these patients and allow physicians to derive important therapy contents from this data.
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Affiliation(s)
- Vera Nieswand
- Headache Clinic, Pain Center, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Matthias Richter
- Department of Pediatrics, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Gudrun Gossrau
- Headache Clinic, Pain Center, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstr 74, 01307, Dresden, Germany.
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Adebayo PB, Otubogun FM, Akinyemi RO. Menstrual-Related Headaches Among a Cohort of African Adolescent Girls. J Pain Res 2020; 13:143-150. [PMID: 32021403 PMCID: PMC6970628 DOI: 10.2147/jpr.s207620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 12/18/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Migraine attacks associated with menstruation are generally perceived as more severe than attacks outside this period. Aim and Objective The study aimed at determining the frequency of menstrual-related headaches among a cohort of senior secondary school girls in Abeokuta, Nigeria. We also determined its burden among these school girls. Methodology This study was cross-sectional using a validated adolescent headache survey questionnaire. A self-administration of the instrument was done during a school visit. A headache was classified using the ICHD-II criteria. Results Of the 183 students interviewed, 123(67.2%) had recurrent headaches. Mean age ±SD, 16.18±1.55 (range 12-19). The prevalence of definite migraine was 17.5% while the prevalence of probable migraine was 6.0%. The prevalence of tension-type headache was 41.0%. Migraine was significantly menstrual-related (p=0.001, 95% CI=1.06-6.63). Median pain severity score was higher among MRH group (p=0.043). The median number of days of reduced productivity and missed social activities was significantly higher in the MRH group; p= 0.001 and p=0.03, respectively. Subjects with MRH were more incapacitated by their headaches (p= 0.003). Conclusion Menstrually related headache is prevalent even among the adolescent and it has adversely affected their productivity and social life. Care of adolescent with headaches should be intensified.
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Affiliation(s)
- Philip B Adebayo
- Neurology Unit, Department of Medicine, Postgraduate Medical Education, Aga Khan University, Dar Es Salaam, Tanzania.,Neurology Unit, Department of Medicine, Federal Medical Centre, Abeokuta, Ogun State, Nigeria
| | - Folajimi M Otubogun
- Neurology Unit, Department of Medicine, Federal Medical Centre, Abeokuta, Ogun State, Nigeria.,Neurology Unit, Department of Medicine, University of Medical Science, Ondo, Ondo State, Nigeria
| | - Rufus O Akinyemi
- Neurology Unit, Department of Medicine, Federal Medical Centre, Abeokuta, Ogun State, Nigeria.,Institute of Advanced Medical Research and Training, University of Ibadan, Ibadan, Oyo State, Nigeria
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Basdav J, Haffejee F, Puckree T. Impact of headaches on university students in Durban, South Africa. SPRINGERPLUS 2016; 5:1679. [PMID: 27733981 PMCID: PMC5042922 DOI: 10.1186/s40064-016-3372-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/23/2016] [Indexed: 02/07/2023]
Abstract
Background Introspection into the factors that affect student success at higher education institutions has gained significant momentum in recent years. Teaching and learning has come under the spotlight with quality enhancement and teaching development funding focussing on student support, enhancing the student environment, and enhancing academics as teachers. Included in this are aspects that try to understand the student. An aspect that is not receiving attention is student health, specifically headaches which could impact student success. The aim of this study was to investigate the impact of primary headaches on student academic, family and social life at one higher education institution in South Africa. Method Data was collected using a questionnaire based descriptive cross sectional survey. Multistage sampling using a ballot method allowed for sampling to obtain representation from across the institution. To achieve a 95 % confidence level, 384 students from across the university were invited to participate after informed consent. Data was analysed using Chi square tests at a probability of p < 0.05. Results Majority of the participants were undergraduates and non-smokers. Half of the population suffered from primary headaches. Headache sufferers experienced limited concentration due to an increased headache intensity during tests and/or the examination period. This negatively impacted on studying which was aggravated by consumption of caffeinated energy drinks, coffee and chocolate resulting in a less effective study session. Activities of daily living and participation in social events which usually leads to relaxation were neglected. Personal and emotional well-being was also negatively affected. Altered sleeping patterns and absence of study breaks also led to headaches. Conclusion Headaches were found to impact on the students study and sleep patterns, their attention levels during lectures and their social and emotional life. Headaches negatively impacted on some participants leading to reduced focus on academic, family, social or leisure activities. Intensity of headaches increased during tests and examinations which could impact their success at University.
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Affiliation(s)
- Jyotika Basdav
- Department of Chiropractic, Faculty of Health Sciences, Durban University of Technology, Gate 8, Steve Biko Road, Durban, South Africa
| | - Firoza Haffejee
- Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, Gate 8, Steve Biko Road, Durban, South Africa
| | - T Puckree
- Faculty of Health Sciences, Durban University of Technology, Gate 8, Steve Biko Road, Durban, South Africa
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