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Lacka K, Maciejewski A, Jarecki P, Herman W, Lacki JK, Żaba R, Kowalczyk MJ. Is There a Link between Thyroid Peroxidase Gene Promoter Polymorphisms and Autoimmune Thyroiditis in the Polish Population? Int J Mol Sci 2024; 25:3312. [PMID: 38542286 PMCID: PMC10969849 DOI: 10.3390/ijms25063312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
(1) Autoimmune thyroiditis (AIT) is the most common cause of primary hypothyroidism and one of the most frequent organ-specific autoimmune diseases. Its pathogenesis is polygenic and still requires further research. The aim of the study was to assess, for the first time in the Caucasian population, the role of selected TPO gene promoter polymorphisms (rs2071399 G/A, rs2071400C/T, rs2071402 A/G, and rs2071403 A/G) in the development of AIT. A total of 237 patients diagnosed with AIT and 130 healthy controls were genotyped for four TPO gene polymorphisms, and the results were statistically analyzed to check for the role of these polymorphisms. There were no significant differences in the genotype and allele frequencies of the studied TPO gene promoter polymorphisms between patients and controls (p > 0.05). The haplotype distribution (rs2071400-rs2071402-rs2071403) between the two studied groups was similar for the most common variants (CGA, CAG, TGG). Only a rare haplotype (CGG) occurred more frequently among patients compared to controls (p = 0.04). The studied TPO gene promoter polymorphisms did not show an association with susceptibility to AIT in the Caucasian Polish population, contrary to the results in Japanese patients.
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Affiliation(s)
- Katarzyna Lacka
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Adam Maciejewski
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | | | - Waldemar Herman
- Outpatients Unit for Endocrine Diseases, 67-400 Wschowa, Poland
| | - Jan K. Lacki
- Department of Medicine, The Jacob of Paradies University, 66-400 Gorzow Wielkopolski, Poland
- Department of Internal Medicine, Collegium Medicum, University of Zielona Gora, 65-417 Zielona Gora, Poland
| | - Ryszard Żaba
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Michał J. Kowalczyk
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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Mao X, Tang L, Li H, Zhang W, Liu L, Wang H, Headar A. Functional enrichment analysis of mutated genes in children with hyperthyroidism. Front Endocrinol (Lausanne) 2023; 14:1213465. [PMID: 37876543 PMCID: PMC10591315 DOI: 10.3389/fendo.2023.1213465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/27/2023] [Indexed: 10/26/2023] Open
Abstract
Objective Hyperthyroidism in Chinese children is relatively high and has been increasing in recent years, which has a significant impact on their healthy development. Hyperthyroidism is a polygenic disorder that presents greater challenges in terms of prediction and treatment than monogenic diseases. This study aims to elucidate the associated functions and gene sets of mutated genes in children with hyperthyroidism in terms of the gene ontology through GO enrichment analysis and in terms of biological signaling pathways through KEGG enrichment analysis, thereby enhancing our understanding of the expected effects of multiple mutated genes on hyperthyroidism in children. Methods Whole-exome sequencing was performed on the DNA samples of children with hyperthyroidism. Screening for pathogenic genes related to hyperthyroidism in affected children was performed using the publicly available disease databases Malacards, MutationView, and Clinvar, and the functions and influences of the identified pathogenic genes were analyzed using statistical analysis and the gene enrichment approach. Results Through GO enrichment analysis, it was found that the most significant gene ontology enrichment was the function "hormone activity" in terms of gene ontology molecular function. The corresponding mutated genes set that has common effects on hyperthyroidism in children included TG, CALCA, POMC, CGA, PTH, GHRL, FBN1, TRH, PRL, LEP, ADIPOQ, INS, GH1. The second most significant gene ontology enrichment was the function "response to peptide hormone" in terms of biological process. The corresponding mutated genes set that has common effects on hyperthyroidism in children included LRP6, TSC2, KANK1, COL1A1, CDKN1B, POMC, STAT1, MEN1, APC, GHRL, TSHR, GJB2, FBN1, GPT, LEP, ADIPOQ, INS, GH1. Through KEGG enrichment analysis, it was found that the most significant biological signaling pathway enrichment was the pathway "Thyroid hormone signaling pathway" function. The corresponding mutated genes set that has common effects on hyperthyroidism in children included NOTCH3, MYH7, TSC2, STAT1, MED13L, MAP2K2, SLCO1C1, SLC16A2, and THRB. The second most significant biological signaling pathway enrichment was the pathway "Hypertrophic cardiomyopathy" in terms of biological process. The corresponding mutated genes set that has common effects on hyperthyroidism in children included IGF1, CACNA1S, MYH7, IL6, TTN, CACNB2, LAMA2, and DMD. Conclusion The mutated genes in children with hyperthyroidism were closely linked to function involved in "hormone activity" and "response to peptide hormone" in terms of the biological signaling pathway, and to the functional pathways involved in "Thyroid hormone signaling pathway" and "Hypertrophic cardiomyopathy" in terms of the biological signaling pathway.
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Affiliation(s)
- Xiaojian Mao
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Liangliang Tang
- Center of Big Data and Business Itelligent, South China University of Technology, Guangzhou, China
| | - Hongyi Li
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Wen Zhang
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Li Liu
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Heyong Wang
- Center of Big Data and Business Itelligent, South China University of Technology, Guangzhou, China
| | - Abdalbari Headar
- Center of Big Data and Business Itelligent, South China University of Technology, Guangzhou, China
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Vargas-uricoechea H. Molecular Mechanisms in Autoimmune Thyroid Disease. Cells 2023; 12:918. [PMID: 36980259 PMCID: PMC10047067 DOI: 10.3390/cells12060918] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
The most common cause of acquired thyroid dysfunction is autoimmune thyroid disease, which is an organ-specific autoimmune disease with two presentation phenotypes: hyperthyroidism (Graves-Basedow disease) and hypothyroidism (Hashimoto’s thyroiditis). Hashimoto’s thyroiditis is distinguished by the presence of autoantibodies against thyroid peroxidase and thyroglobulin. Meanwhile, autoantibodies against the TSH receptor have been found in Graves-Basedow disease. Numerous susceptibility genes, as well as epigenetic and environmental factors, contribute to the pathogenesis of both diseases. This review summarizes the most common genetic, epigenetic, and environmental mechanisms involved in autoimmune thyroid disease.
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Zhang L, Lu Y, Xu L, Liu L, Wu X, Zhang Y, Zhu G, Hong Z. Anti-N-methyl-D-aspartate receptor encephalitis with accompanying ovarian teratoma in female patients from East China: Clinical features, treatment, and prognostic outcomes. Seizure 2019; 75:55-62. [PMID: 31874360 DOI: 10.1016/j.seizure.2019.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The association between anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR encephalitis) and teratoma is formally recognized. This study compared the clinical features, treatments and outcomes between female patients with or without accompanying teratomas and determined the potential influences of coexisting teratomas. METHOD Fifty-six female patients diagnosed with anti-NMDAR encephalitis were enrolled in two major tertiary hospitals in East China from January 2013 through March 2018 and were grouped as patients with or without teratoma. The clinical features were reviewed, and follow-up studies were performed. Comparisons were made between the two groups. RESULTS Patients with teratoma reported fewer viral prodromes (p = 0.0085) and stronger positive intensity of anti-NMDAR antibodies in cerebrospinal fluid (CSF) (p = 0.0368), while nontumor patients tended to demonstrate lymphocytic pleocytosis in CSF (p = 0.0306). Seizure types varied between individuals, with complex partial seizures more common in teratoma patients (p = 0.0105). Nontumor patients frequently required combinations of first-line and second-line immunotherapy (p = 0.0014), which may be attributed to higher mRS scores at admission (p = 0.0300). Also, they had higher mean mRS scores since the 12-month follow-up and greater probability of relapse than did patients with teratomas (p = 0.0286). CONCLUSIONS Symptomatology and auxiliary findings indicate that ovarian teratoma may be the immunologic trigger for anti-NMDAR encephalitis patients, while viral infection is likely to play a major part in pathogenesis for those without any detectable tumor. Overall, anti-NMDAR encephalitis patients with teratomas present with milder neurological symptoms and have better long-term outcomes after tumor removal.
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Affiliation(s)
- Lu Zhang
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Yao Lu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lan Xu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lu Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Xunyi Wu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China.
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
| | - Guoxing Zhu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhen Hong
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
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Xuan M, Zhao SX, Yan CY, Yang J, Li Y, Song LG, Song HD, Zhang XZ. Fine mapping of thyroglobulin gene identifies two independent risk loci for Graves' disease in Chinese Han population. Ann Transl Med 2019; 7:434. [PMID: 31700870 DOI: 10.21037/atm.2019.08.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to determine independent risk loci of Graves' disease (GD) in the thyroglobulin (TG) region. Methods In this two-staged association study, a total of 9,757 patients with GD and 10,626 sex-matched controls were recruited from Chinese Han population. Illumina Human660-Quad BeadChips in the discovery stage and TaqMan SNP Genotyping Assays in the replication stage were used for genotyping. Trend test and logistic regression analysis were performed in this association study. Results In the discovery stage, rs2294025 and rs7005834 were the most highly associated susceptibility loci with GD in TG. In the replication phase, 7 SNPs, including rs2294025 and rs7005834, were selected for fine-mapping. Finally, we confirmed that rs2294025 and rs7005834 were the independent risk loci of GD in the combined populations. At the same time, there was no significant difference between the risk allele frequencies of rs2294025 and rs7005834 in different clinical phenotypes of GD. Conclusions The fine mapping study of thyroglobulin identified two independent SNPs (rs2294025 and rs7005834) for GD susceptibility. However, no significant differences for rs2294025 and rs7005834 were observed, between the different clinical phenotypes of GD, including gender, Graves' ophthalmopathy (GO), and serum levels of thyrotropin receptor antibody, thyroid peroxidase antibody, and thyroglobulin antibody. These results provide a deeper understanding of the association mechanism of thyroglobulin and GD risk.
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Affiliation(s)
- Miao Xuan
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Shuang-Xia Zhao
- The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University (SJTU) School of Medicine, Shanghai 200011, China
| | - Chen-Yan Yan
- The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University (SJTU) School of Medicine, Shanghai 200011, China
| | - Jun Yang
- Department of Clinical Skill Practice and Training Center, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Ying Li
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Li-Ge Song
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Huai-Dong Song
- The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University (SJTU) School of Medicine, Shanghai 200011, China
| | - Xiu-Zhen Zhang
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Tu R, Shen H, Zhu Q, Mao G, Xu X, Yu S. A retrospective analysis of 1,231 patients with anemia after surgical treatment of hyperthyroidism. Exp Ther Med 2018; 16:4664-4668. [PMID: 30542418 PMCID: PMC6257823 DOI: 10.3892/etm.2018.6738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/28/2018] [Indexed: 11/05/2022] Open
Abstract
This study retrospectively analyzed the clinical and pathological data of 1,231 patients affected by anemia after surgical treatment of hyperthyroidism to explore the influencing factors of anemia after surgical treatment of hyperthyroidism. The clinical data of 1,231 patients affected by anemia after surgical treatment of hyperthyroidism from 1987 to 2017 were analyzed. Clinical data included the surgery methods, sex, age and pathological types. SPSS 22.0 statistical software was used for all statistical analyses. Correlation analyses were performed by using logistic regression analysis, and other enumeration data were subjected to χ2 test. p<0.05 was considered to be statistically significant. The occurrence of anemia after surgical treatment of hyperthyroidism was significantly correlated with age and pathological types (p<0.05). Correlation analysis also showed that age and pathological types were significantly correlated with the occurrence of anemia after surgical treatment of hyperthyroidism. Age and pathological types may be the risk factors for anemia in patients with surgical treatment of hyperthyroidism. Age and pathological type were significantly correlated with the occurrence of anemia after surgical treatment of hyperthyroidism, and may be risk factors for this disease.
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Affiliation(s)
- Ruisha Tu
- Department of Neck and Thoracic Surgery, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
| | - Hongfeng Shen
- Department of Urinary Surgery, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
| | - Qicong Zhu
- Department of Internal Medicine-Oncology, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
| | - Gaocai Mao
- Department of Pathology, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
| | - Xiaojiang Xu
- Department of Neck and Thoracic Surgery, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
| | - Shuyong Yu
- Department of Neck and Thoracic Surgery, 187th Hospital of People's Liberation Army, Haikou, Hainan 571100, P.R. China
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Zhang ML, Zhang DM, Wang CE, Chen XL, Liu FZ, Yang JX. Association between thyroglobulin polymorphisms and autoimmune thyroid disease: a systematic review and meta-analysis of case-control studies. Genes Immun 2018; 20:484-492. [PMID: 30139952 DOI: 10.1038/s41435-018-0042-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/11/2018] [Accepted: 06/13/2018] [Indexed: 02/06/2023]
Abstract
Emerging evidence revealed that thyroglobulin (TG) contributes to the development of autoimmune disease, and the relationship between TG and autoimmune thyroid disease (AITD) is still controversial. The aim of this study was to quantify the association between rs2076740, rs853326, rs180223, and rs2069550 TG polymorphisms and risk of AITD using a meta-analysis approach. We identified all studies that assessed the association between TG polymorphisms and AITD from PubMed, Embase, and Web of Science databases. A total of 3013 cases and 1812 controls from ten case-control studies were included. There was no significant associations found between rs2069550, rs180223, and rs853326 polymorphisms and AITD risk. The association between the rs2076740 polymorphism and AITD risk was significant in the codominant model (P = 0.005), suggesting the CC rs2076740 genotype might be a protective factor for AITD. Sensitivity analysis by removing one or two study changed the results in dominant rs2076740 and rs853326 and rs2069550 allele models (P = 0.016, 0.024, 0.027). Latitude and ethnicity significantly affected the association between rs2076740 and rs2069550 polymorphisms and AITD, indicating their protective effects in allele or dominant model (P = 0.012, 0.012, 0.012, 0.009, 0.009). The association between rs2076740, rs2069550, and rs853326 polymorphisms and AITD risk is significantly affected by study characteristics.
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Affiliation(s)
- Ming-Liang Zhang
- Department of Pharmacy, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang; The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Dong-Ming Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cai-E Wang
- Department of Pharmacy, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang; The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Xiao-Long Chen
- Department of Infectious Disease, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fang-Zhou Liu
- Henan Province Chinese Medicine Research Institute, Zhengzhou, Henan, China
| | - Jian-Xue Yang
- Department of Neurology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
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Lahooti H, Edirimanne S, Walsh JP, Delbridge L, Hibbert EJ, Wall JR. Single nucleotide polymorphism 1623 A/G (rs180195) in the promoter of the Thyroglobulin gene is associated with autoimmune thyroid disease but not with thyroid ophthalmopathy. Clin Ophthalmol 2017; 11:1337-1345. [PMID: 28794611 PMCID: PMC5536092 DOI: 10.2147/opth.s136070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Our studies over recent years have focused on some new ideas concerning the pathogenesis for the orbital reaction that characterizes Graves’ ophthalmopathy namely, that there are antigens expressed by thyroid tissue and orbital tissue where they are targeted by autoantibodies and/or sensitized T cells, leading to orbital inflammation. While this has been well studied for the thyroid stimulating hormone-receptor, the possible role of another major thyroid antigen, Thyroglobulin (TG), has been largely ignored. Methods We identified novel variant 1623 A/G single nucleotide polymorphism (SNP) (rs180195) in the promoter of TG gene associated with autoimmune thyroid disorders. We genotyped the TG SNPs rs2069566, rs2076739, rs121912646, rs121912647, rs121912648, rs121912649, rs121912650, rs137854433, rs137854434, and rs180195 by MassARRAY SNP analysis using iPLEX technology in a cohort of 529 patients with thyroid autoimmunity with and without ophthalmopathy, and controls. Results We showed that variant 1623 A/G SNP (rs180195) in the promoter of TG gene is a marker for thyroid autoimmunity, but not for ophthalmopathy. We showed that there was a significant difference in the distribution of the major allele (G) vs minor allele (A) in patients with Hashimoto’s thyroiditis (HT). In HT the wild-type (GG) genotype was less common. We showed that the genotypes homozygous AA and heterozygous GA rs180195 SNP in the promoter of TG gene were more closely associated with thyroid autoimmunity than the wild-type (GG) polymorphism, and are thus, markers of autoimmunity. Conclusion rs180195 SNP was previously identified by Stefan et al independently of us, who showed that this TG SNP predisposed to autoimmune thyroid diseases. However, this is the first study to explore the association between TG SNPs and HT. Our findings support the notion that the thyroid and orbital disorders are not part of the same disease, ie, “Graves’ disease” or “Hashimoto’s disease”, but separate autoimmune disorders.
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Affiliation(s)
- Hooshang Lahooti
- Thyroid Research Laboratory, Sydney Medical School - Nepean Clinical School, The University of Sydney, Kingswood, NSW, Australia.,Nepean Blue Mountains Local Health District, Kingswood, NSW, Australia
| | - Senarath Edirimanne
- Thyroid Research Laboratory, Sydney Medical School - Nepean Clinical School, The University of Sydney, Kingswood, NSW, Australia.,Nepean Blue Mountains Local Health District, Kingswood, NSW, Australia
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA, Australia
| | - Leigh Delbridge
- Department of Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Sydney Medical School - Northern Clinical School, The University of Sydney, NSW, Australia
| | - Emily J Hibbert
- Thyroid Research Laboratory, Sydney Medical School - Nepean Clinical School, The University of Sydney, Kingswood, NSW, Australia.,Nepean Blue Mountains Local Health District, Kingswood, NSW, Australia
| | - Jack R Wall
- Thyroid Research Laboratory, Sydney Medical School - Nepean Clinical School, The University of Sydney, Kingswood, NSW, Australia.,Nepean Blue Mountains Local Health District, Kingswood, NSW, Australia
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