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Ali M, Ullah I, Diwan MN, Aamir A, Awan HA, Waris Durrani A, Qudrat QU, Shoib S, De Berardis D. Zuranolone and its role in treating major depressive disorder: a narrative review. Horm Mol Biol Clin Investig 2023:hmbci-2022-0042. [PMID: 36848317 DOI: 10.1515/hmbci-2022-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 04/28/2022] [Accepted: 12/11/2022] [Indexed: 02/28/2023]
Abstract
Major Depressive Disorder (MDD) is a mood disorder classified as a persistent depressive mood and loss of interest lasting for more than two weeks and accompanied by a list of symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria. MDD affects approximately 264 million people worldwide and is the most prevailing form of neuropsychiatric disorder. Owing to the probable hypothesized pathophysiology of MDD being an outcome of abnormalities in the amino acid neurotransmitter system, including glutamate (the primary excitatory neurotransmitter) and γ-aminobutyric acid (GABA), SAGE-217 (Zuranolone) is being evaluated as a possible therapeutic treatment for MDD. Zuranolone is a synthetic, neuroactive steroid (NAS) and positive allosteric modulator (PMA) of GABAA receptors, regulating both synaptic and extra-synaptic release of GABA. It is administered as a once-daily oral dose for 2 weeks due to its low-moderate clearance. A change in total HAM-D score from baseline was the primary end-point of all the trials. A phase II trial conducted to evaluate the efficacy and safety of Zuranolone (30 mg, once-daily dose), described a significant reduction in total HAM-D score at day 14 and reported the drug to be well tolerated with headache, dizziness, nausea, and somnolence as the most common adverse events (AE). Additional phase III trials were also conducted to evaluate similar outcomes, the interim topline results of which have been released. Consequently, this article attempts to briefly analyze the pharmacology of Zuranolone, review the available clinical data and outcomes regarding its use, and evaluate its place as a prospective novel therapy in the effective management of MDD.
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Affiliation(s)
- Muneeza Ali
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Irfan Ullah
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Mufaddal Najmuddin Diwan
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Alifiya Aamir
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Hashir Ali Awan
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Abdul Waris Durrani
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Qudrat Ullah Qudrat
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Kashmir, India.,Sharda University, Greater Noida, Uttar Pradesh, India.,Mind Wellness Center, Nawab Bazar, Srinagar, India
| | - Domenico De Berardis
- NHS, Department of Mental Health, Psychiatric Service for Diagnosis and Treatment, Hospital "G. Mazzini", ASL 4, Teramo, Italy
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Jawed S, Islam MB, Awan HA, Ullah I, Asghar MS. Cholera outbreak in Balochistan amidst flash floods: an impending public health crisis. Int J Surg 2023; 109:107-108. [PMID: 36799817 PMCID: PMC10389440 DOI: 10.1097/js9.0000000000000150] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Despite being the largest province in Pakistan due to inadequate and underdeveloped infrastructure, Balochistan has been the worst-inflicted region with biblical floods. Following these disastrous flash floods, a sudden rise in cholera cases was seen in the affected province. To overcome this public health crisis, the authorities must put in place a system to ensure food safety, an adequate supply of clean drinking water, and the provision of proper sanitation facilities for the locals.
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Affiliation(s)
- Shizra Jawed
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan
| | | | - Hashir Ali Awan
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
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Yasmin F, Najeeb H, Siddiqui HF, Asghar MS, Awan HA, Usama RM, Allahuddin Z, Tahir MJ, Ullah K, Mahmmoud Fadelallah Eljack M. Frequency of COVID-19 vaccine side effects and its associated factors among the vaccinated population of Pakistan: A cross-sectional study. Health Sci Rep 2023; 6:e1071. [PMID: 36698706 PMCID: PMC9847396 DOI: 10.1002/hsr2.1071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) vaccine side effects have an important role in the hesitancy of the general population toward vaccine administration. Therefore, this study was conducted to document the COVID-19 vaccine side effects in our population. Materials and Methods An online survey-based, cross-sectional study was carried out from September 1, 2021, to October 1, 2021, to document the side effects of the COVID-19 vaccine among the general public. The questionnaire included participants' sociodemographic data, type of vaccine, comorbidities, previous COVID-19 infection, and assessment of side effects reported by them. Results The majority of the participants were <20 years of age (62.2%), females (74.9%), belonged to the educational sector (58.1%), residents of Sindh (65.7%), and were previously unaffected by COVID-19 infection (73.3%). Sinovac (38.7%) followed by Sinopharm (30.4%) and Moderna (18.4%) were administered more frequently. Commonly reported side effects were injection site pain (82%), myalgia (55%), headache (46%), fatigue/malaise (45%), and fever (41%). Vaccine side effects were more likely to be reported with the first dose as compared to the second dose. On regression analysis, factors associated with occurrence of side effects included younger age (odds ratio [OR]: 6.000 [2.065-17.431], p < 0.001), female gender (OR: 2.373 [1.146-4.914], p = 0.020), marital status (OR: 0.217 [0.085-0.556], p < 0.001), graduate level of education (OR: 0.353 [0.153-0.816], p = 0.015), and occupation being either retired, freelancers, or social workers (OR: 0.310 [0.106-0.909]), p = 0.033). Previous infection with COVID-19 (p = 0.458) and comorbidities were found unrelated (p = 0.707) to the occurrence of side effects. Conclusion The overall prevalence of local side effects was quite higher than the systemic ones. Further large-scale studies on vaccine safety are required to strengthen public confidence in the vaccination drive.
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Affiliation(s)
- Farah Yasmin
- Department of Medicine, Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Hala Najeeb
- Department of Medicine, Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Hasan Fareed Siddiqui
- Department of Medicine, Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Muhammad Sohaib Asghar
- Department of Medicine, Dow University Hospital‐Ojha CampusDow University of Health SciencesKarachiPakistan
| | - Hashir Ali Awan
- Department of Medicine, Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | | | - Zoha Allahuddin
- Department of Medicine, Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Muhammad Junaid Tahir
- Department of RadiologyPakistan Kidney and Liver Institute and Research Center (PKLI & RC)LahorePakistan
| | - Kaleem Ullah
- Department of Surgery, Liver Transplant and Hepatobiliary UnitPir Abdul Qadir Shah Jelani Institute of Medical SciencesGambatPakistan
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Awan HA, Awan S, Shaikh HS, Swed S, Hasan MM. Emergence of Omicron BA.2.12.1 in Pakistan: What does it mean for the South Asian nation? Ann Med Surg (Lond) 2022; 79:103943. [PMID: 35702273 PMCID: PMC9181074 DOI: 10.1016/j.amsu.2022.103943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/02/2022] [Indexed: 11/24/2022] Open
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Ullah I, Awan HA, Aamir A, Diwan MN, de Filippis R, Awan S, Irfan M, Fornaro M, Ventriglio A, Vellante F, Pettorruso M, Martinotti G, Di Giannantonio M, De Berardis D. Role and Perspectives of Inflammation and C-Reactive Protein (CRP) in Psychosis: An Economic and Widespread Tool for Assessing the Disease. Int J Mol Sci 2021; 22:ijms222313032. [PMID: 34884840 PMCID: PMC8657450 DOI: 10.3390/ijms222313032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 01/04/2023] Open
Abstract
Schizophrenia is a major psychotic disorder affecting nearly 23.6 million people globally and greatly impacting the cognitive and social functioning of individuals. Multiple risk factors, including genetic, environmental, and epigenetic factors have been identified. However, the exact mechanism by which some factors aid in the development of schizophrenia is still uncertain. Acute and/or long-standing inflammation has been implicated as both a cause and effect of schizophrenia. Heightened immune responses have been documented in large cohorts of individuals with schizophrenia. While not completely known, multiple hypotheses, such as disruption of the blood–brain barrier, alterations in the kynurenine/tryptophan pathway, and increased microglial activation, have been presented to correlate inflammation with schizophrenic symptoms. Measurement of C-reactive protein (CRP) is a commonly performed and inexpensive test on patients’ serum to determine levels of systemic inflammation in the body. Multiple studies have reported an elevated CRP level in different stages of schizophrenia, indicating its potential to be used as a viable biomarker in the diagnosis and monitoring of schizophrenia along with assessing treatment response to conventional and non-conventional treatment regimens. This review aims to evaluate the role of inflammation, in general, and CRP, in particular, in the pathogenesis of schizophrenia and its potential significance in diagnostic, therapeutic, and preventative approaches towards schizophrenia and psychosis.
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Affiliation(s)
- Irfan Ullah
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar 25000, Pakistan;
| | - Hashir Ali Awan
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (A.A.); (M.N.D.); (S.A.)
| | - Alifiya Aamir
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (A.A.); (M.N.D.); (S.A.)
| | - Mufaddal Najmuddin Diwan
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (A.A.); (M.N.D.); (S.A.)
| | - Renato de Filippis
- Department of Health Sciences, University Magna Graecia of Catanzaro, Viale Europa, 88100 Catanzaro, Italy;
| | - Sana Awan
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (A.A.); (M.N.D.); (S.A.)
| | - Muhammad Irfan
- Department of Internal Medicine, Hayatabad Medical Complex, Peshawar 25000, Pakistan;
| | - Michele Fornaro
- Department of Psychiatry, Federico II University, 80131 Naples, Italy;
| | - Antonio Ventriglio
- Department of Experimental and Clinical Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Federica Vellante
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (M.P.); (G.M.); (M.D.G.)
| | - Mauro Pettorruso
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (M.P.); (G.M.); (M.D.G.)
| | - Giovanni Martinotti
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (M.P.); (G.M.); (M.D.G.)
| | - Massimo Di Giannantonio
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (M.P.); (G.M.); (M.D.G.)
| | - Domenico De Berardis
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (M.P.); (G.M.); (M.D.G.)
- Department of Mental Health, Psychiatric Service for Diagnosis and Treatment, Hospital “G. Mazzini”, ASL 4, 64100 Teramo, Italy
- Correspondence:
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Ali Awan H, Najmuddin Diwan M, Aamir A, Ali M, Di Giannantonio M, Ullah I, Shoib S, De Berardis D. SARS-CoV-2 and the Brain: What Do We Know about the Causality of 'Cognitive COVID? J Clin Med 2021; 10:3441. [PMID: 34362224 PMCID: PMC8347421 DOI: 10.3390/jcm10153441] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 06/17/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 12/22/2022] Open
Abstract
The second year of the COVID-19 (coronavirus disease) pandemic has seen the need to identify and assess the long-term consequences of a SARS-CoV-2 infection on an individual's overall wellbeing, including adequate cognitive functioning. 'Cognitive COVID' is an informal term coined to interchangeably refer to acute changes in cognition during COVID-19 and/or cognitive sequelae with various deficits following the infection. These may manifest as altered levels of consciousness, encephalopathy-like symptoms, delirium, and loss of various memory domains. Dysexecutive syndrome is a peculiar manifestation of 'Cognitive COVID' as well. In the previous major outbreaks of viruses like SARS-CoV, MERS-CoV and Influenza. There have been attempts to understand the underlying mechanisms describing the causality of similar symptoms following SARS-CoV-2 infection. This review, therefore, is attempting to highlight the current understanding of the various direct and indirect mechanisms, focusing on the role of neurotropism of SARS-CoV-2, the general pro-inflammatory state, and the pandemic-associated psychosocial stressors in the causality of 'Cognitive COVID.' Neurotropism is associated with various mechanisms including retrograde neuronal transmission via olfactory pathway, a general hematogenous spread, and the virus using immune cells as vectors. The high amounts of inflammation caused by COVID-19, compounded with potential intubation, are associated with a deleterious effect on the cognition as well. Finally, the pandemic's unique psychosocial impact has raised alarm due to its possible effect on cognition. Furthermore, with surfacing reports of post-COVID-vaccination cognitive impairments after vaccines containing mRNA encoding for spike glycoprotein of SARS-CoV-2, we hypothesize their causality and ways to mitigate the risk. The potential impact on the quality of life of an individual and the fact that even a minor proportion of COVID-19 cases developing cognitive impairment could be a significant burden on already overwhelmed healthcare systems across the world make it vital to gather further evidence regarding the prevalence, presentation, correlations, and causality of these events and reevaluate our approach to accommodate early identification, management, and rehabilitation of patients exhibiting cognitive symptoms.
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Affiliation(s)
- Hashir Ali Awan
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (M.N.D.); (A.A.); (M.A.)
| | - Mufaddal Najmuddin Diwan
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (M.N.D.); (A.A.); (M.A.)
| | - Alifiya Aamir
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (M.N.D.); (A.A.); (M.A.)
| | - Muneeza Ali
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan; (H.A.A.); (M.N.D.); (A.A.); (M.A.)
| | - Massimo Di Giannantonio
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy;
| | - Irfan Ullah
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar 25000, Pakistan;
| | - Sheikh Shoib
- Department of Internal Medicine, Jawahar Lal Nehru Memorial Hospital, Srinagar 190003, India;
| | - Domenico De Berardis
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy;
- Department of Internal Medicine, Jawahar Lal Nehru Memorial Hospital, Srinagar 190003, India;
- NHS, National Health Service, Department of Mental Health, Psychiatric Service for Diagnosis and Treatment, Hospital “G. Mazzini,” ASL 4, 64100 Teramo, Italy
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Aamir A, Awan HA, Diwan MN, Kazmi SK, Hasan MM, Douba Z, Ullah I. The dilemma of treating the infected versus the wounded: Gaza's healthcare system is choked. Int J Health Plann Manage 2021; 36:2430-2435. [PMID: 34212406 DOI: 10.1002/hpm.3274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Gaza has been facing persistent disturbance since the last 14 years. Even before the pandemic, Gaza faced a dire healthcare consequence with prevalent instability, lack of adequate medical resources, and limited health-related infrastructure. Gaza continued to struggle while responding to the pandemic as the other nearby countries. However, the challenges were compounded with the onset of the conflict that affected Gaza's infrastructure and displaced tens of thousands to make-shift shelters. The testing capacity of Gaza is alarmingly low that makes any outbreak difficult to document. Additionally, all medical centres have been affected by the ongoing conflict. These centres, if not directly impacted, are severely overwhelmed with those injured during the conflict, shifting focus and resources away from coronavirus. Vaccinations in Gaza cover only 1.9% of the population and a great number of unvaccinated people now may act as vectors of transmission in overcrowded shelters. Furthermore, non-availability of clean water to maintain hygienic conditions has heightened the risk of an explosive surge in cases. Hence, beyond the ceasefire, further steps need to be taken to strengthen Gazan response to COVID-19 pandemic.
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Affiliation(s)
- Alifiya Aamir
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | - Mohammad Mehedi Hasan
- Department of Biochemistry and Molecular Biology, Faculty of Life Science, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh
| | - Zain Douba
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
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Abstract
ABSTRACT To date, there is lack of specific effective treatment or vaccine for the SARS-CoV-2, and clinical and laboratory research is still ongoing to find successful drugs. Therefore, prevention to be infected through social distancing and isolation is the most effective way. However, all the other physical and mental illnesses continue to exist, if possible even more burdened by the emergency situation and social distancing. The COVID-19 pandemic, especially in many low- and middle-income countries, has caused a deeper gap in seeking psychiatric help. In this scenario, telepsychiatry could play a decisive role in implementing clinical care for frail patients and ensuring continuous mental care. Therefore, we felt the urge to write this article to express our hope that the old health care system at this time of crisis, as we know it, can offer the chance to implement pervasive care technologies that perfectly fit current psychiatric needs.
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Affiliation(s)
| | - Hashir Ali Awan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Alifiya Aamir
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Renato de Filippis
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
- Undergraduate Research Organization, Dhaka, Bangladesh
- Naseer Teaching Hospital, Peshawar, Pakistan
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Awan HA, Aamir A, Diwan MN, Ullah I, Pereira-Sanchez V, Ramalho R, Orsolini L, de Filippis R, Ojeahere MI, Ransing R, Vadsaria AK, Virani S. Internet and Pornography Use During the COVID-19 Pandemic: Presumed Impact and What Can Be Done. Front Psychiatry 2021; 12:623508. [PMID: 33796031 PMCID: PMC8007884 DOI: 10.3389/fpsyt.2021.623508] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
The COVID-19 pandemic continues to cause an immense psychosocial strain worldwide. Excessive use of the internet during these psychologically trying times, fueled by physical isolation as a result of lockdowns, has translated into dysfunctional behaviors. A growing body of evidence suggests an unprecedented increase in internet use and consumption of online pornography during the pandemic, and possibly even directly caused by it. In this review, the authors report data from relevant sources to show the rise in pornography use during lockdowns in different countries worldwide. In addition to a brief overview of the neurobiology of internet addiction broadly and problematic online pornography use specifically, similarities with substance use disorders are explained. Further, the current status of the debate about defining diagnostic criteria is discussed. Finally, the review sheds light on the potential detrimental outcomes during the future post-pandemic "re-adaptation," while simultaneously offering preventative and management strategies for harm reduction. The authors conclude that foresightedness with utilizing existing tools and therapies and exercising appropriate amounts of caution could go a long way in addressing the challenges that lie ahead in the post-pandemic era.
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Affiliation(s)
| | - Alifiya Aamir
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Victor Pereira-Sanchez
- Department of Child and Adolescent Psychiatry, School of Medicine, New York University, New York, NY, United States
| | - Rodrigo Ramalho
- Department of Social and Community Health, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, School of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Ramdas Ransing
- Bhaktshreshtha Kamalakarpant Laxman Walawalkar Rural Medical College, Kasarwadi, India
| | | | - Sanya Virani
- Veterans Affairs Connecticut Healthcare System, Yale University School of Medicine, West Haven, CT, United States.,School of Medicine Yale University, New Haven, CT, United States
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