Pregnancy, when accompanied by developed diabetes, may carry significant burdens [1]. Gestational diabetes mellitus (GDM) specifically is defined as any degree of glucose intolerance with onset or first recognition during pregnancy [1]. Current treatment options for GDM include lifestyle changes as well as both implementation of an appropriate diet and—when insufficient on its own—insulin therapy [1]. Type 1 diabetes (T1D), meanwhile, develops as a result of an autoimmune response directed against insulin-producing $\beta$ cells in the pancreas, causing an underproduction of insulin. To achieve euglycemia, T1D patients require insulin replacement [1]. The onset of T1D usually occurs before age 30 and thus can affect reproduction.

Diabetes’ effects on the microvasculature create a wide spectrum of complications, ranging from changes in the cardiovascular system to alterations in the functioning of the nervous tissue, leading to diabetic sensory polyneuropathy and cardiovascular autonomic neuropathy (CAN) [2]. Screening for signs and symptoms of diabetic neuropathy is critical in clinical practice, as it gives a chance to detect the earliest stages of neuropathy, enabling early intervention. Standard methods of screening include dedicated questionnaires and physical examination with of either temperature or pinprick sensation with a monofilament and vibration sensation using a tuning fork. Standard CAN screening requires more elaborate equipment and is time consuming [1, 3]. There is a need to develop simple and cost-effective methods of early identification of patients at risk of developing diabetes complications, as diabetic neuropathy and CAN are strongly associated with increased cardiovascular risk [4]. The saccadic or eye movement system is the ocular motor system that allows the eyes to rapidly fixate a target on the fovea. Saccadic eye movement examination (SEME) is a simple tool that may be a promising new screening method for asymptomatic diabetic neuropathy [5].

Nerves carrying impulses from taste buds can also be affected by diabetic neuropathy in T1D. In young people with T1D, without developed complications and characterized by good metabolic control, in whom typical complications may not be yet detected with standard methods of investigation, gustatory sense can be altered [6]. Nevertheless, this aspect has been rarely studied to date. GDM usually does not cause long-term neurological complications, though some studies indicate that pregnancy and diabetes affect gustatory sense [6, 7]. These reports are, however, often conflicting. Nutritional therapy is the basis of diabetes treatment for both pregnant and non-pregnant patients. Should pregnancy’s effect on gustatory sense be definitively proven, the attenuated taste perception could be a potential explanation for non-compliance with dietary recommendations in GDM patients, a commonly presenting obstacle in their treatment [8]. As gustatory sense examination (GSE) is relatedly rarely studied and, according to some authors it may lack objectivity [7], by joining it with SEME, its value in screening for diabetic neuropathy could be increased.

In this prospective cohort study we included 91 participants—28 women with GDM, 26 nonpregnant women with T1D and 37 non-diabetic non-pregnant women as the control group. The recruitment took place between June 2022 and July 2024. Women with diabetes were recruited from the Diabetes Outpatient Clinic in Department of Metabolic Diseases, University Hospital in Krakow, Poland, a tertiary reference center for pregnant women with diabetes in the Lesser Poland region. Patients who met the inclusion criteria were offered to participate in the study. The inclusion criteria were: age between 18 and 45 years old, diagnosis of GDM or T1D (for T1D—diagnosed at least 1 year before screening) according to the World Health Organization (WHO) recommendations, depending on the study group, and signed patient’s consent to participate in the study. The exclusion criteria were: pregnancy for T1D group, obesity (body mass index [BMI] $>$30 kg/m² at screening or before pregnancy in GDM study group), any form of diabetic neuropathy or retinopathy in recorded medical history, smoking within 6 months before screening, additional comorbidities such as intemperate vomiting, oncological diseases and steroid therapy. Diagnosis of T1D was confirmed based on the Diabetes Poland criteria [1]. GDM was diagnosed in oral glucose tolerance test (OGTT) with 75 g test, the abnormal values were defined as fasting plasma glucose $\ge$5.1 mmol/L, plasma glucose at 1 h $\ge$10.0 mmol/L, and plasma glucose as 2 h $\ge$8.5 mmol/L, according to the Diabetes Poland criteria [1]. Healthy non-pregnant participants were volunteers—employees of the University Hospital in Krakow. Women with T1D and GDM were matched with controls in 1:0.5 ratio.

Data on age, comorbidities, drugs, diabetes duration (on the day of screening), insulin therapy and its mode, total daily dose of insulin (on the day of screening), weight, height and BMI (on the day of screening or before pregnancy in GDM study group), glycated hemoglobin (HbA1c%), serum creatinine, total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglycerides and albumin-to-creatinine ratio were extracted from the medical records. HbA1c% levels were measured using high-performance liquid chromatography. Additionally, for T1D and GDM participants, continuous glucose monitoring metrics were gathered, including time in range (TIR, for GDM women regarded as 63–140 mg/dL [3.5–7.8 mmol/L], for T1D women as 70–180 mg/dL [3.9–10.0 mmol/L]), time below range (TBR, 63 mg/dL [3.5 mmol/L] for GDM women and 70 mg/dL [3.9 mmol/L] for T1D women), time above range (TAR, $>$140 mg/dL [7.8 mmol/L] for GDM women and $>$180 mg/dL [10.0 mmol/L] for T1D women) [1] and glucose management index (GMI). In GDM women, week of pregnancy at screening, current weight, weight gain during pregnancy until screening, past medical history (including risk factors for GDM), fasting plasma glucose (FPG) and/or OGTT results at the time of diagnosis were also recorded. Michigan Neuropathy Screening Instrument (MNSI) questionnaire [9] and physical examination were used as method of screening for diabetes neuropathy. MNSI is a validated tool that is divided into two sections: a 15-item questionnaire filled by patients and a lower extremity examination form for a healthcare professional. A score $>$2 in the first section indicates a suspicion of diabetic polyneuropathy [10].

We analyzed the data of 28 women with GDM, 26 nonpregnant women with T1D and 37 non-diabetic non-pregnant women. The mean age of participants was 29.4 $\pm$ 5.2 years. Women from GDM were examined in 29 $\pm$ 3.9th week of pregnancy. Women with GDM were older as compared to both women with T1D and healthy controls, with no differences between women with T1D and healthy controls (31.0 [IQR: 29.0–35.8] vs. 28.0 [IQR: 22.5–34.8] and 28.0 [IQR: 25.3–30.0] years, respectively, p = 0.003 for Kruskall-Wallis test for age, 0.002 and 0.003 for between-group differences in post hoc, respectively). Women from GDM and T1D groups (although in the case of the latter of borderline significance) had higher pre-pregnancy BMI as compared to healthy controls, with no differences between women with GDM and T1D (26.2 [IQR: 20.8–28.5] vs. 22.6 [IQR: 20.9–24.4] and 20.9 [IQR: 19.1–22.3] kg/m², respectively, p = 0.001 for Kruskall-Wallis test for BMI, 0.001 and 0.056 for between-group differences in post hoc, respectively, Table 1).

In the GDM group, the mean week of pregnancy of first visit in the clinic was 30.0 $\pm$ 3.9 weeks, and in 15 (53.6%) of women GDM was diagnosed before the 3rd trimester (24th week) of pregnancy. For 12 (42.9%) of the GDM women this was their first pregnancy, for 11 (39.3%) the second. All women in GDM group were treated with insulin, with 25 (89.3%) of them treated with basal insulin and 3 (10.7%) with a basal-bolus insulin regimen, with the mean TDD of insulin being 22.1 $\pm$ 3.9 units. The mean continuous glucose monitoring (CGM) metrics of GDM women were: GMI: 5.6% $\pm$ 0.2%, TIR for pregnancy (63–140 mg/dL): 94.0% $\pm$ 4.2%, TAR: 2.9% $\pm$ 3.1% and TBR: 3.5% $\pm$ 4.2%.

In the T1D group, the mean duration of T1D was 10.7 $\pm$ 6.0 years. 14 (53.8%) patients used insulin pumps and TDD of insulin was 43.2 $\pm$ 12.0 units. The mean HbA1c% was 7.16% $\pm$ 1.2%. The mean CGM metrics of T1D women were: GMI: 6.9% $\pm$ 0.8%, TIR (70–180 mg/dL): 73.3% $\pm$ 14.4%, TAR: 19.3% $\pm$ 13.0% and TBR: 4.7% $\pm$ 2.9%. Mean MNSI score was 1.4 $\pm$ 1.1 with 5 women (19.2%) scoring $>$2 points indicating suspicion of diabetic polyneuropathy.

3.1 GSE

There were significant differences in the total gustatory score between the study groups, with women with GDM and T1D scoring lower than healthy controls, with no significant difference between the GDM and T1D groups (p 0.001 for Kruskall-Wallis test and p 0.001 and p = 0.001 for between-group differences in post hoc, respectively, Table 2, Fig. 1). Considering the individual modalities, sweet, bitter and umami taste scores were lower in the T1D group as compared to healthy controls (p = 0.030 for Kruskall-Wallis test for sweet, 0.024 for between-group differences in post hoc; 0.003 for bitter, 0.033 for Kruskall-Wallis test for umami; 0.042 for between-group differences in post hoc, respectively; Table 2, Fig. 1).

Fig. 1.

Comparison of taste scores (box plots with medians and IQRs). (A) Total gustatory score (%). (B) Total gustatory score minus bitter taste score (%). (C) Sweet taste score. (D) Salty taste score. (E) Sour taste score. (F) Bitter taste score. (G) Umami taste score. Circles mark outliers. Significant differences are marked with p values. T1D, type 1 diabetes; GDM, gestational diabetes mellitus; IQRs, interquartile ranges.

Table 2. Results of GSE.

Gustatory sense examination	GDM	T1D	Control group	Adjusted p value
	n = 28	n = 26	n = 37
Total score [N]	11.0 (9.0–12.0)$	13.5 (11.0–15.3)#	16.0 (14.0–17.0)$#	0.001*
Total score [%]	68.8 (56.3–75.0)$	67.5 (55.0–76.3)#	80.0 (70.0–85.0)$#	0.001*
Total score minus bitter score [N]	11.0 (9.0–12.0)†	10.5 (8.8–11.3)‡	12.0 (10.0–13.0)†‡	0.004*
Total score minus bitter score [%]	68.8 (56.3–75.0)†	65.6 (54.7–70.3)‡	75.0 (62.5–81.3)†‡	0.004*
Sweet [N]	4.0 (3.3–4.0)	4.0 (3.0–4.0)§	4.0 (4.0–4.0)§	0.030*
Sour [N]	2.0 (1.3–3.0)	2.0 (1.8–3.0)	2.0 (2.0–3.0)	NS
Salty [N]	2.0 (2.0–3.0)	3.0 (2.0–3.0)	3.0 (2.0–3.0)	NS
Bitter [N]	NA	3.5 (2.8–4.0)ǁ	4.0 (4.0–4.0)ǁ	0.003*
Umami [N]	2.0 (1.0–3.0)	2.0 (1.0–3.0)ª	3.0 (2.0–4.0)ª	0.033*

Data are presented as medians (interquartile range).

GSE, gustatory sense examination; T1D, type 1 diabetes; GDM, gestational diabetes mellitus; NA, not assessed; NS, not significant; N, number of score points; n, number of participants.

*, adjusted p value 0.05; $, there is a difference in the total score between GDM and control group, p 0.001; # there is a difference in the total score between T1D and control group, adjusted p = 0.001; there is no difference in the total score between GDM and T1D; † there is a difference in the total score minus bitter score between GDM and control group, adjusted p = 0.032; ‡ there is a difference in the total score minus bitter score between T1D and control group, adjusted p = 0.008; there is no difference in the total score minus bitter score between GDM and T1D; §, there is a difference in the sweet score between T1D and control group, adjusted p = 0.024; ǁ, there is a difference in the bitter score between T1D and control group, adjusted p = 0.003; ª, there is a difference in the umami score between T1D and control group, adjusted p = 0.042.

3.2 SEME

Analysis showed that there were significant differences in SEM latency and duration between the study groups (p = 0.050 and 0.046, respectively). Latency was borderline higher (p = 0.054) in GDM than in the control group and duration was shorter in GDM than in T1D group (p = 0.041). There were no differences in SEM amplitude, mean and peak velocity between the studied groups (Table 3, Fig. 2).

Fig. 2.

Comparison of saccadic eye movement parameters ((box plots with medians and IQRs). (A) Latency. (B) Duration. (C) Amplitude. (D) Mean velocity. (E) Peak velocity. Circles mark outliers. Significant differences are marked with p values. T1D, type 1 diabetes; GDM, gestational diabetes mellitus; IQRs, interquartile ranges.

Table 3. Results of SEME.

Saccadic eye movement examination	GDM	T1D	Control group	Adjusted p value
	n = 28	n = 26	n = 37
Latency [ms]	189.5 (162.8–214.3)#	177.5 (148.3–192.5)	167.5 (154.5–186.3)#	0.050*
Duration [ms]	50.0 (47.0–53.0)$	54.5 (48.0–60.3)$	52.0 (49.0–54.0)	0.046*
Amplitude [deg]	10.8 (10.1–11.8)	10.8 (10.1–11.5)	10.9 (10.2–11.5)	NS
Mean velocity [deg/s]	216.0 (197.8–233.5)	204.5 (174.8–227.5)	216.5 (195.0–238.3)	NS
Peak velocity [deg/s]	409.5 (373.3–453.0)	412.0 (342.5–438.8)	405.0 (369.0–445.0)	NS

Data are presented as medians (interquartile range).

SEME, saccadic eye movement examination; T1D, type 1 diabetes; GDM, gestational diabetes mellitus; NS, not significant; n, number of participants.

*, adjusted p value equal or 0.05; #, there is a borderline significant difference in SEM latency between GDM and control group, adjusted p = 0.054; $, there is a borderline significant difference in SEM duration between GDM and T1D, adjusted p = 0.041.

In this study we showed that gustatory sense is attenuated to similar extent in nonpregnant women with T1D and those with GDM, when compared to non-diabetic non-pregnant women. This resemblance is surprising, as it seems that even short duration of relatively mild hyperglycemia in GDM may more significantly that suspected impact gustatory sense. Importantly, these differences in GDM women were independent of typical characteristics of this population, that is older age and higher BMI.

Some changes have been demonstrated regarding the sense of taste in pregnant women [7]. The most frequently studied modality in pregnancy was sweet taste, but the results obtained are inconclusive, showing either decrease [14, 15, 16] or increase [17] in the intensity of sensation of this modality, with some reporting no changes [18, 19, 20, 21]. Additionally, some studies showed trajectories of changes to be dependent on the trimester of pregnancy [14, 15, 16, 17]. Sour taste perception during pregnancy remained unchanged [18, 19, 22] or was reduced [14, 15], similarly to a decrease in the intensity of salty taste sensation. The authors linked changes in these modalities to the promotion of electrolyte replenishment [18, 20]. Some researchers have shown greater sensitivity of pregnant women to bitter taste, postulating that this is a protective mechanism against harmful substances—usually bitter in taste [17, 18], with others reporting impairment in the perception of bitter taste [14, 19, 22].

We identified only singular studies that assessed changes in taste in women with GDM [16, 23] but, again, they were inconclusive due to lacking thorough gustatory sense testing. In one study, the evaluation was conducted using a strawberry-flavored beverage sweetened in varying concentrations. Women with GDM in the third trimester of pregnancy rated sweeter drinks as tastier than women without GDM [16]. This is a more natural way of taste testing, however it comes at a cost of objectivity. Moreover, it focuses on assessing rather the hedonic response to sweet taste and the modality of taste itself.

A potential source of such a wide variety of inconclusive results may be the methodology of gustatory testing [7]. In some studies women subjectively, retrospectively described changes in their sense of taste during pregnancy [7, 15]. The design of the remaining studies was based on comparing pregnant women (in different trimesters) with non-pregnant women as a control group [14, 16, 17, 18, 19]. Only one study tracked the sensory changes of the same group of women before pregnancy and at each trimester of pregnancy, as well as at corresponding time intervals in the control group [18].

Similar attenuation of taste function that was observed in our study could have been caused by low-grade inflammation that was reported to be present in patients with T1D and GDM [24, 25]. Immunological factors, such as interleukin-10 (IL-10) and tumor necrosis factor alpha (TNF-alpha), were proved to affect the gustatory sense function [24]. Multiple cytokine levels are increased in pregnanciec complicated by GDM, including interleukin-6 (IL-6) and human chitinase-3-like protein 1 [26, 27]. One interesting finding from mice models was the presence of a local production of TNF-alpha and sensitivity to it in taste bud cells containing the taste-1-receptor-3 (T1R3) subunit. Mice lacking the TNF-alpha gene had a significantly elevated threshold for detecting bitter taste [28].

Endocrine factors affect the gustatory sense in a major way. Receptors for many hormones have been discovered on taste bud cells, including those for estrogen, progesterone and oxytocin [29, 30]. Studies on mice lacking the oxytocin gene suggest that it led to the reduction of intensity of sweet taste perception [31, 32]. During pregnancy, oxytocin concentrations are increased but its action is locally blocked in the myometrium until delivery. Another potential modulator of taste is leptin as its receptors have also been discovered on taste buds. Leptin, a satiety hormone secreted by white adipose tissue cells, inhibits the sensation of sweet taste in mice [33, 34]. Leptin levels gradually increase during pregnancy as body fat increases. In one study of GDM women, fasting leptin and insulin concentration were positively correlated with higher with the liking scores of sweet solutions [23]. Thus, leptin may be another factor in the downward modulation of sweet taste sensation. Finally, angiotensin II receptors can also be found on taste bud cells containing the T1R3 subunit. In an animal model, administration of angiotensin II increased the frequency of potentials in nerve endings conducting sweet taste sensation and decreased the frequency for salty taste [35]. Pregnant women experience an increase in all components of the renin-angiotensin-aldosterone system [36], which may thus lead to the increase in intensity of sweet taste sensation [17] and decrease gustatory sensation for salty taste [18, 20] as was reported in some studies.

The total gustatory score was higher in women treated with insulin but all women with diabetes in our study (either with GDM or T1D) were using insulin. Still, insulin has been reported to downregulate in the proliferation of taste bud cells in vitro [37], potentially leading to attenuation of taste perception as observed in our study. This concept warrants further clinical investigation.

Finally, our study is the first one to report on umami taste perception in GDM women, showing no differences between them and non-pregnant non-diabetic controls. Previous studies in patients with diabetes [38] and metabolic syndrome [39] showed lower sensitivity to this modality. One study in patients with diabetes attributed this to the vicious cycle of deterioration of the oral environment causing taste disorders that lead to non-compliance to dietary recommendations and poor glycemic control [38]. Products rich in umami taste have also been linked to an increased risk of obesity and metabolic syndrome but the mechanism responsible is still poorly understood [39]. Strikingly, we also did not identify any studies in pregnant women. This scarcity of evidence calls for a larger research effort.

In summary, women with GDM two factors potentially affecting the gustatory sense are present—hyperglycemia and pregnancy, and the combined effects of these two states seem to results in similar attenuation of taste as is observed in non-complicated T1D. Hormonal changes, such as leptin and insulin, have been suggested to affect gustatory sense in GDM but their levels are also secondary to both diabetes and pregnancy [23], justifying investigation of these two states together. Our findings, which support diminished gustatory sense in GDM women, somewhat explain the phenomenon of, and enable giving more accurate feedback for, cravings and other dietary preferences that may emerge during GDM—complicated pregnancy. This in turn should lead to improved control of glycemia and reducing the risk of maternal and neonatal complications of pregnancy. GSE in people with diabetes can be treated as a non-invasive, low-cost but effective example of personalized medicine, an approach that has been gaining extensive attention recently.

T1D women in our study had lower sensitivity to sweet and umami tastes than non-diabetic controls. Several studies have unanimously shown a decrease in sensitivity to the primary modalities of taste—sweet, salty, sour and bitter [6, 40, 41, 42] but only a few investigated umami taste [38]. One study linked these gustatory changes to polyneuropathy and factors that predispose to diabetes development, smoking and alcohol consumption [6]. It has been suggested that these predisposing factors may affect dietary choices and preference for sweet foods, which exacerbates hyperglycemia [42]. Contradicting these findings, however, is an another study of patients with T1D but no developed diabetic complications, that found no significant changes in the sensitivity of the senses of taste and smell [43]. Our study falls in support of diabetes causing a change in gustatory sensation, as differences in sensation were seen when compared to non-diabetic non-pregnant women, despite moderately short duration of diabetes and no history of diagnosed diabetes complications.

Contrary to our expectations and previous research [5, 44, 45, 46], there were no statistically significant differences in SEME results between women with T1D and healthy controls. Our results may be explained by moderately short duration of diabetes in T1D women and their relatively good metabolic control [47]. The above mentioned studies [5, 44] included cohorts of patients treated in the 1990s when most current therapies for T1D had not been available, possibly resulting in unsatisfactory metabolic control. A recent study, that excluded patients with developed T1D complications, reported some abnormalities in the function of oculomotor system in this population [46]. However, it used a different type of computer-assisted eye-tracking-based system, thus limiting the extrapolation these results to ours. In our population, the MNSI questionnaire seemed to be more effective in the early stages of the development of diabetic neuropathy. Despite this, we believe that SEME may be a promising tool in screening for diabetic neuropathy due to its objectivity. For this reason, in future we plan to focus solely on T1D patients with a wide spectrum of metabolic control, diabetes duration and different stages of diabetic neuropathy. Finally, our finding that GDM affects SEME latency and duration is novel and noteworthy as we were not able to identify any studies investigating saccades in pregnancy, GDM or new-onset diabetes of any type. We suspect that the longer SEM latency in GDM women in our study should not be attributed to hyperglycemia, usually mild and transient. Other factors, such as hormonal changes or diabetic distress could be the culprits. The shorter saccadic duration observed in our study could be secondary to longer latency.

An intriguing explanation of discrepancy between GSE and SEME results in T1D patients could be an early and selective damage due to hyperglycemia to taste bud cells and/or nerve fibers carrying impulses from the taste buds to the central nervous system. Moreover, as taste sensation can be affected by neuropathy, we searched for correlations between SEME and GSE results and found a negative correlation between the total gustatory score and SEM latency. This is logical, as better gustatory sense may indicate a better condition of nerves, thus shorter causing (“more normal”) SEM latency.

We acknowledge some limitations of our study. First, the number of participants was relatively small. Based on the sample size calculation it was adequate to detect a difference in SEME parameters reported previously. However, the only studies on SEM in people with T1D included distinctively different population than ours. Second, we did not include comparisons between pregnant women with T1D, women with GDM and non-diabetic pregnant controls. This would add to our study, however it would also require a much larger study group to achieve adequate power of statistical analysis. Third, we did not include people with T1D and diabetic neuropathy. Finally, there is no universally accepted methodology of gustatory sense testing, potentially limiting extrapolation of our results to wider cohorts. Still, it should be noted that the advantage of our study is the use of a control group of non-diabetic, non-pregnant women. Moreover, our study is the first one thoroughly assess the gustatory sense and SEM in GDM women.

In this study, we showed that gustatory sense is attenuated to similar extent in nonpregnant women with T1D and those with GDM, when compared to non-diabetic non-pregnant women, potentially affecting dietary choices, compliance to dietary recommendations and, finally, the metabolic control of diabetes. This finding may partially explain the phenomenon of cravings and enable giving more accurate dietary feedback during GDM. Gustatory testing could be a potential measure to improve the metabolic control of diabetes and reducing the risk of maternal and neonatal complications of pregnancy. There were however no differences in the quantitative parameters of SEM between the compared groups. More studies in T1D patients with longer duration of diabetes are needed to assess the effectiveness of saccadometry in screening for diabetic neuropathy.

The data analyzed in the paper is available from the corresponding author upon reasonable request.

MiK and MS designed the study. MiK, MW, MagKw, MarK, PW and MagKr qualified the patients and performed the study procedures. MiK and MW were responsible for the data curation, MiK performed statistical analysis, validated and visualized the study results. MiK and MS acquired finding for the study. MiK, KC and MS designed the methodology of the study. MiK and MS were responsible for the project administration. MagKw, MarK, PW, MagKr, PW and KC provided resources for the study. MiK wrote the original draft of the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Jagiellonian University Bioethics Committee (Komisja Bioetyczna Uniwersytetu Jagiellońskiego), approval number 1072.6120.126.2021. The study was conducted in accordance with local legislation and institutional requirements. All the participants provided written informed consent to participate in this study. This study was started prior to the requirement for registration of cohort studies. The present study reported in accordance with the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines (Supplementary File 2).

The authors acknowledge the editorial assistance of Ms. Joana Mielko, School of Medicine in English, Jagiellonian University Medical College.

This study was funded Jagiellonian University Medical College (grant number N41/DBS/001196).

The authors declare no conflict of interest.

Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.31083/j.ceog5112277.