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Zielinski JM, Reisert M, Sajonz BEA, Teo SJ, Thierauf-Emberger A, Wessolleck J, Frosch M, Spittau B, Leupold J, Döbrössy MD, Coenen VA. In Search for a Pathogenesis of Major Depression and Suicide-A Joint Investigation of Dopamine and Fiber Tract Anatomy Focusing on the Human Ventral Mesencephalic Tegmentum: Description of a Workflow. Brain Sci 2024; 14:723. [PMID: 39061463 DOI: 10.3390/brainsci14070723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Major depressive disorder (MDD) is prevalent with a high subjective and socio-economic burden. Despite the effectiveness of classical treatment methods, 20-30% of patients stay treatment-resistant. Deep Brain Stimulation of the superolateral branch of the medial forebrain bundle is emerging as a clinical treatment. The stimulation region (ventral tegmental area, VTA), supported by experimental data, points to the role of dopaminergic (DA) transmission in disease pathology. This work sets out to develop a workflow that will allow the performance of analyses on midbrain DA-ergic neurons and projections in subjects who have committed suicide. Human midbrains were retrieved during autopsy, formalin-fixed, and scanned in a Bruker MRI scanner (7T). Sections were sliced, stained for tyrosine hydroxylase (TH), digitized, and integrated into the Montreal Neurological Institute (MNI) brain space together with a high-resolution fiber tract atlas. Subnuclei of the VTA region were identified. TH-positive neurons and fibers were semi-quantitatively evaluated. The study established a rigorous protocol allowing for parallel histological assessments and fiber tractographic analysis in a common space. Semi-quantitative readings are feasible and allow the detection of cell loss in VTA subnuclei. This work describes the intricate workflow and first results of an investigation of DA anatomy in VTA subnuclei in a growing naturalistic database.
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Affiliation(s)
- Jana M Zielinski
- Department of Stereotactic and Functional Neurosurgery, Medical Center of Freiburg University, Breisacher Straße 64, 79106 Freiburg i.Br., Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center of Freiburg University, Breisacher Straße 64, 79106 Freiburg i.Br., Germany
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, Medical Physics, Medical Center-University of Freiburg, 79106 Freiburg, Germany
| | - Bastian E A Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center of Freiburg University, Breisacher Straße 64, 79106 Freiburg i.Br., Germany
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
| | - Shi Jia Teo
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, Medical Physics, Medical Center-University of Freiburg, 79106 Freiburg, Germany
| | - Annette Thierauf-Emberger
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Institute of Forensic Medicine, Medical Center of Freiburg University, 79104 Freiburg, Germany
| | - Johanna Wessolleck
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional, Neurosurgery, Medical Center of Freiburg University, 79106 Freiburg, Germany
| | - Maximilian Frosch
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Institute of Neuropathology, Medical Center of Freiburg University, 79106 Freiburg, Germany
| | - Björn Spittau
- Medical School OWL, Anatomy and Cell Biology, Bielefeld University, 33501 Bielefeld, Germany
- Institute for Anatomy and Cell Biology, Department of Molecular Embryologie, Faculty of Medicine, Freiburg University, 79104 Freiburg, Germany
| | - Jochen Leupold
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, Medical Physics, Medical Center-University of Freiburg, 79106 Freiburg, Germany
| | - Máté D Döbrössy
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional, Neurosurgery, Medical Center of Freiburg University, 79106 Freiburg, Germany
- Faculty of Biology, University of Freiburg, 79104 Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center of Freiburg University, Breisacher Straße 64, 79106 Freiburg i.Br., Germany
- Medical Faculty of University of Freiburg, 79106 Freiburg, Germany
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional, Neurosurgery, Medical Center of Freiburg University, 79106 Freiburg, Germany
- Center for Deep Brain Stimulation, Medical Center of Freiburg University, 79106 Freiburg, Germany
- Center for Basics in Neuromodulation, Medical Faculty of Freiburg University, 79106 Freiburg, Germany
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Deng X, Launer LJ, Lawrence KG, Werder EJ, Buller ID, Jackson WB, Sandler DP. Association between solar radiation and mood disorders among Gulf Coast residents. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2024:10.1038/s41370-024-00691-w. [PMID: 38831020 DOI: 10.1038/s41370-024-00691-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Climate factors such as solar radiation could contribute to mood disorders, but evidence of associations between exposure to solar radiation and mood disorders is mixed and varies by region. OBJECTIVE To evaluate the association of solar radiation with depression and distress among residents living in U.S. Gulf states. METHODS We enrolled home-visit participants in the Gulf Long-Term Follow-up Study who completed validated screening questionnaires for depression (Patient Health Questionnaire-9, N = 10,217) and distress (Kessler Psychological Distress Questionnaire, N = 8,765) for the previous 2 weeks. Solar radiation estimates from the Daymet database (1-km grid) were linked to residential addresses. Average solar radiation exposures in the seven (SRAD7), 14 (SRAD14), and 30 days (SRAD30) before the home visit were calculated and categorized into quartiles (Q1-Q4). We used generalized linear mixed models to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for associations between solar radiation and depression/distress. RESULTS Higher levels of SRAD7 were non-monotonically inversely associated with depression [PRVs.Q1 (95%CI): Q2 = 0.81 (0.68, 0.97), Q3 = 0.80 (0.65, 0.99), Q4 = 0.88 (0.69, 1.15)] and distress [PRVs.Q1 (95%CI): Q2 = 0.76 (0.58, 0.99), Q3 = 0.77 (0.57, 1.06), Q4 = 0.84 (0.58, 1.22)]. Elevated SRAD14 and SRAD30 appeared to be associated with decreasing PRs of distress. For example, for SRAD14, PRs were 0.86 (0.63-1.19), 0.80 (0.55-1.18), and 0.75 (0.48-1.17) for Q2-4 versus Q1. Associations with SRAD7 varied somewhat, though not significantly, by season with increasing PRs of distress in spring and summer and decreasing PRs of depression and distress in fall. IMPACT STATEMENT Previous research suffered from exposure misclassification, which impacts the validity of their conclusions. By leveraging high-resolution datasets and Gulf Long-term Follow-up Cohort, our findings support an association between increased solar radiation and fewer symptoms of mood disorders.
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Affiliation(s)
- Xinlei Deng
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Lenore J Launer
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, Bethesda, MD, USA
| | - Kaitlyn G Lawrence
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Emily J Werder
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Ian D Buller
- Social & Scientific Systems, Inc., a DLH Holdings Company, Silver Spring, MD, USA
| | | | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA.
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Raza A, Partonen T, Hanson LM, Asp M, Engström E, Westerlund H, Halonen JI. Daylight during winters and symptoms of depression and sleep problems: A within-individual analysis. ENVIRONMENT INTERNATIONAL 2024; 183:108413. [PMID: 38171042 DOI: 10.1016/j.envint.2023.108413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/23/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND With climate change Northern areas of the globe are expected to have less daylight during winters due to less snow and more cloudiness. While wintertime has been linked to mental health problems, the role of wintertime daylight has been scarcely studied. We examined longitudinal associations for wintertime objective exposure to global radiation and self-reported daylight exposure with symptoms of depression and sleep problems. METHODS Our analytical sample included 15,619 respondents from three Swedish Longitudinal Occupational Surveys of Health (2012, 2014 and 2016). Objective exposure was global radiation (MJ/m2, November-January and November-February). Subjective exposure was based on self-reported time spent outdoors in daylight (<1 h vs. ≥ 1 h, November-January). Symptoms of depression were evaluated using a six-item subscale of the (Hopkins) Symptom Checklist. Fixed-effects method with conditional logistic regression controlled for time-invariant participant characteristics by design and time-varying covariates were added into models. RESULTS One unit increase in the four-month averaged global radiation was associated with lower odds of depressive symptoms (OR 0.69, 95 % CI 0.52-0.91). These findings were confirmed using four-month cumulative exposure (OR 0.91, 95 % CI 0.85-0.98). Individuals reporting ≥ 1 h exposure to daylight during winter months were less likely to report depressive symptoms (OR 0.72, 95 % CI 0.60-0.82) compared to time when their exposure was < 1 h. Higher three-month exposure to global radiation suggested a protective association for sleep problems. CONCLUSION These findings suggest that higher exposure to daylight during winters may contribute to lower likelihood of depression symptoms.
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Affiliation(s)
- Auriba Raza
- Stress Research Institute, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.
| | - Timo Partonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, P.O. Box 30, FI-00271 Helsinki, Finland
| | - Linda Magnusson Hanson
- Stress Research Institute, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden
| | - Magnus Asp
- Department of Community Planning Services, Swedish Meteorological and Hydrological Institute, SE-601 76 Norrköping, Sweden
| | - Erik Engström
- Department of Community Planning Services, Swedish Meteorological and Hydrological Institute, SE-601 76 Norrköping, Sweden
| | - Hugo Westerlund
- Stress Research Institute, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden
| | - Jaana I Halonen
- Stress Research Institute, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden; Department of Health Security, Finnish Institute for Health and Welfare, P.O. Box 30, FI-00271 Helsinki, Finland
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Lin J, Yang H, Zhang Y, Cao Z, Li D, Sun L, Zhang X, Wang Y. Association of time spent in outdoor light and genetic risk with the incidence of depression. Transl Psychiatry 2023; 13:40. [PMID: 36737433 PMCID: PMC9898270 DOI: 10.1038/s41398-023-02338-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
Depression is the consequence of both environment and genes working together. Genetic factors increase depression risk, but it is unclear whether this association can be offset by time spent in outdoor light. The study was undertaken to investigate the optimal time spent in outdoor light for lowering the risk of depression and the joint association of time spent in outdoor light and depression genetic risk. In UK Biobank, 380,976 depression-free individuals were included in this study. Polygenic risk score (PRS) was categorized into three groups in terms of tertiles. Time spent in outdoor light on a typical day in summer or winter originated from the questionnaire survey. Depression was defined as hospital admission. The potential dose-response relationship between time spent in outdoor light and depression risk was shown by a restricted cubic spline. Data were analyzed using Cox regressions and Laplace regression. After the median follow-up of 12.6 years, 13,636 individuals suffered from depression in the end. A nonlinear (J-shaped relationship) trend was observed between time spent in outdoor light and depression risk. On average, 1.5 h/day of outdoor light was related to the minimum risk of depression. Individuals below and above this optimal time both had elevated depression risk (below, HR = 1.09, 95% CI: 1.02-1.16; above, HR = 1.13, 95% CI: 1.07-1.20), and the time to incident depression were both shortened by 0.46 years (50th percentile differences [PD] = -0.46, 95% CI: -0.78, -0.14) and 0.63 years (50th PD = -0.63, 95% CI: -0.90, -0.35) years, respectively. In a comparison of individuals with the lowest tertile of PRS and average 1.5 h/day outdoor light, the HRs and 95% CIs of depression were 1.36 (1.21-1.53) and 1.43 (1.29-1.58) in those with the highest tertile of PRS and below/above this reference value, respectively. Significant multiplicative interactions were observed between intermediate genetic risks and longer time spent in outdoor light. We found that an average of 1.5 h/day spent in outdoor light was associated with a lower depression risk whatever the degree of depression genetic predisposition. Moderate time spent in outdoor light may contribute to a decreased depression risk even among people with a higher genetic risk of depression.
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Affiliation(s)
- Jing Lin
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Hongxi Yang
- Department of Bioinformatics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Yuan Zhang
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zhi Cao
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Dun Li
- School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Li Sun
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Xinyu Zhang
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Yaogang Wang
- School of Public Health, Tianjin Medical University, Tianjin, China.
- School of Integrative Medicine, Public Health Science and Engineering College, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
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Ji Y, Chen C, Xu G, Song J, Su H, Wang H. Effects of sunshine duration on daily outpatient visits for depression in Suzhou, Anhui Province, China. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:2075-2085. [PMID: 35927404 DOI: 10.1007/s11356-022-22390-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/01/2022] [Indexed: 06/15/2023]
Abstract
Previous epidemiological studies have reported seasonal variation patterns of depression symptoms, which may be influenced by bad weather conditions, such as a lack of sunlight. However, evidence on the acute effects of sunshine duration on outpatient visits for depression is limited, especially in developing countries, and the results are inconsistent. We collected daily outpatient visits for depression from the local mental health centre in Suzhou, Anhui Province, China, during 2017-2019. We defined the 5th and 95th sunshine percentiles as short and long sunshine durations, respectively. A quasi-Poisson generalized linear regression model combined with a distributed lag nonlinear model was used to quantitatively assess the effects of short and long sunshine durations on outpatient visits for depression. Stratified analyses were further performed by gender, age and number of visits to identify vulnerable populations. A total of 26,343 depression cases were collected during the study period. An approximate U-shaped exposure-response association was observed between sunshine duration and depression outpatient visits. The cumulative estimated relative risks (RRs) for short and long sunshine durations at lag 0-21 days were 1.53 [95% confidence intervals (CI): 1.14, 2.06] and 1.13 (95% CI: 0.88, 1.44), respectively. Moreover, a short sunshine duration was associated with a greater disease burden than a long sunshine duration, with attributable fractions (AFs) of 16.64% (95% CI: 7.8%, 23.89%) and 2.24% (95% CI: -2.65%, 5.74%), respectively. Subgroup analysis showed that males, people aged less than 45 years and first-visit cases may be more susceptible to a lack of sunlight. For a long sunshine duration, no statistically significant associations were found in any population groups. Our study found that a short sunshine duration was associated with an increased risk of depression. The government, medical institutions, family members and patients themselves should fully recognize the important role of sunlight and take active measures to prevent depression.
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Affiliation(s)
- Yanhu Ji
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Changhao Chen
- Department of Psychiatry, Suzhou Second People's Hospital, Suzhou, China
| | - Guangxing Xu
- Shantou Center for Disease Control and Prevention, Shantou, China
| | - Jian Song
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Hong Su
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Heng Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China.
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Hwang HJ, Choi YJ, Hong D. The Association between Self-Rated Health Status, Psychosocial Stress, Eating Behaviors, and Food Intake According to the Level of Sunlight Exposure in Korean Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010262. [PMID: 36612583 PMCID: PMC9819439 DOI: 10.3390/ijerph20010262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 06/01/2023]
Abstract
Sunlight exposure has been reported to have various beneficial effects on human health. This study investigated the relationship between self-rated health status, psychosocial stress, eating behaviors, and food intake according to sunlight exposure in 948 adults. Sunlight exposure was classified as less than one hour, less than three hours, and greater than three hours. Of the participants, 49.2% had fewer than three hours of daily exposure to sunlight. Regarding participants exposed to sunlight for less than one hour, the largest response was that they did not engage in outdoor activities on weekdays or weekends, and the rate of being outdoors in the shade on sunny days was the highest in this group at 42.7%. Furthermore, the participants exposed to sunlight for less than one hour had a lower health response than the other two groups, and there were significantly more participants classified in the stress risk group. Regarding eating habits, those with less than an hour of exposure to sunlight frequently ate fried foods, fatty foods, added salt, and snacks, and had significantly lower total dietary scores or three regular meals. Additionally, their frequency of consumption of cereals, milk and dairy products, orange juice, and pork was also significantly lower than the other groups. Thus, it is necessary to provide sufficient guidelines for adequate sunlight exposure and food intake because participants with low sunlight exposure may have low vitamin D synthesis and insufficient food intake.
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Affiliation(s)
- Hyo-Jeong Hwang
- Department of Food and Nutrition, Sahmyook University, Seoul 01795, Republic of Korea
| | - Yean-Jung Choi
- Department of Food and Nutrition, Sahmyook University, Seoul 01795, Republic of Korea
| | - Dongwan Hong
- Department of Medical Informatics, College of Medicine, Catholic University of Korea, Seoul 06591, Republic of Korea
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Wang L, Zhang J, Wei J, Zong J, Lu C, Du Y, Wang Q. Association of ambient air pollution exposure and its variability with subjective sleep quality in China: A multilevel modeling analysis. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2022; 312:120020. [PMID: 36028077 DOI: 10.1016/j.envpol.2022.120020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
Growing epidemiological evidence has shown that exposure to ambient air pollution contributes to poor sleep quality. However, whether variability in air pollution exposure affects sleep quality remains unclear. Based on a large sample in China, this study linked individual air pollutant exposure levels and temporal variability with subjective sleep quality. Town-level data on daily air pollution concentration for 30 days prior to the survey date were collected, and the monthly mean value, standard deviations, number of heavily polluted days, and trajectory for six common pollutants were calculated to measure air pollution exposure and its variations. Sleep quality was subjectively assessed using the Pittsburgh Sleep Quality Index (PSQI), and a PSQI score above 5 indicated overall poor sleep quality. Multilevel and negative control models were used. Both air pollution exposure and variability contributed to poor sleep quality. A one-point increase in the one-month mean concentration of particulate matter with aerodynamic diameters of ≤2.5 μm (PM2.5) and ≤10 μm (PM10) led to 0.4% (95% confidence interval (CI): 1.002-1.006) and 0.3% (95% CI: 1.001-1.004) increases in the likelihoods of overall poor sleep quality (PSQI score >5), respectively; the odds ratios of a heavy pollution day with PM2.5 and PM10 were 2.2% (95% CI: 1.012-1.032) and 2.2% (95% CI: 1.012-1.032), respectively. Although the mean concentrations of nitrogen dioxide, sulfur dioxide, and carbon monoxide met the national standard, they contributed to the likelihood of overall poor sleep quality (PSQI score >5). A trajectory of air pollution exposure with maximum variability was associated with a higher likelihood of overall poor sleep quality (PSQI score >5). Subjective measures of sleep latency, duration, and efficiency (derived from PSQI) were affected in most cases. Thus, sleep health improvements should account for air pollution exposure and its variations in China under relatively high air pollution levels.
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Affiliation(s)
- Lingli Wang
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China; National Institute for Medical Dataology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jingxuan Zhang
- Shandong Provincial Mental Health Center, Jinan City, Shandong, China
| | - Jing Wei
- Department of Atmospheric and Oceanic Science, Earth System Science Interdisciplinary Center, University of Maryland, USA
| | - Jingru Zong
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China; National Institute for Medical Dataology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chunyu Lu
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China; National Institute for Medical Dataology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yajie Du
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China; National Institute for Medical Dataology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qing Wang
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China; National Institute for Medical Dataology, Cheeloo College of Medicine, Shandong University, Jinan, China.
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