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Bahamón-Pinzón D, Vélez-Torres I, Estes SL, Lee C, Moore A, Bridges W, Carraway E, Blazer H, Gutiérrez Zapata HM, Vanegas D. Confined within a sugarcane monoculture: A participatory assessment of water pollution and potential health risks in the community of El Tiple, Colombia. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 946:174072. [PMID: 38897454 DOI: 10.1016/j.scitotenv.2024.174072] [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: 03/09/2024] [Revised: 06/02/2024] [Accepted: 06/15/2024] [Indexed: 06/21/2024]
Abstract
Communities neighboring monoculture plantations are vulnerable to different forms of pollution associated with agro-industrial operations. Herein, we examine the case of El Tiple, a rural Afro descendant community embedded within one of the largest sugarcane plantations in the Americas. We implemented a participatory approach to assess water pollution, exposure via water ingestion, and non-carcinogenic health risks associated with the use of local water sources available to the community. We conducted household surveys to unveil demographic characteristics and family dynamics linked to water consumption. Additionally, we measured water quality parameters and assessed the concentration glyphosate, its major metabolite (aminomethylphosphonic acid) and metals and metalloids. Drinking water El Tiple households is sourced from three primary sources: the local aqueduct system, water delivery trucks, and private deep wells. Tests on water samples from both the local aqueduct and delivery trucks showed no traces of pesticides, metals, or metalloids surpassing regulatory limits set by Colombian or EPA standards. However, we found concentration of contaminants of primary concern, including mercury (up to 0.0052 ppm) and lead (up to 0.0375 ppm) that exceed the permissible regulatory thresholds in water from groundwater wells. Residents of the peripheric subdivisions of El Tiple are four times more reliant on well water extraction than residents of the central area of the town due to lack of access to public drinking water and sanitation infrastructure. Finally, adult women and school-age children have a higher health risk associated with exposure to local pollutants than adult men due to their constant presence in the town. We conclude that expanding the coverage of clean water and sanitation infrastructure to include all households of the community would be the most recommended measure to minimize exposure and risk via ingestion of water pollutants.
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Affiliation(s)
- David Bahamón-Pinzón
- Department of Environmental Engineering and Earth Sciences, Clemson University, Clemson, United States
| | - Irene Vélez-Torres
- School of Natural Resources and Environmental Engineering (EIDENAR), Universidad del Valle, Cali, Colombia; Interdisciplinary Group for Biotechnology Innovation and Ecosocial Change -BioNovo, Universidad del Valle, Cali, Colombia
| | - Shanna L Estes
- Department of Environmental Engineering and Earth Sciences, Clemson University, Clemson, United States
| | - Cindy Lee
- Department of Environmental Engineering and Earth Sciences, Clemson University, Clemson, United States; Department of Engineering and Science Education, Clemson University, Clemson, SC, United States
| | - Arelis Moore
- Department of Languages, Clemson University, Clemson, United States
| | - William Bridges
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, United States
| | - Elizabeth Carraway
- Department of Environmental Engineering and Earth Sciences, Clemson University, Clemson, United States
| | - Haley Blazer
- Department of Languages, Clemson University, Clemson, United States
| | | | - Diana Vanegas
- Department of Environmental Engineering and Earth Sciences, Clemson University, Clemson, United States; Interdisciplinary Group for Biotechnology Innovation and Ecosocial Change -BioNovo, Universidad del Valle, Cali, Colombia; Global Alliance for Rapid Diagnostics, Michigan State University, East Lancing, MI, United States.
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Zou Y, Wu S, Xu X, Tan X, Yang S, Chen T, Zhang J, Li S, Li W, Wang F. Cope with copper: From molecular mechanisms of cuproptosis to copper-related kidney diseases. Int Immunopharmacol 2024; 133:112075. [PMID: 38663316 DOI: 10.1016/j.intimp.2024.112075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
Cuproptosis has recently been identified as a novel regulatory mechanism of cell death. It is characterized by the accumulation of copper in mitochondria and its binding to acylated proteins. These characteristics lead to the downregulation of iron-sulfur cluster proteins and protein toxicity stress, ultimately resulting in cell death. Cuproptosis is distinct from other types of cell death, including necrosis, apoptosis, ferroptosis, and pyroptosis. Cu induces oxidative stress damage, protein acylation, and the oligomerization of acylated TCA cycle proteins. These processes lead to the downregulation of iron-sulfur cluster proteins and protein toxicity stress, disrupting cellular Cu homeostasis, and causing cell death. Cuproptosis plays a significant role in the development and progression of various kidney diseases such as acute kidney injury, chronic kidney disease, diabetic nephropathy, kidney transplantation, and kidney stones. On the one hand, inducers of cuproptosis, such as disulfiram (DSF), chloroquinolone, and elesclomol facilitate cuproptosis by promoting cell oxidative stress. In contrast, inhibitors of Cu chelators, such as tetraethylenepentamine and tetrathiomolybdate, relieve these diseases by inhibiting apoptosis. To summarize, cuproptosis plays a significant role in the pathogenesis of kidney disease. This review comprehensively discusses the molecular mechanisms underlying cuproptosis and its significance in kidney diseases.
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Affiliation(s)
- Yurong Zou
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shukun Wu
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingli Xu
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaoqiu Tan
- Key Laboratory of Medical Electrophysiology, Ministry of Education & Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Shuang Yang
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Tangting Chen
- Key Laboratory of Medical Electrophysiology, Ministry of Education & Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Jiong Zhang
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shengqiang Li
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, China.
| | - Wei Li
- Department of Emergency Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
| | - Fang Wang
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
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Wu M, Hou W, Qin R, Wang G, Sun D, Geng Y, Du Y. Comparative mathematical modeling of causal association between metal exposure and development of chronic kidney disease. Front Endocrinol (Lausanne) 2024; 15:1362085. [PMID: 38752174 PMCID: PMC11094205 DOI: 10.3389/fendo.2024.1362085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Previous studies have identified several genetic and environmental risk factors for chronic kidney disease (CKD). However, little is known about the relationship between serum metals and CKD risk. Methods We investigated associations between serum metals levels and CKD risk among 100 medical examiners and 443 CKD patients in the medical center of the First Hospital Affiliated to China Medical University. Serum metal concentrations were measured using inductively coupled plasma mass spectrometry (ICP-MS). We analyzed factors influencing CKD, including abnormalities in Creatine and Cystatin C, using univariate and multiple analysis such as Lasso and Logistic regression. Metal levels among CKD patients at different stages were also explored. The study utilized machine learning and Bayesian Kernel Machine Regression (BKMR) to assess associations and predict CKD risk based on serum metals. A chained mediation model was applied to investigate how interventions with different heavy metals influence renal function indicators (creatinine and cystatin C) and their impact on diagnosing and treating renal impairment. Results Serum potassium (K), sodium (Na), and calcium (Ca) showed positive trends with CKD, while selenium (Se) and molybdenum (Mo) showed negative trends. Metal mixtures had a significant negative effect on CKD when concentrations were all from 30th to 45th percentiles compared to the median, but the opposite was observed for the 55th to 60th percentiles. For example, a change in serum K concentration from the 25th to the 75th percentile was associated with a significant increase in CKD risk of 5.15(1.77,8.53), 13.62(8.91,18.33) and 31.81(14.03,49.58) when other metals were fixed at the 25th, 50th and 75th percentiles, respectively. Conclusions Cumulative metal exposures, especially double-exposure to serum K and Se may impact CKD risk. Machine learning methods validated the external relevance of the metal factors. Our study highlights the importance of employing diverse methodologies to evaluate health effects of metal mixtures.
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Affiliation(s)
- Miaoling Wu
- Department of Environmental Health, School of Public Health, China Medical University, Shenyang, China
| | - Weiming Hou
- Department of Medical Engineering, Air Force Medical Center, PLA, Beijing, China
| | - Ruonan Qin
- Department of Environmental Health, School of Public Health, China Medical University, Shenyang, China
| | - Gang Wang
- Experimental and Teaching Center, School of Public Health, China Medical University, Shenyang, China
| | - Da Sun
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Ye Geng
- Blood Purification Center, The First Hospital of China Medical University, Shenyang, China
| | - Yinke Du
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
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Buralli RJ, Albuquerque PLMM, Santo CDE, Calice-Silva V, Nerbass FB. Occupational risks associated with chronic kidney disease of non-traditional origin (CKDnt) in Brazil: it is time to dig deeper into a neglected problem. J Bras Nefrol 2024; 46:e20230123. [PMID: 38591822 PMCID: PMC11248720 DOI: 10.1590/2175-8239-jbn-2023-0123en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/14/2023] [Indexed: 04/10/2024] Open
Abstract
In the past decades, an epidemic of chronic kidney disease (CKD) has been associated with environmental and occupational factors (heat stress from high workloads in hot temperatures and exposure to chemicals, such as pesticides and metals), which has been termed CKD of non-traditional origin (CKDnt). This descriptive review aims to present recent evidence about heat stress, pesticides, and metals as possible causes of CKDnt and provide an overview of the related Brazilian regulation, enforcement, and health surveillance strategies. Brazilian workers are commonly exposed to extreme heat conditions and other CKDnt risk factors, including increasing exposure to pesticides and metals. Furthermore, there is a lack of adequate regulation (and enforcement), public policies, and strategies to protect the kidney health of workers, considering the main risk factors. CKDnt is likely to be a significant cause of CKD in Brazil, since CKD's etiology is unknown in many patients and several conditions for its development are present in the country. Further epidemiological studies may be conducted to explore causal associations and estimate the impact of heat, pesticides, and metals on CKDnt in Brazil. Moreover, public policies should prioritize reducing workers´ exposure and promoting their health and safety.
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Affiliation(s)
- Rafael Junqueira Buralli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Medicina Preventiva, São Paulo, SP, Brazil
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Atlani M, Kumar A, Ahirwar R, Meenu MN, Goel SK, Kumari R, Anirudhan A, Vallamshetla S, Reddy GST. Heavy metal association with chronic kidney disease of unknown cause in central India-results from a case-control study. BMC Nephrol 2024; 25:120. [PMID: 38570752 PMCID: PMC10988978 DOI: 10.1186/s12882-024-03564-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 03/26/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Chronic Kidney Disease of unknown cause (CKDu) a disease of exclusion, and remains unexplained in various parts of the world, including India. Previous studies have reported mixed findings about the role of heavy metals or agrochemicals in CKDu. These studies compared CKDu with healthy controls but lacked subjects with CKD as controls. The purpose of this study was to test the hypothesis whether heavy metals, i.e. Arsenic (As), Cadmium (Cd), Lead (Pb), and Chromium (Cr) are associated with CKDu, in central India. METHODS The study was conducted in a case-control manner at a tertiary care hospital. CKDu cases (n = 60) were compared with CKD (n = 62) and healthy subjects (n = 54). Blood and urine levels of As, Cd, Pb, and Cr were measured by Inductively Coupled Plasma- Optical Emission Spectrometry. Pesticide use, painkillers, smoking, and alcohol addiction were also evaluated. The median blood and urine metal levels were compared among the groups by the Kruskal-Wallis rank sum test. RESULTS CKDu had significantly higher pesticide and surface water usage as a source of drinking water. Blood As levels (median, IQR) were significantly higher in CKDu 91.97 (1.3-132.7) µg/L compared to CKD 4.5 (0.0-58.8) µg/L and healthy subjects 39.01 (4.8-67.4) µg/L (p < 0.001) On multinominal regression age and sex adjusted blood As was independently associated with CKDu[ OR 1.013 (95%CI 1.003-1.024) P < .05].Blood and urinary Cd, Pb, and Cr were higher in CKD compared to CKDu (p > .05). Urinary Cd, Pb and Cr were undetectable in healthy subjects and were significantly higher in CKDu and CKD compared to healthy subjects (P = < 0.001). There was a significant correlation of Cd, Pb and Cr in blood and urine with each other in CKDu and CKD subjects as compared to healthy subjects. Surface water use also associated with CKDu [OR 3.178 (95%CI 1.029-9.818) p < .05). CONCLUSION The study showed an independent association of age and sex adjusted blood As with CKDu in this Indian cohort. Subjects with renal dysfunction (CKDu and CKD) were found to have significantly higher metal burden of Pb, Cd, As, and Cr as compared to healthy controls. CKDu subjects had significantly higher pesticide and surface water usage, which may be the source of differential As exposure in these subjects.
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Affiliation(s)
- Mahendra Atlani
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Room No-3022, Academic Block, 3rd Floor, Saket Nagar, Bhopal, Madhya Pradesh, 462020, India.
| | - Ashok Kumar
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India.
| | - Rajesh Ahirwar
- Department of Environmental Biochemistry, ICMR-National Institute for Research in Environmental Health (NIREH), Bhopal, Madhya Pradesh, India
| | - M N Meenu
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Room No-3022, Academic Block, 3rd Floor, Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
| | - Sudhir K Goel
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
| | - Ravita Kumari
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
| | - Athira Anirudhan
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Room No-3022, Academic Block, 3rd Floor, Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
| | | | - G Sai Tharun Reddy
- All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Zhang Z, Guo S, Hua L, Wang B, Chen Q, Liu L, Xiang L, Sun H, Zhao H. Urinary Levels of 14 Metal Elements in General Population: A Region-Based Exploratory Study in China. TOXICS 2023; 11:488. [PMID: 37368588 DOI: 10.3390/toxics11060488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
Metal pollution may lead to a variety of diseases; for this reason, it has become a matter of public concern worldwide. However, it is necessary to use biomonitoring approaches to assess the risks posed to human health by metals. In this study, the concentrations of 14 metal elements in 181 urine samples obtained from the general population of Gansu Province, China, were analyzed using inductively coupled plasma mass spectrometry. Eleven out of fourteen target elements had detection frequencies above 85%, namely, Cr, Ni, As, Se, Cd, Al, Fe, Cu and Rb. The concentrations of most metal elements in the urine of our subjects corresponded to the medium levels of subjects in other regional studies. Gender exerted a significant influence (p < 0.05) on the concentrations of Tl, Rb and Zn. The concentrations of Ni, As, Pb, Sr, Tl, Zn, Cu and Se showed significant differences among different age groups and the age-related concentration trends varied among these elements. There were significant differences in the urine concentrations of Zn and Sr between those subjects in the group who were frequently exposed to soil (exposed soil > 20 min/day) and those in the group who were not, indicating that people in regular contact with soil may be more exposed to metals. This study provides useful information for evaluating the levels of metal exposure among general populations.
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Affiliation(s)
- Zining Zhang
- Ministry of Education Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin 300350, China
| | - Sai Guo
- Ministry of Education Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin 300350, China
| | - Liting Hua
- Ministry of Education Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin 300350, China
| | - Beibei Wang
- School of Energy and Environmental Engineering, University of Science and Technology Beijing, Beijing 100083, China
| | - Qiusheng Chen
- Institute of Agro-Product Safety and Nutrition, Tianjin Academy of Agricultural Sciences, Tianjin 300381, China
| | - Lu Liu
- Institute of Agro-Product Safety and Nutrition, Tianjin Academy of Agricultural Sciences, Tianjin 300381, China
| | - Li Xiang
- State Key Laboratory of Environmental and Biological Analysis, Department of Chemistry, Hong Kong Baptist University, Hong Kong, China
| | - Hongwen Sun
- Ministry of Education Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin 300350, China
| | - Hongzhi Zhao
- Ministry of Education Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin 300350, China
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Fang YJ, Lin KL, Lee JH, Luo KH, Chen TH, Yang CC, Chuang HY. Interaction between Single Nucleotide Polymorphisms (SNP) of Tumor Necrosis Factor-Alpha (TNF-α) Gene and Plasma Arsenic and the Effect on Estimated Glomerular Filtration Rate (eGFR). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074404. [PMID: 35410083 PMCID: PMC8999026 DOI: 10.3390/ijerph19074404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 12/04/2022]
Abstract
When poisons enter the human body, tumor necrosis factor (TNF-α) will increase and cause damage to tissues through oxidative stress or inflammatory reaction. In previous studies, arsenic (As) has known to cause many health problems. Some studies have shown that As exposure is negatively correlated with estimated glomerular filtration rate (eGFR), or with the prevalence of proteinuria. At present, there are few studies focusing on the effects of As exposure and TNF-α single nucleotide polymorphism (SNP) to eGFR; thus, this study was intended to explore the interactions between TNF-α SNPs and plasma As and their effects on eGFR. A cohort of 500 adults, aged 30 to 70 years, was randomly selected from Taiwan Biobank (TWB). We used the gene chip to screen out seven SNPs of the TNF-α gene and used the results, combined with questionnaires, biochemical tests, and stored plasma samples from the TWB, for the analysis of As by inductively coupled plasma mass spectrometry (ICP-MS). After adjustments for BMI, hypertension, hyperlipidemia, kidney stones, and smoking habits, multiple regression statistics were performed to explore the interaction between SNPs and plasma As with eGFR. In this sample of the general population, plasma As had a significant association with the decline of eGFR (β (SE) = −7.92 (1.70), p < 0.0001). TNF-α gene SNP rs1800629 had the property of regulating TNF-α, which interacts with plasma As; individuals with the AG type had a significantly lower eGFR than those with the GG type, by 9.59 mL/min/1.73 m2 (p < 0.05), which, regarding the dominant model, could infer that the A allele is a risk allele. SNP rs769177 had no interaction with plasma As; however, participants with the TT or TC type had significantly higher eGFR levels than the CC carriers, by 4.02 mL/min/1.73 m2 (p < 0.05). While rs769176 interacted with plasma As, if a person with the TC type had a higher plasma As concentration, that would sustain higher eGFR. This study found that certain SNPs of the TNF-α gene would be robust to the decline of eGFR caused by As exposure. Still, we need further research to confirm the protective regulation mechanism of these SNPs.
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Affiliation(s)
- Yi-Jen Fang
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-J.F.); (J.-H.L.)
- Digestive Disease Center, Show-Chwan Memorial Hospital, Changhua 500, Taiwan
| | - Kuan-Lin Lin
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Jyuhn-Hsiarn Lee
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-J.F.); (J.-H.L.)
- National Institute of Environmental Health Sciences, National Health Research Institutes, Miaoli County 350, Taiwan
| | - Kuei-Hau Luo
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Tzu-Hua Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan;
| | - Chen-Cheng Yang
- Department of Occupational Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan;
| | - Hung-Yi Chuang
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-J.F.); (J.-H.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Research Center for Environmental Medicine, Department of Public Health and Environmental Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: ; Tel.: +886-7312-1101
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