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Huang YC, Liu SP, Chen SY, Lin JM, Lin HJ, Lei YJ, Wang YH, Huang WT, Liao WL, Tsai FJ. Increased Expression of Ecto-NOX Disulfide-thiol Exchanger 1 (ENOX1) in Diabetic Mice Retina and its Involvement in Diabetic Retinopathy Development. In Vivo 2019; 33:1801-1806. [PMID: 31662505 DOI: 10.21873/invivo.11671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/08/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIM Diabetic retinopathy (DR) is a type of retinal damage caused by a complication of diabetes and is a major cause of blindness in working-age adults. Ecto-NOX disulfide-thiol exchanger 1 (ENOX1) is a member of the ecto-NOX family involved in the plasma membrane electron transport pathway. This study aimed to investigate the role of ENOX1 in the development of DR. MATERIALS AND METHODS Human retinal endothelial cells (HRECs) and human retinal pigment epithelial cells (HREpiCs) exposed to a high concentration (25 mM) of D-glucose and type 2 diabetes (T2D) mice (+Leprdb/+Leprdb, db/db) with retinopathy were used as models to determine the ENOX1 expression levels there. RESULTS Our results showed that ENOX1 expression levels did not significantly change in both HRECs and HREpiCs under hyperglycemic conditions for 48 h. Nevertheless, ENOX1 expression increased significantly in T2D mouse retinas, particularly in the photoreceptor layer, compared to the control mouse retinas. CONCLUSION Different retinal ENOX1 expression in T2D mice and control mice suggested that ENOX1 may be involved in DR development.
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Affiliation(s)
- Yu-Chuen Huang
- School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Shih-Ping Liu
- Center for Translational Medicine, China Medical University Hospital, Taichung, Taiwan, R.O.C.,Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan, R.O.C
| | - Shih-Yin Chen
- School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Jane-Ming Lin
- School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Department of Ophthalmology, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Hui-Ju Lin
- School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Department of Ophthalmology, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Yu-Jie Lei
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Yeh-Han Wang
- Department of Anatomical Pathology, Taipei Institute of Pathology, Taipei, Taiwan, R.O.C
| | - Wan-Ting Huang
- Department of Public Health, China Medical University, Taichung, Taiwan, R.O.C
| | - Wen-Ling Liao
- Center for Personalized Medicine, China Medical University Hospital, Taichung, Taiwan, R.O.C. .,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan, R.O.C
| | - Fuu-Jen Tsai
- School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C. .,School of Chinese Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Children's Hospital of China Medical University, Taichung, Taiwan, R.O.C.,Department of Medical Genetics, China Medical University Hospital, Taichung, Taiwan, R.O.C
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Zhou TC, Yang L, Liu YY, Qin Y, Li YP, Zhang L, Yang K, Yang Y. Polymorphisms in the Uncoupling Protein 2 Gene Are Associated with Diabetic Retinopathy in Han Chinese Patients with Type 2 Diabetes. Genet Test Mol Biomarkers 2018; 22:637-643. [PMID: 30359091 DOI: 10.1089/gtmb.2018.0115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The uncoupling protein 2 (UCP2) gene plays an important role in the complications of type 2 diabetes (T2D). However, the association between variants in the UCP2 gene and diabetic retinopathy (DR) in Han Chinese T2D patients remains unclear. METHODS Two single-nucleotide polymorphisms (SNPs) [rs659366 (-866G/A) and a 45-bp insertion/deletion (I/D) in the 3'-UTR] in the UCP2 gene were genotyped in a study cohort of 209 T2D patients with DR and 199 T2D patients without DR by direct DNA sequencing. RESULTS Logistic regression analysis showed that the AA and GA genotypes of rs659366 were significantly associated with an increased risk for nonproliferative DR (NPDR) in the codominant model (corrected p-value <0.01) and the dominant model (corrected p-value = 0.006). Patients harboring the II and DI genotypes had a higher risk for PDR in the codominant model (corrected p-value = 0.011) and the dominant model (corrected p-value = 0.006), and the DI genotype showed a higher risk for NPDR in the dominant model (corrected p-value = 0.007) or codominant model (corrected p-value = 0.006). Further, haplotype analyses verified that the A-I haplotype is a risk haplotype for NPDR and PDR. CONCLUSION This study suggests that the UCP2 gene may be involved in the pathogenesis of NPDR and PDR in Han Chinese patients with T2D.
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Affiliation(s)
- Tai-Cheng Zhou
- 1 Central Laboratory, Department of Endocrinology, Second People's Hospital of Yunnan Province , Kunming, China
| | - Lei Yang
- 2 Nuclear Medicine Department, Second Affiliated Hospital of Kunming Medical University , Kunming, China
| | - Yong-Ying Liu
- 3 First Affiliated Hospital of Medical College, Shihezi University , Shihezi, China
| | - Yuan Qin
- 1 Central Laboratory, Department of Endocrinology, Second People's Hospital of Yunnan Province , Kunming, China
| | - Yi-Ping Li
- 1 Central Laboratory, Department of Endocrinology, Second People's Hospital of Yunnan Province , Kunming, China
| | - Liang Zhang
- 1 Central Laboratory, Department of Endocrinology, Second People's Hospital of Yunnan Province , Kunming, China
| | - Ke Yang
- 4 Cardiology Laboratory of Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China
| | - Ying Yang
- 1 Central Laboratory, Department of Endocrinology, Second People's Hospital of Yunnan Province , Kunming, China
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3
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Broadgate S, Kiire C, Halford S, Chong V. Diabetic macular oedema: under-represented in the genetic analysis of diabetic retinopathy. Acta Ophthalmol 2018; 96 Suppl A111:1-51. [PMID: 29682912 DOI: 10.1111/aos.13678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022]
Abstract
Diabetic retinopathy, a complication of both type 1 and type 2 diabetes, is a complex disease and is one of the leading causes of blindness in adults worldwide. It can be divided into distinct subclasses, one of which is diabetic macular oedema. Diabetic macular oedema can occur at any time in diabetic retinopathy and is the most common cause of vision loss in patients with type 2 diabetes. The purpose of this review is to summarize the large number of genetic association studies that have been performed in cohorts of patients with type 2 diabetes and published in English-language journals up to February 2017. Many of these studies have produced positive associations with gene polymorphisms and diabetic retinopathy. However, this review highlights that within this large body of work, studies specifically addressing a genetic association with diabetic macular oedema, although present, are vastly under-represented. We also highlight that many of the studies have small patient numbers and that meta-analyses often inappropriately combine patient data sets. We conclude that there will continue to be conflicting results and no meaningful findings will be achieved if the historical approach of combining all diabetic retinopathy disease states within patient cohorts continues in future studies. This review also identifies several genes that would be interesting to analyse in large, well-defined cohorts of patients with diabetic macular oedema in future candidate gene association studies.
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Affiliation(s)
- Suzanne Broadgate
- Nuffield Laboratory of Ophthalmology; Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
| | - Christine Kiire
- Nuffield Laboratory of Ophthalmology; Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
- Oxford Eye Hospital; John Radcliffe Hospital; Oxford University NHS Foundation Trust; Oxford UK
| | - Stephanie Halford
- Nuffield Laboratory of Ophthalmology; Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
| | - Victor Chong
- Nuffield Laboratory of Ophthalmology; Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
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4
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Abstract
PURPOSE OF REVIEW Ocular genetics is an emerging specialty which has accompanied the advancement of modern genetic technology. This review is to understand the current status of practice in ocular genetics in Taiwan. RECENT FINDINGS There is only one ocular genetics clinic in Taiwan. Certified clinical laboratories provide few gene tests in ocular genetics. Most ocular genetic study is focused on myopia. Financial obstacles are a major problem for patients to seek gene tests. SUMMARY Despite a relatively successful, healthcare system in Taiwan, when compared with developed countries, ocular genetics is at an early stage of development. More financial resources and labor are needed to advance clinical care and research.
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Affiliation(s)
- Yu-Hung Lai
- aDepartment of Ophthalmology, Kaohsiung Medical University Hospital bDepartment of Ophthalmology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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5
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Priščáková P, Minárik G, Repiská V. Candidate gene studies of diabetic retinopathy in human. Mol Biol Rep 2016; 43:1327-1345. [PMID: 27730450 PMCID: PMC5102952 DOI: 10.1007/s11033-016-4075-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 09/09/2016] [Indexed: 12/13/2022]
Abstract
Diabetic retinopathy (DR) is a multifactorial disease with complex pathophysiology. It is the main cause of blindness among the people in productive age. The purpose of this literature review is to highlight recent achievements in the genetics of diabetic retinopathy with particular focus on candidate gene studies. We summarized most of the available published data about candidate genes for diabetic retinopathy with the goal to identify main genetic aspects. We conclude that genetic studies reported contradictory findings and no genetic variants meet criteria of a diagnostic marker, or significantly elucidate the root of DR development. Based on these findings it is important to continue with the research in the field of DR genetics, mainly due to the fact that currently new possibilities and approaches associated with utilization of next-generation sequencing are available.
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Affiliation(s)
- Petra Priščáková
- Faculty of Medicine, Institute of Medical Biology, Genetics and Clinical Genetics, University Hospital Bratislava, Comenius University in Bratislava, Sasinkova 4, 81108, Bratislava, Slovakia
| | - Gabriel Minárik
- Medirex Group Academy n.o., Galvaniho 17/C, 82016, Bratislava, Slovakia
| | - Vanda Repiská
- Faculty of Medicine, Institute of Medical Biology, Genetics and Clinical Genetics, University Hospital Bratislava, Comenius University in Bratislava, Sasinkova 4, 81108, Bratislava, Slovakia.
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6
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Agarwal A, Ingham SA, Harkins KA, Do DV, Nguyen QD. The role of pharmacogenetics and advances in gene therapy in the treatment of diabetic retinopathy. Pharmacogenomics 2016; 17:309-20. [PMID: 26807609 DOI: 10.2217/pgs.15.173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Diabetic retinopathy (DR) and its complications such as diabetic macular edema continue to remain a major cause for legal blindness in the developed world. While the introduction of anti-tVEGF agents has significantly improved visual outcomes of patients with DR, unpredictable response, largely due to genetic polymorphisms, appears to be a challenge with this therapy. With advances in identification of various genetic biomarkers, novel therapeutic strategies consisting of gene transfer are being developed and tested for patients with DR. Application of pharmacogenetic principles appears to be a promising futuristic strategy to attenuate diabetes-mediated retinal vasculopathy. In this comprehensive review, data from recent studies in the field of pharmacogenomics for the treatment of DR have been provided.
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Affiliation(s)
- Aniruddha Agarwal
- Ocular Imaging Research & Reading Center (OIRRC), Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA
| | - Sally A Ingham
- College of Medicine, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA
| | - Keegan A Harkins
- Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA
| | - Diana V Do
- Ocular Imaging Research & Reading Center (OIRRC), Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA.,Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA
| | - Quan Dong Nguyen
- Ocular Imaging Research & Reading Center (OIRRC), Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA.,Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, South 42nd Street & Emile St, Omaha, NE 68198, USA
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7
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Hampton BM, Schwartz SG, Brantley MA, Flynn HW. Update on genetics and diabetic retinopathy. Clin Ophthalmol 2015; 9:2175-93. [PMID: 26648684 PMCID: PMC4664538 DOI: 10.2147/opth.s94508] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Clinical risk factors for diabetic retinopathy (DR), such as duration of disease and degree of glucose control, do not adequately predict disease progression in individual patients, suggesting the presence of a genetic component. Multiple smaller studies have investigated genotype–phenotype correlations in genes encoding vascular endothelial growth factor, aldose reductase, the receptor for advanced glycation end products, and many others. In general, reported results have been conflicting, due to factors including small sample sizes, variations in study design, differences in clinical end points, and underlying genetic differences between study groups. At this time, there is no confirmed association with any risk allele reported. As we continue to collect data from additional studies, the role of genetics in DR may become more apparent.
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Affiliation(s)
- Blake M Hampton
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Milam A Brantley
- Department of Ophthalmology, Vanderbilt Eye Institute, Nashville, TN, USA
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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8
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Wong CW, Teo BW, Lamoureux E, Ikram MK, Wang JJ, Tai ES, Sethi S, Wong TY, Sabanayagam C. Serum Cystatin C, Markers of Chronic Kidney Disease, and Retinopathy in Persons with Diabetes. J Diabetes Res 2015; 2015:404280. [PMID: 26576434 PMCID: PMC4630396 DOI: 10.1155/2015/404280] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/13/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We examined the association of CKD defined by serum creatinine, serum cystatin C, and albuminuria with moderate diabetic retinopathy (DR). METHODS We examined 1,119 Indian adults with diabetes, aged 40-80 years, who participated in the Singapore Indian Eye Study (2007-2009), a population-based cross-sectional study. The associations of CKD defined by each of the three markers alone and in combination with moderate DR were examined using logistic regression models adjusted for potential confounding factors including duration of diabetes, smoking, body mass index, systolic blood pressure, and HbA1c. RESULTS The prevalence of moderate DR was significantly higher among those with CKD defined by triple markers (41.1%) compared to CKD defined separately by creatinine (26.6%), cystatin C (20.9%), and albuminuria (23.4%). People with CKD defined by triple markers had a fourteenfold higher odds of moderate DR (OR (95% CI) = 13.63 (6.08-30.54)) compared to those without CKD by any marker. Nearly half (48.7%) of participants with cystatin C ≥ 1.12 mg/L have moderate DR. CONCLUSIONS CKD defined by a triple marker panel was strongly associated with moderate DR in this Asian population with diabetes.
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Affiliation(s)
- Chee Wai Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
| | - Boon Wee Teo
- Department of Medicine, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Ecosse Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Mohammad Kamran Ikram
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Jie Jin Wang
- Westmead Millennium Institute for Medical Research, C24 Westmead Hospital, University of Sydney, Sydney, NSW 2006, Australia
| | - E. Shyong Tai
- Department of Medicine, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Sunil Sethi
- Department of Pathology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
- *Charumathi Sabanayagam:
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Agarwal A, Soliman MK, Sepah YJ, Do DV, Nguyen QD. Diabetic retinopathy: variations in patient therapeutic outcomes and pharmacogenomics. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2014; 7:399-409. [PMID: 25548526 PMCID: PMC4271791 DOI: 10.2147/pgpm.s52821] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Diabetes and its microvascular complications in patients poses a significant challenge and constitutes a major health problem. When it comes to manifestations in the eye, each case of diabetic retinopathy (DR) is unique, in terms of the phenotype, genotype, and, more importantly, the therapeutic response. It is therefore important to identify factors that distinguish one patient from another. Personalized therapy in DR is a new trend aimed at achieving maximum therapeutic response in patients by identifying genotypic and phenotypic factors that may result in less than optimal response to conventional therapy, and consequently, lead to poorer outcome. With advances in the identification of these genetic markers, such as gene polymorphisms and human leucocyte antigen associations, as well as development of drugs that can target their effects, the future of personalized medicine in DR is promising. In this comprehensive review, data from various studies have been analyzed to present what has been achieved in the field of pharmacogenomics thus far. An insight into future research is also provided.
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Affiliation(s)
- Aniruddha Agarwal
- Ocular Imaging Research and Reading Center, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, USA
| | - Mohamed K Soliman
- Ocular Imaging Research and Reading Center, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, USA
| | - Yasir J Sepah
- Ocular Imaging Research and Reading Center, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, USA
| | - Diana V Do
- Ocular Imaging Research and Reading Center, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, USA
| | - Quan Dong Nguyen
- Ocular Imaging Research and Reading Center, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, USA
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10
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Liao WL, Tsai FJ. Personalized medicine in Type 2 Diabetes. Biomedicine (Taipei) 2014; 4:8. [PMID: 25520921 PMCID: PMC4264975 DOI: 10.7603/s40681-014-0008-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/03/2014] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes (T2D) is a global public health concern, its prevalence in Asia, especially Taiwan, rising every year. The risk of developing T2D and diabetes complications is not only controlled by environmental but also by genetic factors. Genetic association studies have shown polymorphisms at specific loci may help identify individuals at greatest risk and response to oral antidiabetic drugs. This review probes effect of genetic profiling on T2D and its complications, using our study population as examples. Also, pharmacogenetics and pharmacogenomics of oral anitdiabetic drug will be explored.
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Affiliation(s)
- Wen-Ling Liao
- Center for Personalized Medicine, China Medical University Hospital, Taichung, Taiwan ; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Fuu-Jen Tsai
- Department of Medical Research and Medical Genetics, China Medical University Hospital Taichung, Taichung, Taiwan ; School of Chinese Medicine, China Medical University, Taichung, Taiwan ; Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan ; Department of Health and Nutrition Biotechnology, Asia University, Taichung, Taiwan ; Department of Medical Genetics, Pediatrics and Medical Research, China Medical University Hospital, No.2 Yuh-Der Road, 404 Taichung, Taiwan
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