1
|
Li X, Wei Y, Wen K, Han Q, Ogino K, Ma G. Novel insights on the encapsulation mechanism of PLGA terminal groups on ropivacaine. Eur J Pharm Biopharm 2021; 160:143-151. [PMID: 33524537 DOI: 10.1016/j.ejpb.2021.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/25/2020] [Accepted: 01/23/2021] [Indexed: 11/19/2022]
Abstract
Currently, the influences of free terminal groups (hydroxyl, carboxyl and ester) of PLGA on encapsulating active pharmaceutical ingredient are relatively ambiguous even though PLGA types were defined as critical quality attributes in vast majority of design of experiment process. In this study, emulsion method combined with premix membrane emulsification technique has been used to encapsulate ropivacaine (RVC), a small molecule local anesthetic in clinical. Based on the narrow particle size distribution, the influences and mechanisms of the terminal groups on properties of ropivacaine loaded microspheres have been investigated in detail. It was found that microspheres prepared by PLGA with hydroxyl or ester groups exhibited lower encapsulation efficiency but faster in vitro release rate than that of carboxyl groups. In the meanwhile, on microcosmic level analysis by quartz crystal microbalance with dissipation, atomic force microscope and confocal laser scanning microscopy, we attributed this distinction to the specific interaction between ropivacaine and different terminal groups. Subsequently, the reaction activation centers were verified by density functional simulation calculation and frontier molecular orbital theory at molecular level. Additionally, pharmacokinetics and pharmacodynamic research of infiltration anesthesia model were performed to compare sustained release ability, duration and intensity of the anesthetic effect in vivo. Finally, potential safety and toxicity were evaluated by the biochemical analysis. This study not only provides a novel mechanism of drug encapsulation process but also potential flexible selections in terms of various anesthesia indications in clinical.
Collapse
Affiliation(s)
- Xun Li
- State Key Laboratory of Biochemical Engineering, PLA Key Laboratory of Biopharmaceutical Production & Formulation Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing 100190, PR China; University of the Chinese Academy of Sciences, Beijing 100049, PR China
| | - Yi Wei
- State Key Laboratory of Biochemical Engineering, PLA Key Laboratory of Biopharmaceutical Production & Formulation Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing 100190, PR China.
| | - Kang Wen
- State Key Laboratory of Biochemical Engineering, PLA Key Laboratory of Biopharmaceutical Production & Formulation Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing 100190, PR China; University of the Chinese Academy of Sciences, Beijing 100049, PR China
| | - Qingzhen Han
- State Key Laboratory of Multiphase Complex Systems, Research Department for Environmental Technology and Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing 100190, PR China
| | - Kenji Ogino
- Graduate School of Bio-Applications Systems Engineering, Tokyo University of Agriculture and Technology, Koganei, Tokyo 184-8588, Japan
| | - Guanghui Ma
- State Key Laboratory of Biochemical Engineering, PLA Key Laboratory of Biopharmaceutical Production & Formulation Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing 100190, PR China.
| |
Collapse
|
2
|
Chou AK, Chiu CC, Chen YW, Wang JJ, Hung CH. Skin nociceptive block with pramoxine delivery by subcutaneous injection in rats. Pharmacol Rep 2018; 70:1180-1184. [PMID: 30326418 DOI: 10.1016/j.pharep.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pramoxine has been shown to produce spinal anesthesia, while cutaneous analgesia (peripheral) of pramoxine is not established. The experimental goal was to examine cutaneous antinociception produced by a local anesthetic (LA) pramoxine and compare this result with that of another well-known LA lidocaine. METHODS Cutaneous antinociception was evaluated by blockade of pinprick- induced cutaneous trunci muscle reflex (CTMR) on the skin of rat's back. After the dose-related curves were constructed, the quality and duration of drug's (lidocaine and pramoxine) cutaneous antinociception were compared. RESULTS We showed that pramoxine, as well as lidocaine produced skin antinociception in a dose-related fashion. The relative potency (ED50 [50% effective dose] basis) was lidocaine (5.44 [4.67-6.35] μmol) greater than pramoxine (42.1 [38.8-45.7] μmol) (p < 0.01). On the basis of equianalgesic doses (ED75, ED50, and ED25), pramoxine caused equivalent duration of cutaneous antinociception to lidocaine. CONCLUSIONS These preclinical data indicated that pramoxine elicits skin antinociception dose-relatedly. Pramoxine exhibits a potency less than that of lidocaine while they have a comparable duration of skin antinociceptive action.
Collapse
Affiliation(s)
- An-Kuo Chou
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan; Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan.
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
3
|
Tzeng JI, Chiu CC, Wang JJ, Hung CH, Chen YW. Spinal sensory and motor blockade by intrathecal doxylamine and triprolidine in rats. J Pharm Pharmacol 2018; 70:1654-1661. [PMID: 30251371 DOI: 10.1111/jphp.13017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 09/02/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of this experiment was mainly to examine the effects of intrathecally injected doxylamine and triprolidine, two antihistamine drugs spinal motor and sensory functions. METHODS After intrathecally injecting the rats with five different doses, the dose-response curves of spinal sensory and motor block with doxylamine and triprolidine were constructed. In comparison with the local anaesthetic mepivacaine, the quality and duration of spinal anaesthesia with doxylamine or triprolidine were conducted. KEY FINDINGS Doxylamine, mepivacaine and triprolidine elicited spinal motor and sensory (nociception and proprioception) blockades in a dose-dependent fashion. On the ED50 (50% effective dose) basis, the rank order of drug potency was triprolidine > mepivacaine > doxylamine (P < 0.05) at provoking spinal motor, proprioceptive and nociceptive blockades. On the equianaesthetic doses (ED25 , ED50 and ED75 ), the duration of spinal anaesthesia with doxylamine was longer (P < 0.01) than that with mepivacaine or triprolidine. Moreover, doxylamine or triprolidine displayed greater potency (ED50 ) (P < 0.05) and duration (P < 0.05) of sensory block over motor block. CONCLUSIONS Doxylamine or triprolidine produces a dose-dependent effect of spinal motor and sensory block. Triprolidine with a better nociception-selective action over motor block has a better potency than mepivacaine or doxylamine. Doxylamine and triprolidine produce longer durations than mepivacaine.
Collapse
Affiliation(s)
- Jann-Inn Tzeng
- Department of Anesthesiology, Chi-Mei Medical Center, Yong Kang, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi-Mei Medical Center, Tainan and Liouying, Taiwan
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan
| |
Collapse
|
4
|
Hung CH, Shieh JP, Chiu CC, Wang JJ, Chen YW. Subcutaneous infiltration of doxylamine on cutaneous analgesia in rats. Pharmacol Rep 2018; 70:565-569. [PMID: 29679880 DOI: 10.1016/j.pharep.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 11/28/2017] [Accepted: 12/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to evaluate the effect of doxylamine, a first generation antihistamine, as a local analgesic agent by comparing its effect to bupivacaine. METHODS After blocking the cutaneous trunci muscle reflex (CTMR) by subcutaneous injection of doxylamine, we assessed doxylamine's cutaneous analgesic effect in rats. The dose-related effect and duration of doxylamine on infiltrative cutaneous analgesia were compared with that of bupivacaine. RESULTS We demonstrated that doxylamine, as well as the local anesthetic bupivacaine produced the cutaneous analgesic effects in a dose-related fashion. At the equipotent dose (50% effective doses (ED50)), the relative potency was bupivacaine (0.41 (0.36-0.48) mmol)> doxylamine (7.39 (6.91-7.91)mmol) (p<0.01). On an equipotent basis (ED25, ED50 and ED75), subcutaneous doxylamine resulted in greater duration of action (p<0.01) than bupivacaine at producing cutaneous analgesia. CONCLUSIONS The result of this experiment indicated that doxylamine has the local anesthetic property less potent than bupivacaine, but its nociceptive block duration is longer than that of bupivacaine at an equianalgesic dose.
Collapse
Affiliation(s)
- Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ja-Ping Shieh
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan; Center for General Education, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan.
| |
Collapse
|
5
|
Chen YW, Chiu CC, Lin HT, Wang JJ, Hung CH. Adding Dopamine to Proxymetacaine or Oxybuprocaine Solutions Potentiates and Prolongs the Cutaneous Antinociception in Rats. Anesth Analg 2018; 126:1721-1728. [PMID: 29381510 DOI: 10.1213/ane.0000000000002635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated the interaction of dopamine-proxymetacaine and dopamine- oxybuprocaine antinociception using isobolograms. METHODS This experiment uses subcutaneous drug (proxymetacaine, oxybuprocaine, and dopamine) injections under the skin of the rat's back, thus simulating infiltration blocks. The dose-related antinociceptive curves of proxymetacaine and oxybuprocaine alone and in combination with dopamine were constructed, and then the antinociceptive interactions between the local anesthetic and dopamine were analyzed using isobolograms. RESULTS Subcutaneous proxymetacaine, oxybuprocaine, and dopamine produced a sensory block to local skin pinpricks in a dose-dependent fashion. The rank order of potency was proxymetacaine (0.57 [0.52-0.63] μmol/kg) > oxybuprocaine (1.05 [0.96-1.15] μmol/kg) > dopamine (165 [154-177] μmol/kg; P < .01 for each comparison) based on the 50% effective dose values. On the equianesthetic basis (25% effective dose, 50% effective dose, and 75% effective dose), the nociceptive block duration of proxymetacaine or oxybuprocaine was shorter than that of dopamine (P < .01). Oxybuprocaine or proxymetacaine coinjected with dopamine elicited a synergistic antinociceptive effect and extended the duration of action. CONCLUSIONS Oxybuprocaine and proxymetacaine had a higher potency and provoked a shorter duration of sensory block compared with dopamine. The use of dopamine increased the quality and duration of skin antinociception caused by oxybuprocaine and proxymetacaine.
Collapse
Affiliation(s)
- Yu-Wen Chen
- From the Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Heng-Teng Lin
- Department of Physical Medicine and Rehabilitation, Madou Sin-Lau Hospital, Tainan, Taiwan
- Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
6
|
Han MM, Chiu CC, Wang JJ, Chen YW, Hung CH. Mexiletine co-injected with clonidine increases the quality and duration of cutaneous analgesia in response to skin pinpricks in the rat. Neurosci Lett 2017. [PMID: 28625576 DOI: 10.1016/j.neulet.2017.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The goal of the experimental design was to assess the cutaneous analgesic effect of mexiletine by co-injection with clonidine. The effect of nociceptive block was evaluated according to the inhibition of the cutaneous trunci muscle reflex (CTMR) in response to skin pinpricks in rats. The dose-related analgesic effect of mexiletine alone or mexiletine co-administrated with clonidine was constructed after subcutaneous injection. Subcutaneous injections of mexiletine elicited dose-related cutaneous analgesia. Compared with mexiletine (1.8μmol), adding clonidine to mexiletine (1.8μmol) solutions for skin nociceptive block potentiated and prolonged the action (p<0.01). Mexiletine (6μmol) combined with clonidine extended the duration of cutaneous analgesia when compared with mexiletine (6μmol) alone (p<0.01). Co-administration of clonidine increases the potency and extends the duration of cutaneous analgesia by mexiletine, and the minimal dose of clonidine to intensify the analgesic effect is 0.06μmol.
Collapse
Affiliation(s)
- Ming-Ming Han
- Department of Anesthesiology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan.
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
7
|
Chen YW, Chen CM, Liu KS, Wang JJ, Hung CH. 2-Adamantanamine produces prolonged spinal block in rats. Neurosci Lett 2017; 653:168-172. [DOI: 10.1016/j.neulet.2017.05.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/22/2017] [Accepted: 05/22/2017] [Indexed: 02/07/2023]
|
8
|
Cutaneous synergistic analgesia of bupivacaine in combination with dopamine in rats. Neurosci Lett 2016; 620:88-92. [DOI: 10.1016/j.neulet.2016.03.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/28/2015] [Accepted: 03/23/2016] [Indexed: 11/19/2022]
|
9
|
Tzeng JI, Wang JN, Wang JJ, Chen YW, Hung CH. Intrathecal rimantadine induces motor, proprioceptive, and nociceptive blockades in rats. Neurosci Lett 2016; 618:94-98. [DOI: 10.1016/j.neulet.2016.02.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/27/2016] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
|
10
|
Hung CH, Chiu CC, Liu KS, Wang JJ, Chen YW. Clonidine as an adjuvant for propranolol enhances its effect on infiltrative cutaneous analgesia in rats. Neurosci Lett 2016; 616:70-4. [PMID: 26828301 DOI: 10.1016/j.neulet.2016.01.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 01/13/2016] [Accepted: 01/26/2016] [Indexed: 02/07/2023]
Abstract
Clonidine prolongs duration of analgesia when used as an adjunct to local anesthetics for infiltrative cutaneous analgesia, and propranolol produces local anesthesia. The purpose of the experiment was to evaluate clonidine as an adjuvant for propranolol on the quality and duration of cutaneous analgesia. A rat model of cutaneous trunci muscle reflex (CTMR) in response to local skin pinprick was employed to evaluate the cutaneous analgesic effect of propranolol combined with clonidine. The long-lasting local anesthetic bupivacaine was used as control. Cutaneous analgesia elicited by propranolol and bupivacaine was dose-dependent, and both propranolol (9.0μmol) and bupivacaine (1.8μmol) produced 100% nociceptive blockade. On an 50% effective dose (ED50) basis, the relative potency was bupivacaine [0.48 (0.42-0.55) μmol] greater than propranolol [2.27 (1.98-2.54) μmol] (p<0.01). Subcutaneous saline and clonidine (0.12μmol) did not produce cutaneous analgesia. The mixture of an ineffective-dose clonidine (0.12μmol) and a drug (propranolol or bupivacaine) at ED50 or ED95 increased the potency and extended the duration at producing cutaneous analgesia. The resulting data demonstrated that propranolol is less potent than bupivacaine as an infiltrative anesthetic. Clonidine as an adjuvant for propranolol or bupivacaine has a significant peripheral action in increasing the depth and duration of action on infiltrative cutaneous analgesia.
Collapse
Affiliation(s)
- Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Kuo-Sheng Liu
- Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan.
| |
Collapse
|
11
|
Chen YW, Chiu CC, Liu KS, Hung CH, Wang JJ. Memantine elicits spinal blockades of motor function, proprioception, and nociception in rats. Fundam Clin Pharmacol 2015; 29:567-74. [PMID: 26301611 DOI: 10.1111/fcp.12142] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/07/2015] [Accepted: 08/18/2015] [Indexed: 02/05/2023]
Abstract
Although memantine blocks sodium currents and produces local skin anesthesia, spinal anesthesia with memantine is unknown. The purpose of the study was to evaluate the local anesthetic effect of memantine in spinal anesthesia and its comparison with a widely used local anesthetic lidocaine. After intrathecally injecting the rats with five doses of each drug, the dose-response curves of memantine and lidocaine were constructed. The potencies of the drugs and durations of spinal anesthetic effects on motor function, proprioception, and nociception were compared with those of lidocaine. We showed that memantine produced dose-dependent spinal blockades in motor function, proprioception, and nociception. On a 50% effective dose (ED50 ) basis, the rank of potency was lidocaine greater than memantine (P < 0.05 for the differences). At the equipotent doses (ED25 , ED50 , ED75 ), the block duration produced by memantine was longer than that produced by lidocaine (P < 0.05 for the differences). Memantine, but not lidocaine, displayed more sensory/nociceptive block than motor block. The preclinical data demonstrated that memantine is less potent than lidocaine, whereas memantine produces longer duration of spinal anesthesia than lidocaine. Memantine shows a more sensory-selective action over motor blockade.
Collapse
Affiliation(s)
- Yu-Wen Chen
- Department of Physical Therapy & Graduate Institute of Rehabilitation Science, College of Health Care, China Medical University, Taichung, Taiwan
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Kuo-Sheng Liu
- Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| |
Collapse
|