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Rubboli G, Beier CP, Selmer KK, Syvertsen M, Shakeshaft A, Collingwood A, Hall A, Andrade DM, Fong CY, Gesche J, Greenberg DA, Hamandi K, Lim KS, Ng CC, Orsini A, Striano P, Thomas RH, Zarubova J, Richardson MP, Strug LJ, Pal DK. Variation in prognosis and treatment outcome in juvenile myoclonic epilepsy: a Biology of Juvenile Myoclonic Epilepsy Consortium proposal for a practical definition and stratified medicine classifications. Brain Commun 2023; 5:fcad182. [PMID: 37361715 PMCID: PMC10288558 DOI: 10.1093/braincomms/fcad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/21/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
Reliable definitions, classifications and prognostic models are the cornerstones of stratified medicine, but none of the current classifications systems in epilepsy address prognostic or outcome issues. Although heterogeneity is widely acknowledged within epilepsy syndromes, the significance of variation in electroclinical features, comorbidities and treatment response, as they relate to diagnostic and prognostic purposes, has not been explored. In this paper, we aim to provide an evidence-based definition of juvenile myoclonic epilepsy showing that with a predefined and limited set of mandatory features, variation in juvenile myoclonic epilepsy phenotype can be exploited for prognostic purposes. Our study is based on clinical data collected by the Biology of Juvenile Myoclonic Epilepsy Consortium augmented by literature data. We review prognosis research on mortality and seizure remission, predictors of antiseizure medication resistance and selected adverse drug events to valproate, levetiracetam and lamotrigine. Based on our analysis, a simplified set of diagnostic criteria for juvenile myoclonic epilepsy includes the following: (i) myoclonic jerks as mandatory seizure type; (ii) a circadian timing for myoclonia not mandatory for the diagnosis of juvenile myoclonic epilepsy; (iii) age of onset ranging from 6 to 40 years; (iv) generalized EEG abnormalities; and (v) intelligence conforming to population distribution. We find sufficient evidence to propose a predictive model of antiseizure medication resistance that emphasises (i) absence seizures as the strongest stratifying factor with regard to antiseizure medication resistance or seizure freedom for both sexes and (ii) sex as a major stratifying factor, revealing elevated odds of antiseizure medication resistance that correlates to self-report of catamenial and stress-related factors including sleep deprivation. In women, there are reduced odds of antiseizure medication resistance associated with EEG-measured or self-reported photosensitivity. In conclusion, by applying a simplified set of criteria to define phenotypic variations of juvenile myoclonic epilepsy, our paper proposes an evidence-based definition and prognostic stratification of juvenile myoclonic epilepsy. Further studies in existing data sets of individual patient data would be helpful to replicate our findings, and prospective studies in inception cohorts will contribute to validate them in real-world practice for juvenile myoclonic epilepsy management.
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Affiliation(s)
- Guido Rubboli
- Danish Epilepsy Centre, Filadelfia, Dianalund 4293, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - Kaja K Selmer
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo 0372, Norway
- National Centre for Epilepsy, Oslo University Hospital, Oslo 1337, Norway
| | - Marte Syvertsen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Oslo 3004, Norway
| | - Amy Shakeshaft
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
| | - Amber Collingwood
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Anna Hall
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Danielle M Andrade
- Adult Epilepsy Genetics Program, Krembil Research Institute, University of Toronto, Toronto M5T 0S8, Canada
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Pediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Joanna Gesche
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - David A Greenberg
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus 43215, USA
| | - Khalid Hamandi
- Department of Neurology, Cardiff & Vale University Health Board, Cardiff CF14 4XW, UK
| | - Kheng Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Ching Ching Ng
- Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Alessandro Orsini
- Department of Clinical and Experimental Medicine, Pisa University Hospital, Pisa 56126, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto ‘G. Gaslini’, Genova 16147, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova 16132, Italy
| | - Rhys H Thomas
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Jana Zarubova
- Department of Neurology, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
- Motol University Hospital, Prague 150 06, Czech Republic
| | - Mark P Richardson
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
- School of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
| | - Lisa J Strug
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto M5G 1X8, Canada
- Departments of Statistical Sciences and Computer Science and Division of Biostatistics, The University of Toronto, Toronto M5G 1Z5, Canada
| | - Deb K Pal
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
- School of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
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Cuéllar-Barboza AB, McElroy SL, Veldic M, Singh B, Kung S, Romo-Nava F, Nunez NA, Cabello-Arreola A, Coombes BJ, Prieto M, Betcher HK, Moore KM, Winham SJ, Biernacka JM, Frye MA. Potential pharmacogenomic targets in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection. Int J Bipolar Disord 2020; 8:23. [PMID: 32632502 PMCID: PMC7338319 DOI: 10.1186/s40345-020-00184-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/07/2020] [Indexed: 12/13/2022] Open
Abstract
Background Treatment in bipolar disorder (BD) is commonly applied as a multimodal therapy based on decision algorithms that lack an integrative understanding of molecular mechanisms or a biomarker associated clinical outcome measure. Pharmacogenetics/genomics study the individual genetic variation associated with drug response. This selective review of pharmacogenomics and pharmacogenomic testing (PGT) in BD will focus on candidate genes and genome wide association studies of pharmacokinetic drug metabolism and pharmacodynamic drug response/adverse event, and the potential role of decision support tools that incorporate multiple genotype/phenotype drug recommendations. Main body We searched PubMed from January 2013 to May 2019, to identify studies reporting on BD and pharmacogenetics, pharmacogenomics and PGT. Studies were selected considering their contribution to the field. We summarize our findings in: targeted candidate genes of pharmacokinetic and pharmacodynamic pathways, genome-wide association studies and, PGT platforms, related to BD treatment. This field has grown from studies of metabolizing enzymes (i.e., pharmacokinetics) and drug transporters (i.e., pharmacodynamics), to untargeted investigations across the entire genome with the potential to merge genomic data with additional biological information. Conclusions The complexity of BD genetics and, the heterogeneity in BD drug-related phenotypes, are important considerations for the design and interpretation of BD PGT. The clinical applicability of PGT in psychiatry is in its infancy and is far from reaching the robust impact it has in other medical disciplines. Nonetheless, promising findings are discovered with increasing frequency with remarkable relevance in neuroscience, pharmacology and biology.
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Affiliation(s)
- Alfredo B Cuéllar-Barboza
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Susan L McElroy
- Lindner Center of HOPE and Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA
| | - Marin Veldic
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Balwinder Singh
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Francisco Romo-Nava
- Lindner Center of HOPE and Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA
| | - Nicolas A Nunez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alejandra Cabello-Arreola
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Miguel Prieto
- Department of Psychiatry, Universidad de los Andes, Santiago, Chile
| | - Hannah K Betcher
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Katherine M Moore
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Stacey J Winham
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Joanna M Biernacka
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Mark A Frye
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Mu L, Lin Y, Huang X, Ning Y, Wu F, Zhang XY. Sex differences in the prevalence and clinical correlates of hyperhomocysteinemia in patients with bipolar disorder. Hum Psychopharmacol 2020; 35:e2724. [PMID: 32052509 DOI: 10.1002/hup.2724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/21/2019] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Sex differences in bipolar disorder are well recognized but little attention has been paid to sex differences in homocysteine or hyperhomocysteinemia in bipolar patients. This study compared gender differences in homocysteine levels and rates of hyperhomocysteinemia in Chinese inpatients with bipolar disorder. METHODS A total of 198 BD patients and 84 healthy controls were enrolled. The Young Mania Rating Scale, Hamilton Depression Rating Scale, and the Clinical Global Impressions-Severity scale were used to assess the affective symptomatology. Fasting plasma Hcy levels were measured by high-performance liquid chromatography. RESULTS Men had higher homocysteine levels than women and the prevalence of hyperhomocysteinemia in male patients was approximately twice that in female patients. Logistic regression analyses showed that HHcy was associated with less frequent use of valproate in males and being overweight in females. Further correlation analysis and multivariate regression analysis demonstrated that Hcy levels were inversely correlated with valproate treatment in men and positively associated with overweight in women. CONCLUSIONS In bipolar patients, there are significant differences between sexes in the levels of homocysteine and prevalence of hyperhomocysteinemia. This appears to be associated with lower prevalence of valproate prescribing in men and with being overweight in women.
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Affiliation(s)
- Li Mu
- Research Center of Brain and Cognitive Neuroscience, Liaoning Normal University, Dalian, China
| | - Yezhe Lin
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Xingbing Huang
- Department of Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Psychiatry, Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yuping Ning
- Department of Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Psychiatry, Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Fengchun Wu
- Department of Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Psychiatry, Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Xiang Yang Zhang
- Department of Psychiatry, Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China.,CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Science, Beijing, China
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Malerba N, De Nittis P, Merla G. The Emerging Role of Gβ Subunits in Human Genetic Diseases. Cells 2019; 8:E1567. [PMID: 31817184 PMCID: PMC6952978 DOI: 10.3390/cells8121567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/23/2019] [Accepted: 11/29/2019] [Indexed: 12/20/2022] Open
Abstract
Environmental stimuli are perceived and transduced inside the cell through the activation of signaling pathways. One common type of cell signaling transduction network is initiated by G-proteins. G-proteins are activated by G-protein-coupled receptors (GPCRs) and transmit signals from hormones, neurotransmitters, and other signaling factors, thus controlling a number of biological processes that include synaptic transmission, visual photoreception, hormone and growth factors release, regulation of cell contraction and migration, as well as cell growth and differentiation. G-proteins mainly act as heterotrimeric complexes, composed of alpha, beta, and gamma subunits. In the last few years, whole exome sequencing and biochemical studies have shown causality of disease-causing variants in genes encoding G-proteins and human genetic diseases. This review focuses on the G-protein β subunits and their emerging role in the etiology of genetically inherited rare diseases in humans.
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Affiliation(s)
- Natascia Malerba
- Division of Medical Genetics Unit, IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini, 71013 San Giovanni Rotondo (FG), Italy;
| | - Pasquelena De Nittis
- Center for Integrative Genomics, University of Lausanne, CH-1015 Lausanne, Switzerland;
| | - Giuseppe Merla
- Division of Medical Genetics Unit, IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini, 71013 San Giovanni Rotondo (FG), Italy;
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Pisanu C, Williams MJ, Ciuculete DM, Olivo G, Del Zompo M, Squassina A, Schiöth HB. Evidence that genes involved in hedgehog signaling are associated with both bipolar disorder and high BMI. Transl Psychiatry 2019; 9:315. [PMID: 31754094 PMCID: PMC6872724 DOI: 10.1038/s41398-019-0652-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/23/2019] [Accepted: 10/20/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with bipolar disorder (BD) show higher frequency of obesity and type 2 diabetes (T2D), but the underlying genetic determinants and molecular pathways are not well studied. Using large publicly available datasets, we (1) conducted a gene-based analysis using MAGMA to identify genes associated with BD and body mass index (BMI) or T2D and investigated their functional enrichment; and (2) performed two meta-analyses between BD and BMI, as well as BD and T2D using Metasoft. Target druggability was assessed using the Drug Gene Interaction Database (DGIdb). We identified 518 and 390 genes significantly associated with BD and BMI or BD and T2D, respectively. A total of 52 and 12 genes, respectively, were significant after multiple testing correction. Pathway analyses conducted on nominally significant targets showed that genes associated with BD and BMI were enriched for the Neuronal cell body Gene Ontology (GO) term (p = 1.0E-04; false discovery rate (FDR) = 0.025) and different pathways, including the Signaling by Hedgehog pathway (p = 4.8E-05, FDR = 0.02), while genes associated with BD and T2D showed no specific enrichment. The meta-analysis between BD and BMI identified 64 relevant single nucleotide polymorphisms (SNPs). While the majority of these were located in intergenic regions or in a locus on chromosome 16 near and in the NPIPL1 and SH2B1 genes (best SNP: rs4788101, p = 2.1E-24), five were located in the ETV5 gene (best SNP: rs1516725, p = 1E-24), which was previously associated with both BD and obesity, and one in the RPGRIP1L gene (rs1477199, p = 5.7E-09), which was also included in the Signaling by Hedgehog pathway. The meta-analysis between BD and T2D identified six significant SNPs, three of which were located in ALAS1 (best SNP: rs352165, p = 3.4E-08). Thirteen SNPs associated with BD and BMI, and one with BD and T2D, were located in genes which are part of the druggable genome. Our results support the hypothesis of shared genetic determinants between BD and BMI and point to genes involved in Hedgehog signaling as promising targets.
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Affiliation(s)
- Claudia Pisanu
- Unit of Functional Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden.
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.
| | - Michael J Williams
- Unit of Functional Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Diana M Ciuculete
- Unit of Functional Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Gaia Olivo
- Unit of Functional Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Maria Del Zompo
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
| | - Alessio Squassina
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
| | - Helgi B Schiöth
- Unit of Functional Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden.
- Institute for Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia.
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Hsueh YS, Chang HH, Shan YS, Sun HS, Fletcher JA, Li CF, Chen LT. Nuclear KIT induces a NFKBIB-RELA-KIT autoregulatory loop in imatinib-resistant gastrointestinal stromal tumors. Oncogene 2019; 38:6550-6565. [PMID: 31363162 PMCID: PMC6756115 DOI: 10.1038/s41388-019-0900-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/04/2019] [Accepted: 06/26/2019] [Indexed: 02/07/2023]
Abstract
Gastrointestinal stromal tumors (GISTs) are frequently driven by auto-activated, mutant KIT and have durable response to KIT tyrosine kinase inhibitor. However, acquired resistance is an increasing clinical issue in GIST patients receiving front-line imatinib therapy. Our previous studies showed the colocalization of KIT with DAPI-stained nuclei in GIST cells without knowing the role of nuclear KIT in GIST tumorigenesis. In this article, we first identified the binding of nuclear KIT to the promoter of NFKB inhibitor beta (NFKBIB) by chromatin immunoprecipitation (ChIP) sequencing and ChIP assays, which was accompanied with enhanced NFKBIB protein expression in GIST cells. Clinically, high NCCN risk GISTs had significantly higher mean expression levels of nuclear phospho-KIT and NFKBIB as compared with those of intermediate or low/very low-risk GISTs. Conversely, downregulation of NFKBIB by siRNA led to RELA nuclear translocation that could bind to the KIT promoter region and subsequently reduced KIT transcription/expression and the viability of GIST cells. These findings were further confirmed by either RELA overexpression or NFKB/RELA inducer, valproic acid, treatment to result in reduced KIT expression and relative cell viability of imatinib-resistant GIST cells. Combining valproic acid with imatinib showed significantly better growth inhibitory effects on imatinib-resistant GIST48 and GIST430 cells in vitro, and in the GIST430 animal xenograft model. Taken together, these results demonstrate the existence of a nuclear KIT-driven NFKBIB-RELA-KIT autoregulatory loop in GIST tumorigenesis, which are potential targets for developing combination therapy to overcome imatinib-resistant of KIT-expressing GISTs.
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Affiliation(s)
- Yuan-Shuo Hsueh
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan.,International Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan
| | - Hui Hua Chang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
| | - Yan-Shen Shan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - H Sunny Sun
- Institute of Molecular Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Bioinformatics Center, National Cheng Kung University, Tainan, Taiwan
| | - Jonathan Alfred Fletcher
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Chien-Feng Li
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan. .,Department of Pathology, Chi-Mei Foundation Medical Center, Tainan, Taiwan. .,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan.
| | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan. .,Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Internal Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan. .,Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
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