1
|
Zhang Q, Zhang Z, He X, Liu Z, Shen L, Long C, Wei G, Liu X, Guo C. Vitamin D levels and the risk of overactive bladder: a systematic review and meta-analysis. Nutr Rev 2024; 82:166-175. [PMID: 37195440 DOI: 10.1093/nutrit/nuad049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
CONTEXT Overactive bladder is treated mainly with behavioral and drug therapy, and symptoms of urinary frequency and incontinence are challenging to eliminate. There is thus a continuous unmet need for new drugs with a substitution effect mechanism. OBJECTIVE It not known whether vitamin D deficiency can lead to overactive bladder or urinary incontinence or whether vitamin D supplementation alleviates bladder symptoms. This comprehensive systematic review with meta-analysis was conducted to determine whether overactive bladder is associated with vitamin D deficiency. DATA SOURCES The PubMed and Cochrane Library databases were searched systematically up to July 3, 2022. DATA EXTRACTION Initially, 706 articles were identified in the literature search, of which 13 were included in the systematic review: 4 randomized controlled trials, 3 cohort studies, 3 cross-sectional studies, and 3 case-control studies. DATA ANALYSIS An increased risk of overactive bladder and urinary incontinence was observed with vitamin D deficiency (odds ratio [OR] = 4.46; 95%CI, 1.03-19.33; P = 0.046 and OR = 1.30; 95%CI, 1.01-1.66; P = 0.036, respectively). Vitamin D levels were relatively low in patients with overactive bladder or urinary incontinence (SMD = -0.33; 95%CI, -0.61 to -0.06, P = 0.019). On the basis of existing data, the risk of urinary incontinence was reduced by 66% after vitamin D supplementation (OR = 0.34; 95%CI, 0.18-0.66; P = 0.001). Egger test was conducted to assess publication bias, and the results were tested for robustness using a sensitivity analysis. CONCLUSIONS Vitamin D deficiency increases the risk of overactive bladder and urinary incontinence, and vitamin D supplementation reduces the risk of urinary incontinence. The development of new strategies to prevent or alleviate bladder symptoms is crucial. Vitamin D supplementation may be gaining recognition as an effective strategy for prevention or alleviation of bladder symptoms such as overactive bladder and incontinence. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42022351443.
Collapse
Affiliation(s)
- Qiang Zhang
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zhicheng Zhang
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xueyu He
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zhenmin Liu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Lianju Shen
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chunlan Long
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Guanghui Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xing Liu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Program for Youth Innovation in Future Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Chunming Guo
- School of Life Sciences, Yunnan University, Kunming, China
| |
Collapse
|
2
|
Yeo JK, Park SG, Park MG. Effects of Vitamin D Supplementation on Testosterone, Prostate, and Lower Urinary Tract Symptoms: A Prospective, Comparative Study. World J Mens Health 2023; 41:874-881. [PMID: 36649925 PMCID: PMC10523120 DOI: 10.5534/wjmh.220180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/04/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Several studies have associated the serum vitamin D level with total testosterone levels and the prostate volume. Herein, we investigated the effect of vitamin D supplementation on testosterone, prostate, and lower urinary tract symptoms (LUTS) in men. MATERIALS AND METHODS Men over 40 years of age diagnosed with a vitamin D deficiency (25[OH]D <20 ng/mL) who received vitamin D supplementation for one year were included in the study and administered 25,000 IU of cholecalciferol every 2 weeks. Prostate ultrasound, uroflowmetry, postvoid residual urine volume measurement, and serological tests (serum testosterone levels, etc.) were performed upon diagnosis and one year later. Participants also answered the International Prostate Symptom Score (IPSS) and Aging Males' Symptoms Scale (AMS) questionnaires. RESULTS A significant increase was observed in the vitamin D level following one year of vitamin D supplementation, with a significant decrease in the postvoid residual urine volume, total IPSS score and without a significant change in the prostate volume. Improved psychological subscale score of AMS questionnaire was observed with a statistical significance. CONCLUSIONS Vitamin D supplementation suppressed the increase in the prostate volume and improved the LUTS. Although there is no direct effect on serum testosterone levels, vitamin D supplementation helped improve hypogonadal symptoms.
Collapse
Affiliation(s)
- Jeong Kyun Yeo
- Department of Urology, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sun Gu Park
- Department of Clinical Laboratory Science, Daejeon Health Institute of Technology, Daejeon, Korea
- Department of Biomedical Laboratory Science, College of Software and Digital Healthcare Convergence, Yonsei University, Wonju, Korea
| | - Min Gu Park
- Department of Urology, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea.
| |
Collapse
|
3
|
The role of the serum 25-OH vitamin D level on detecting prostate cancer in men with elevated prostate-specific antigen levels. Sci Rep 2022; 12:14089. [PMID: 35982094 PMCID: PMC9388499 DOI: 10.1038/s41598-022-17563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/27/2022] [Indexed: 12/24/2022] Open
Abstract
We aimed to determine whether vitamin D levels before prostate biopsy have diagnostic value for clinically significant prostate cancer. The study cohort included patients who underwent prostate biopsy. A total of 224 patients were enrolled in our study and serum vitamin D levels were measured from February 2016 to December 2019 in routine laboratory tests. To determine the relationship between vitamin D levels and aggressiveness of prostate cancer, we used logistic multivariate analysis. Based on the histopathological results of patients who underwent radical prostatectomy, the serum vitamin D level was significantly lower with the large tumor volume group. In the univariate analysis, the prostate cancer diagnosis rate was associated with low vitamin D levels. Low vitamin D level is negatively correlated with clinically significant prostate cancer (biopsy Gleason score of 7 or higher) in the univariate (Odds ratio [OR], 0.955; P < 0.001) and multivariate (OR, 0.944; P = 0.027) analyses. In conclusion, we found that the incidence of clinically significant prostate cancer might related to low vitamin D level in the Asian population. In the future, a larger population and prospective study are needed.
Collapse
|
4
|
Özçift B, Micoogullari U. The effect of vitamin D deficiency in children with overactive bladder related urinary incontinence. Int Braz J Urol 2022; 48:316-325. [PMID: 35170894 PMCID: PMC8932037 DOI: 10.1590/s1677-5538.ibju.2021.0645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/18/2021] [Indexed: 02/02/2023] Open
Abstract
Purpose: Overactive bladder (OAB) is a common syndrome associated with lower urinary tract symptoms (LUTS), especially urinary incontinence in children, which may affect the patient's quality of life (QoL). Vitamin D deficiency has been shown to be associated with OAB syndrome. This study evaluated the relationship between vitamin D status and OAB-related symptoms and QoL in children. Materials and Methods: The study included 52 pediatric patients with OAB-related urinary incontinence and 41 healthy children. LUTS were assessed using the Dysfunctional Voiding and Incontinence Symptoms Score (DVISS) questionnaire, and QoL was assessed using the Pediatric Incontinence Questionnaire (PINQ). Oral vitamin D supplementation was given to patients with OAB with vitamin D deficiency. Urinary symptoms and QoL were evaluated before and after vitamin D supplementation. Results: Vitamin D deficiency was more common in the OAB group (75%) than in the control group (36.6%). Logistic regression analysis revealed that vitamin D status (<20ng/mL) was a significant predictor of OAB. Both pre-treatment and post-treatment DVISS and PINQ scores showed a positive correlation. After vitamin D supplementation, 8 (23.5%) patients had a complete response and 19 (55.9%) patients had a partial response. Significant improvement in QoL was also achieved. Conclusions: Vitamin D deficiency is more common in children with urinary incontinence and OAB than in healthy children. Although vitamin D deficiency is not routinely evaluated for every patient, it should be evaluated in treatment-resistant OAB cases. Vitamin D supplementation may improve urinary symptoms and QoL in patients with OAB.
Collapse
Affiliation(s)
- Burak Özçift
- Health Sciences University, Izmir Dr. Behcet Uz Child Diseases and Surgery Training and Research Hospital - Pediatric Urology Izmir, Turkey
| | - Uygar Micoogullari
- Izmir Tepecik Training and Research Hospital - Urology Konak, Izmir,Turkey
| |
Collapse
|
5
|
Kim HS, Cho MC. Low Serum 25-Hydroxyvitamin D Level as a Potential Risk Factor of Erectile Dysfunction in Elderly Men with Moderate to Severe Lower Urinary Tract Symptoms. World J Mens Health 2021; 40:139-148. [PMID: 33663029 PMCID: PMC8761244 DOI: 10.5534/wjmh.200176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose To evaluate the correlation between vitamin D level and erectile dysfunction (ED) in male lower urinary tract symptoms (LUTS) patients. Materials and Methods We analyzed data from 534 male patients who were tested for LUTS from 2014 to 2017. LUTS severity was classified into mild (≤7) or moderate to severe (≥8) based on total IPSS scores. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D [25(OH)D] level of less than 20 ng/mL. The severity of ED was dichotomized into mild (≥17 points) or moderate to severe (≤16 points) depending on total IIEF-5 scores. The association of the serum 25(OH)D level with moderate to severe ED was assessed using logistic regression analysis. Results In the entire cohort, moderate to severe ED was significantly associated with age ≥60 years (odds ratio [OR], 1.762; 95% confidence interval [CI], 1.011–3.073) and moderate to severe LUTS (OR, 2.075; 95% CI, 1.134–3.789), but not with serum 25(OH)D level (OR, 1.001; 95% CI, 0.979–1.023). Whereas, in the subgroup consisting of moderate to severe LUTS patients over 60 years (n=223), either low serum 25(OH)D level (OR, 0.944; 95% CI, 0.903–0.986) or vitamin D deficiency (OR, 2.949; 95% CI, 1.118–7.782) was the independent risk factor of moderate to severe ED as a result of each multivariate analysis. Conclusions Low vitamin D status closely correlated with moderate to severe ED in elderly men with moderate to severe LUTS.
Collapse
Affiliation(s)
- Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Min Chul Cho
- Department of Urology, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea.
| |
Collapse
|
6
|
Santos HO, Howell S, Nichols K, Teixeira FJ. Reviewing the Evidence on Vitamin D Supplementation in the Management of Testosterone Status and Its Effects on Male Reproductive System (Testis and Prostate): Mechanistically Dazzling but Clinically Disappointing. Clin Ther 2020; 42:e101-e114. [PMID: 32446600 DOI: 10.1016/j.clinthera.2020.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/11/2020] [Accepted: 03/24/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Vitamin D supplementation has been suggested to increase testosterone levels. The primary purpose of this literature review was to critically assess the physiologic effects of vitamin D supplementation on serum testosterone concentrations in men and the secondary purpose was to evaluate the feasibility of vitamin D status toward urologic health (testis and prostate). METHODS A structured literature review was performed using the Cochrane, MEDLINE, and Web of Science databases. The literature search encompassed studies published between 2011 and 2019. FINDINGS Observational studies suggest an association between higher testosterone and serum vitamin D concentrations. Conversely, most randomized clinical trials that investigated the effect of vitamin D administration on testosterone levels have failed to detect any significant effect. Physiologically, vitamin D is engaging in spermatogenesis, but it remains unclear whether vitamin D is a determinant of fertility. With prostate support, the management of vitamin D status has been associated with a decreased prevalence of benign prostatic hyperplasia and symptoms (ie, lower urinary tract symptoms). However, with prostate cancer, there is a paucity of evidence pertaining to vitamin D supplementation. IMPLICATIONS Mechanistically, vitamin D exhibits essential roles in the testis and prostate; otherwise, there is no apparent evidence to support the use of vitamin D supplementation to increase testosterone levels and to improve clinical outcomes related to the male reproductive system.
Collapse
Affiliation(s)
- Heitor O Santos
- School of Medicine, Federal University of Uberlandia, Uberlandia, Minas Gerais, Brazil.
| | - Scott Howell
- Center for Research, Tier 1 Health and Wellness, Chattanooga, TN, USA
| | - Keith Nichols
- Center for Research, Tier 1 Health and Wellness, Chattanooga, TN, USA
| | - Filipe J Teixeira
- Research Center for Biosciences & Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
| |
Collapse
|
7
|
Abdul‐Razzak KK, Alshogran OY, Altawalbeh SM, Al‐Ghalayini IF, Al‐Ghazo MA, Alazab RS, Halalsheh OM, Sahawneh FE. Overactive bladder and associated psychological symptoms: A possible link to vitamin D and calcium. Neurourol Urodyn 2019; 38:1160-1167. [DOI: 10.1002/nau.23975] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/11/2019] [Accepted: 02/26/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Khalid K. Abdul‐Razzak
- Department of Clinical PharmacyFaculty of PharmacyJordan University of Science and TechnologyIrbid Jordan
| | - Osama Y. Alshogran
- Department of Clinical PharmacyFaculty of PharmacyJordan University of Science and TechnologyIrbid Jordan
| | - Shoroq M. Altawalbeh
- Department of Clinical PharmacyFaculty of PharmacyJordan University of Science and TechnologyIrbid Jordan
| | | | | | | | | | | |
Collapse
|
8
|
Tzeng NS, Chang HA, Chung CH, Kao YC, Yeh HW, Yeh CB, Chiang WS, Huang SY, Lu RB, Chien WC. Risk of psychiatric disorders in overactive bladder syndrome: a nationwide cohort study in Taiwan. J Investig Med 2018; 67:312-318. [PMID: 30275006 DOI: 10.1136/jim-2018-000835] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 01/03/2023]
Abstract
Population-based cohort study investigating the risk of depression and other psychiatric disorders for patients with overactive bladder (OAB) syndrome is unavailable. This study investigated the subsequent risk of psychiatric disorders among patients with OAB in an Asian population. Using data from the National Health Insurance Research Database of Taiwan, we established a cohort with 811 patients in an exposed group with OAB between January 1, 2000 and December 31, 2000, and a non-exposed group, without OAB, of 2433 patients without OAB matched by age and year of diagnosis. The occurrence of psychiatric disorders and Cox regression model measured adjusted HRs (aHR) were monitored until the end of 2013. The overall incidence of psychiatric disorders was 41.7% higher in the exposed group with OAB than in the non-exposed group without OAB (14.2% vs 10.1%, p<0.001), with an aHR of 1.34 (95% CI 1.12 to 1.80, p<0.001) for the OAB cohort. OAB was associated with the increased risk of dementia, anxiety, depressive, sleep, and psychotic disorders, with aHRs as 1.53 (p=0.040), 1.61 (p<0.001), 2.10 (p<0.001), 1.43 (p<0.001), and 2.49 (p=0.002), respectively. The risk of psychiatric disorders, including depression and anxiety, is significantly higher in patients with OAB than in those without OAB. Evaluation of psychiatric status in patients with OAB is strongly recommended.
Collapse
Affiliation(s)
- Nian-Sheng Tzeng
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Student Counseling Center, National Defense Medical Center, Taipei, Republic of China
| | - Hsin-An Chang
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Student Counseling Center, National Defense Medical Center, Taipei, Republic of China
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,School of Public Health, National Defense Medical Center, Taipei, Republic of China.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Republic of China
| | - Yu-Chen Kao
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Department of Psychiatry, Tri-Service General Hospital, Song-Shan Branch, National Defense Medical Center, Taipei, Republic of China
| | - Hui-Wen Yeh
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Institute of Bioinformatics and System Biology, National Chiao Tung University, Hsinchu, Republic of China.,Department of Nursing, School of Nursing, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Department of Nursing, Kang-Ning University (Taipei Campus), Taipei, Republic of China
| | - Chin-Bin Yeh
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China
| | - Wei-Shan Chiang
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China
| | - San-Yuan Huang
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China
| | - Ru-Band Lu
- Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,Department of Psychiatry, College of Medicine and Hospital, National Cheng-Kung University, Tainan, Republic of China
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Republic of China.,School of Public Health, National Defense Medical Center, Taipei, Republic of China.,Institute of Life Sciences, National Defense Medical Center, Taipei, Republic of China
| |
Collapse
|