1
|
Boelig RC, Kaushal G, Rochani A, McKenzie SE, Kraft WK. Aspirin pharmacokinetics and pharmacodynamics through gestation. Am J Obstet Gynecol 2024; 231:344.e1-344.e16. [PMID: 38145726 PMCID: PMC11193839 DOI: 10.1016/j.ajog.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Low dose aspirin is recommended for prevention of preeclampsia, however there is not consensus on the appropriate dose. Pregnancy specific changes have the potential to impact the pharmacology of aspirin in pregnancy, however there are very limited studies on aspirin pharmacokinetics in pregnancy and none linking pharmacokinetics (PK, drug dose and drug level) to pharmacodynamics (PD, drug dose and physiologic response) in pregnancy. As a result, we do not have a good understanding of the pharmacologic response to aspirin in pregnancy, which has important implications for clinical efficacy. We sought to describe the PK and PD of aspirin through pregnancy and to identify individual covariates that impacted aspirin PK/PD. OBJECTIVE We sought to describe the PK and PD of aspirin through pregnancy (first and third trimester), to identify covariates that significantly impact aspirin PK and to identify the relationship between aspirin PK and PD. STUDY DESIGN This is a prospective study of patients at high risk for preeclampsia recommended to take 81 mg aspirin daily. This study involved 3 visits as follows: (1) baseline, first trimester (10-16 weeks of gestation) 6-hour PK visit, done before initiation of aspirin; (2) follow-up 1: 2 to 4 weeks after aspirin initiation; and (3) follow-up 2: third trimester 6-hour PK visit (28-32 weeks of gestation). The following were assessed at each visit: weight or body mass index, platelet function analysis-100 (Siemens), urinary thromboxane B2, serum thromboxane B2, and plasma salicylic acid. The PK visits consisted of blood work done at baseline (predose), administration of 81 mg nonenteric coated aspirin, and then plasma blood level of salicylic acid assessed at 30 minutes and then hourly 1 to 6 hours after dose. Pearson correlation and multivariable regression were used to identify associations between parameters and identify relevant covariates. Log-adjusted values were used for regression analysis. P<.05 was considered statistically significant. RESULTS Nineteen participants were included with first trimester data, and 16 with third trimester data. There was no statistically significant change in mean PK parameters between the first and third trimester, although there was a trend to lower peak concentration in the third than in the first trimester (P=.08). In multivariable regression, baseline obesity and current body mass index as a continuous measures were negatively associated with log-adjusted peak salicylic acid concentration (-0.28 [-0.46 to -0.11], P=.003 and -0.02 [-0.03 to -0.009], P=.001, respectively) and log-adjusted plasma salicylic acid area under the curve 0 to 6 hours postdose (-0.25 [-0.45 to 0.05], P=.02, -0.04 [-0.07 to -0.01], P=.008 respectively). There was a significant decrease in urinary thromboxane 2 to 4 weeks after aspirin initiation compared with baseline, which correlated with a concomitant increase in platelet function analysis-100 closure time. In multivariable regression model, there was a strong association between plasma salicylic acid concentration (area under the curve 0-6 hours postdose) and urinary thromboxane (B=-3.12 [-5.38 to -1.04], P=.006), and with urinary thromboxane suppression and platelet inhibition, platelet function analysis-100 (-0.23 [-0.31 to -0.14], P<.001). With progressive thromboxane suppression, platelet inhibition (platelet function analysis-100 closure time) increased. Individual comorbidities, including weight, hypertension, and pregestational diabetes (Type I or II), also impacted aspirin response. CONCLUSION We have demonstrated the relationship between individual factors, plasma concentrations of salicylic acid, thromboxane suppression, and platelet inhibition at a single dose (81 mg) of aspirin taken through pregnancy. Our findings suggest that dose modification of aspirin in pregnancy may help to achieve the optimal response. Our results may be used to facilitate computational modeling to identify optimal dosing, taking into consideration individual factors.
Collapse
Affiliation(s)
- Rupsa C Boelig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Gagan Kaushal
- College of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Ankit Rochani
- Wegmans School of Pharmacy, St. John Fisher University, Rochester, NY
| | - Steven E McKenzie
- Division of Hematology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Walter K Kraft
- Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
2
|
Dehne S, Heck C, Sander J, Meisenbacher K, Arens C, Niklas C, Kronsteiner D, Giannitsis E, Böckler D, Weigand MA, Larmann J. Association of PeriOPerative Aspirin-ResisTance and CardioVascular Outcome (POPART- CVO) - a prospective non-interventional cohort study. Eur J Vasc Endovasc Surg 2022; 64:407-415. [PMID: 35963514 DOI: 10.1016/j.ejvs.2022.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES New onset of aspirin-resistance during surgery, known as perioperative aspirin-resistance, is observed in up to 30% of vascular surgery patients and is associated with post-OP myocardial damage; questioning aspirin effectiveness towards perioperative cardiovascular events. The objective of this study was to prospectively evaluate whether perioperative aspirin-resistance in vascular surgery is associated with adverse cardiovascular outcome. DESIGN AND METHODS Based on a sample size calculation, 194 adult elective vascular or endovascular surgery patients receiving aspirin were analyzed in this prospective, single-centered, non-interventional cohort study. Platelet function was measured before surgery, one hour after incision, four hours postoperatively, and on the morning of the first and second postoperative days using the Multiplate® analyzer. The primary outcome was Myocardial Injury after Non-Cardiac Surgery (MINS). Secondary outcomes included major bleeding, admission to intensive care unit, length of hospital stay, and Major Adverse Cardiac and Cerebrovascular Events. Subgroup analyses were performed for patients with different cardiovascular risk and for patients who underwent endovascular surgery. RESULTS Perioperative aspirin-resistance was observed in 27.8% of patients but was not associated with MINS (27.8% vs. 32.1%, aspirin-resistance vs. no aspirin-resistance, OR 0.812, 95% CI [0.406;1.624], p=.555) or with any of the secondary endpoints (all p>.05). In nine of the ten subgroup analyses, aspirin-resistance was not associated with a difference in MINS rate. However, in patients with a low cardiovascular risk profile (RCRI 0-2), MINS occurred more frequently in patients without aspirin-resistance (p=.049). CONCLUSIONS We confirmed previous reports demonstrating that perioperative aspirin-resistance is frequent in patients undergoing vascular or endovascular surgery. However, in patients who continue aspirin throughout the perioperative period, aspirin-resistance is a phenomenon, that does not appear to be related to MINS. Measuring perioperative platelet function using the Multiplate® analyzer with the intention to identify and potentially prevent or treat perioperative aspirin-resistance seems to be dispensable.
Collapse
Affiliation(s)
- Sarah Dehne
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christian Heck
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Julia Sander
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christoph Arens
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christian Niklas
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| |
Collapse
|
3
|
Zhao Y, Yang S, Wu M. Mechanism of Improving Aspirin Resistance: Blood-Activating Herbs Combined With Aspirin in Treating Atherosclerotic Cardiovascular Diseases. Front Pharmacol 2022; 12:794417. [PMID: 34975490 PMCID: PMC8718695 DOI: 10.3389/fphar.2021.794417] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/29/2021] [Indexed: 01/03/2023] Open
Abstract
Atherosclerotic thrombotic disease continues to maintain a high morbidity and mortality rate worldwide at present. Aspirin, which is reckoned as the cornerstone of primary and secondary prevention of atherosclerotic cardiovascular diseases (ASCVDs), has been applied in clinics extensively. However, cardiovascular events continue to occur even though people utilize aspirin appropriately. Therefore, the concept of aspirin resistance (AR) was put forward by scholars, which is of great significance for the prediction of the clinical outcome of diseases. The pathogenesis of AR may be incorporated with low patient compliance, insufficient dose, genetic polymorphism, increased platelet transformation, inflammation, and the degenerative changes and calcification of platelets. The improvement of AR in the treatment of ASCVDs has gradually become a research hot spot in recent years. Traditional Chinese medicine (TCM) regards individuals as a whole and treats them from a holistic view, which has been found to have advantages in clinical studies on the treatment of AR. Many kinds of blood-activating TCM have the effect of improving AR. The potential mechanism for the improvement of AR by blood-activating herbs combined with aspirin was explored. The combination of blood-activating herbs and aspirin to improve AR is likely to turn into a hot topic of research in the future.
Collapse
Affiliation(s)
- Yixi Zhao
- Comprehensive Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Shengjie Yang
- Comprehensive Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Wu
- Comprehensive Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| |
Collapse
|
4
|
Wang J, Cao B, Gao Y, Han D, Zhao H, Chen Y, Luo Y, Feng J, Guo Y. Long Non-Coding RNA H19 Positively Associates With Aspirin Resistance in the Patients of Cerebral Ischemic Stroke. Front Pharmacol 2020; 11:580783. [PMID: 33101034 PMCID: PMC7545008 DOI: 10.3389/fphar.2020.580783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
Background and purpose Aspirin is a novel anti-platelet drug that is intensively recommended for the prevention and treatment of cerebral ischemic stroke. However, the existence of aspirin resistance weakens the effects of aspirin and usually induces the recurrence of ischemic stroke. While the mechanism underlying aspirin resistance is still unclear. Long non-coding RNA H19 (H19) is closely associated with the onset and prognosis of cerebral ischemic stroke. Since the relationship between H19 and aspirin resistance have never been reported, herein, we aimed to evaluate the H19 expression in aspirin-resistant ischemic stroke patients and subsequently, ascertain the ability of H19 to diagnose aspirin resistance. Methods We included 150 patients with acute cerebral ischemic stroke who were followed up for one year to determine stroke recurrence. Levels of 11-dehydro thromboxane B2 (11dhTXB2) in urine were tested to evaluate the status of aspirin resistance, and those of H19 and 8-iso-prostaglandin-2α in plasma were assessed. The relationship between 11dhTXB2 or and 8-iso-prostaglandin-2α and H19, and the receiver operating characteristic curve of H19, the association of H19 and aspirin resistance with the recurrence of stoke were statistically analyzed. Results Plasma H19 was significantly up-regulated in patients with aspirin resistance (p=0.0203), and the H19 levels were positively associated with urine 11dhTXB2/creatinine (R=0.04364, p=0.0106) and positively associated with the level of 8-iso-PGF2α (R=0.04561, p=0.0089). The ROC curves indicated that H19 can sensitively and specifically diagnose aspirin resistance (area under the curve, 0.8005; 95% CI, 0.7301–0.8710; p < 0.0001; specificity, 75.86207%; sensitivity, 73.84615%.). H19 is an independent risk factor for aspirin resistance (OR=1.129, p=0.0321), and aspirin resistance and H19 are closely related with ischemic stroke recurrence. Conclusions H19 is closely associated with aspirin resistance, and H19 probably induces aspirin resistance through increasing the production of 8-iso-prostaglandin-2α. Besides which, H19 may serve as a serological marker for diagnosing aspirin resistance with high specificity and sensitivity, and the test of H19 could give clues to the recurrence of ischemic stroke.
Collapse
Affiliation(s)
- Jue Wang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Bin Cao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yan Gao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dong Han
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Haiping Zhao
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, Shenyang, China
| | - Yuhua Chen
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Yumin Luo
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, Shenyang, China
| | - Juan Feng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanxia Guo
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
5
|
Guo J, Wang J, Guo Y, Feng J. Association of aspirin resistance with 4-hydroxynonenal and its impact on recurrent cerebral infarction in patients with acute cerebral infarction. Brain Behav 2020; 10:e01562. [PMID: 32027781 PMCID: PMC7066347 DOI: 10.1002/brb3.1562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To investigate the association of aspirin resistance (AR) with the plasma 4-hydroxynonenal (4-HNE) level and its impact on recurrent cerebral infarction (CI) in patients with acute cerebral infarction (ACI) who were receiving aspirin therapy. METHODS One hundred and fifty-four ACI patients who previously received aspirin therapy (100 mg/day) were enrolled. Whole urine (for measuring 11dhTXB2 and creatinine) along with blood (for measuring the plasma 4-HNE level) were collected at least 7 days after the patients received aspirin. A cutoff of 1500 pg/mg of 11dhTXB2/ creatinine was used to determine AR. A follow-up period to monitor recurrence CI events was 1 year. In addition, blood testing was performed when the patients were first admitted to hospital. RESULTS Forty-six of the 154 enrolled patients (29.9%) were found to be AR. No statistical difference in age, sex, hypertension, diabetes mellitus, coronary disease, smoking status, NIHSS score, TOAST classification, platelet count, thrombocytocrit, LDL-C, HDL-C, TG, and TC was found between the AR and aspirin-sensitive (AS) patients, but the plasma 4-HNE level was found to be higher in the AR patients than AS patients (p < .05). Multiple logistic regression analysis showed that the 4-HNE level was associated with a higher risk of AR (OR = 1.034; 95% CI = 1.011-1.058; p < .05). Moreover, 1-year follow-up showed that AR was more prevalent in patients with recurrent CI (26 (56.6%)) than those without (20/(43.5%)) (p < .001). CONCLUSIONS The plasma 4-HNE level is strongly associated with AR and thus may be a factor contributing to AR. Patients with AR have a greater risk of recurrence CI.
Collapse
Affiliation(s)
- Juan Guo
- Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Jue Wang
- Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yanxia Guo
- Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Juan Feng
- Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China
| |
Collapse
|
6
|
Zheng X, Wu W, Zhang Y, Wu G. Changes in and significance of platelet function and parameters in Kawasaki disease. Sci Rep 2019; 9:17641. [PMID: 31776411 PMCID: PMC6881449 DOI: 10.1038/s41598-019-54113-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/05/2019] [Indexed: 02/05/2023] Open
Abstract
Kawasaki disease (KD) is a systemic febrile, inflammatory vascular disease of unknown etiology. The coronary artery abnormality (CAA) caused by KD has become the most commonly acquired heart disease in children. Initial treatment of intravenous immunoglobulin (IVIG) can reduce the incidence of CAA. Thrombocytosis is common during the course of KD, but changes in and significances of platelet function and parameters are unclear. In this study, we enrolled 120 patients, including 40 patients with KD, 40 febrile controls, and 40 afebrile controls. The platelet function was assessed using the platelet function analyzer (PFA)-200. Platelet parameters, including platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), and platelet hematocrit (PCT) were measured. In the febrile period, the PDW and MPV were lower in KD patients (P < 0.05). The platelet function did not change significantly during the febrile period of KD but weakened in the defervescence phase. No significant differences between the CAA and normal groups, and between IVIG resistance and response groups. The diagnostic cutoff value of the PDW level for predicting KD was 10.85 fL with a sensitivity of 55% and a specificity of 77.5% (area under curve (AUC) = 0.690, 95% confidence interval (CI): 0.574–0.806, P < 0.01). Besides, the MPV level was 9.55 fL with sensitivity of 75% and specificity of 70% (AUC = 0.733, 95%CI: 0.620–0.846, P < 0.001). This is the first longitudinal study of platelet function changes in KD patients using PFA-200. Besides, lower PDW and MPV may be available markers for early diagnosis of KD.
Collapse
Affiliation(s)
- Xiaolan Zheng
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.,West China Medical School, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Wenchao Wu
- Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zhang
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
| | - Gang Wu
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
| |
Collapse
|
7
|
Chen HY, Chou P. Associations Between PFA-Measured Aspirin Resistance, Platelet Count, Renal Function, and Angiotensin Receptor Blockers. Clin Appl Thromb Hemost 2018; 24:63S-68S. [PMID: 29996660 PMCID: PMC6714849 DOI: 10.1177/1076029618786588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aspirin resistance is used to describe patients who are undergoing aspirin therapy but fail for the inhibition of thromboxane biosynthesis in platelets. Although the true mechanism is unclear, drug–drug interaction remains a possible factor. The study aimed to determine whether there was association between aspirin resistance and the concomitant cardiovascular medication. Using the Platelet Function Analyzer-100 system, aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. The associations between aspirin resistance and their concomitant common cardiovascular medication were analyzed. Aspirin resistance was prevalent in 147 (17.7%) of 831 patients. Concomitant angiotensin receptor blocker (ARB) treatment and low platelet count were associated with aspirin response (P = .04, .02, respectively). Multivariate logistic regression analysis results showed an association between aspirin response and ARB therapy (adjusted odds ratio [OR] 1.48; 95% confidence interval, CI: 1.08-2.18). And the association was blunted when platelet count was considered (adjusted OR 1.43, 95% CI: 0.92-2.23). In ARB-treated patients, increased creatinine and decreased hematocrit laboratory data increased the risk of aspirin resistance (P = .02, .04, respectively), and the effect of platelet count on aspirin resistance was diminished by ARB therapy. Concomitant ARB treatment in aspirin-treated patients decreased the risk of aspirin resistance, and the effect was dependent on low platelet count. In ARB-treated patients, increased creatinine and decreased hematocrit data increased the risk of aspirin resistance. In addition, the effect of platelet count on aspirin resistance was diminished by ARB treatment.
Collapse
Affiliation(s)
- Hung Yi Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Pesus Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| |
Collapse
|