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Liu Y, Li Y, Deng Z, Zhao Y, Yuan R, Yang M, Wang L, Fang Y, Ding D, Zhou F, Kang H. Protective and immunomodulatory effects of mesenchymal stem cells on multiorgan injury in male rats with heatstroke. J Therm Biol 2023; 118:103696. [PMID: 37871397 DOI: 10.1016/j.jtherbio.2023.103696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/01/2023] [Accepted: 08/25/2023] [Indexed: 10/25/2023]
Abstract
Heatstroke (HS) causes multiple organ dysfunction syndrome (MODS) with a mortality rate of 60% after hospitalization. Currently, there is no effective and targeted approach for the treatment of HS. Despite growing evidence that mesenchymal stem cells (MSCs) may reduce multiorgan damage and improve survival through immunomodulatory effects in several diseases, no one has tested whether MSCs have immunomodulatory effects in heatstroke. The present study focused on pathological changes and levels of the cytokines and immunoglobulins to investigate the mechanisms underlying the protective effect and the anti-inflammatory effects of MSCs. We found that MSCs treatment significantly reduced the 28-day mortality rate (P < 0.05), the levels of hepatic and renal function markers on day 1 (P < 0.01) and the pathological lesion scores of multiple organs in HS rats. The levels of IgG1, IgM, and IgA of the HS + MSC group was significantly higher than that in HS group on days 3 and 28(P < 0.05). In conclusion, MSCs contribute to protecting against multiorgan injury, reducing pro-inflammatory cytokines, stabilizing immunoglobulins, and reducing the mortality rate of HS rats.
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Affiliation(s)
- Yuyan Liu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yun Li
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zihui Deng
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Basic Medicine, Graduate School, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yan Zhao
- Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Rui Yuan
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Mengmeng Yang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lu Wang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuan Fang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Dengfeng Ding
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Laboratory Animal Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, PR China
| | - Feihu Zhou
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Laboratory Animal Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, PR China
| | - Hongjun Kang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
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Bouchama A, Abuyassin B, Lehe C, Laitano O, Jay O, O'Connor FG, Leon LR. Classic and exertional heatstroke. Nat Rev Dis Primers 2022; 8:8. [PMID: 35115565 DOI: 10.1038/s41572-021-00334-6] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 12/28/2022]
Abstract
In the past two decades, record-breaking heatwaves have caused an increasing number of heat-related deaths, including heatstroke, globally. Heatstroke is a heat illness characterized by the rapid rise of core body temperature above 40 °C and central nervous system dysfunction. It is categorized as classic when it results from passive exposure to extreme environmental heat and as exertional when it develops during strenuous exercise. Classic heatstroke occurs in epidemic form and contributes to 9-37% of heat-related fatalities during heatwaves. Exertional heatstroke sporadically affects predominantly young and healthy individuals. Under intensive care, mortality reaches 26.5% and 63.2% in exertional and classic heatstroke, respectively. Pathological studies disclose endothelial cell injury, inflammation, widespread thrombosis and bleeding in most organs. Survivors of heatstroke may experience long-term neurological and cardiovascular complications with a persistent risk of death. No specific therapy other than rapid cooling is available. Physiological and morphological factors contribute to the susceptibility to heatstroke. Future research should identify genetic factors that further describe individual heat illness risk and form the basis of precision-based public health response. Prioritizing research towards fundamental mechanism and diagnostic biomarker discovery is crucial for the design of specific management approaches.
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Affiliation(s)
- Abderrezak Bouchama
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
| | - Bisher Abuyassin
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Cynthia Lehe
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Orlando Laitano
- Department of Nutrition & Integrative Physiology, College of Health and Human Sciences, Florida State University, Tallahassee, FL, USA
| | - Ollie Jay
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Francis G O'Connor
- Military and Emergency Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Lisa R Leon
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
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Modulation of microglial phenotypes by dexmedetomidine through TREM2 reduces neuroinflammation in heatstroke. Sci Rep 2021; 11:13345. [PMID: 34172807 PMCID: PMC8233427 DOI: 10.1038/s41598-021-92906-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/17/2021] [Indexed: 02/06/2023] Open
Abstract
No FDA approved pharmacological therapy is available to reduce neuroinflammation following heatstroke. Previous studies have indicated that dexmedetomidine (DEX) could protect against inflammation and brain injury in various inflammation-associated diseases. However, no one has tested whether DEX has neuro-protective effects in heatstroke. In this study, we focused on microglial phenotypic modulation to investigate the mechanisms underlying the anti-inflammatory effects of DEX in vivo and in vitro. We found that DEX treatment reduced the expression of CD68, iNOS, TNF-α, and IL-1β, and increased the expression of CD206, Arg1, IL-10 and TGF-β in microglia, ameliorating heatstroke induced neuroinflammation and brain injury in mice. TREM2, whose neuro-protective function has been validated by genetic studies in Alzheimer's disease and Nasu-Hakola disease, was significantly promoted by DEX in the microglia. TREM2 esiRNA reversed the DEX-induced activation of PI3K/Akt signalling. Overall these findings indicated that DEX may serve, as a potential therapeutic approach to ameliorate heatstroke induced neuroinflammation and brain injury via TREM2 by activating PI3K/Akt signalling.
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Wang L, Deng Z, Yuan R, Zhao Y, Yang M, Hu J, Zhang Y, Li Y, Zhou F, Kang H. Protective effect and mechanism of mesenchymal stem cells on heat stroke induced intestinal injury. Exp Ther Med 2020; 20:3041-3050. [PMID: 32855671 PMCID: PMC7444330 DOI: 10.3892/etm.2020.9051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/29/2020] [Indexed: 11/06/2022] Open
Abstract
Heat stroke (HS) is considered to be a severe systemic inflammatory reaction disease that is caused by high fever. The mortality of HS is high worldwide due to the lack of effective treatments. Presently, mesenchymal stem cells (MSCs) have been demonstrated to serve roles in inflammation and immune regulation. Therefore, the current study aimed to investigate the protective effect and mechanism of MSCs against the HS-induced inflammatory response and organ dysfunction. A rat model of HS was induced by a high-temperature environment and treated with MSCs via tail veins. The levels of molecular markers of organ function, inflammatory factors and chemokines were examined at days 1, 7, 14 and 28. Histological staining was performed on the intestines of rats and control groups, and the Chiu's scores of the two groups were compared. The results revealed that MSCs injection significantly reduced the mortality and inhibited the circulatory inflammatory response. Additionally, main organ function, such as in the liver and kidney, were significantly improved following MSCs infusion in HS rats. Furthermore, MSCs treatment significantly improved edema, necrosis and villus exfoliation of intestinal mucosa, and reduced the inflammatory response of intestinal tissue. These results indicated that MSC infusion had therapeutic effects on HS of rats by regulating the circulatory and intestinal inflammatory response. Moreover, MSCs may be able to protect organ function and promote tissue repair in HS. The results of the current study indicated that MSCs may be used as a potential method to treat HS and the resulting organ dysfunction.
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Affiliation(s)
- Lu Wang
- Medical School of Chinese PLA, Beijing 100853, P.R. China.,Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Zihui Deng
- Department of Biochemistry, Graduate School, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Rui Yuan
- Medical School of Chinese PLA, Beijing 100853, P.R. China.,Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Yan Zhao
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Mengmeng Yang
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Jie Hu
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Yu Zhang
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Yun Li
- Medical School of Chinese PLA, Beijing 100853, P.R. China.,Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Feihu Zhou
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Hongjun Kang
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, P.R. China
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Zhang Y, Deng Z, Li Y, Yuan R, Yang M, Zhao Y, Wang L, Zhou F, Kang H. Mesenchymal Stem Cells Provide Neuroprotection by Regulating Heat Stroke-Induced Brain Inflammation. Front Neurol 2020; 11:372. [PMID: 32477247 PMCID: PMC7232542 DOI: 10.3389/fneur.2020.00372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/14/2020] [Indexed: 01/01/2023] Open
Abstract
Heat stroke (HS) is the most acute type of heat illness accompanied with serious central nervous system (CNS) dysfunction. Despite the pathological process being clearly studied, effective treatment is deficient. Currently, mesenchymal stem cells (MSCs) have been demonstrated to have neuroprotective effects as there are no old ones. Thus, the purpose of the present study was to explore the neuroprotective effects and mechanisms of MSCs against HS-induced CNS injury. HS in rat models was induced by a high-temperature environment and treated with MSCs via the tail vein. The results demonstrated that MSC injection significantly reduced the mortality and inhibited the circulation inflammatory response. Moreover, the HS-induced neurological deficit and neuronic damage of the hippocampus were significantly ameliorated by MSC administration. In addition, MSC administration significantly restored astrocytes and inhibited cerebral inflammatory response. These results indicate that MSC infusion has therapeutic effects in HS of rats by regulating the circulation and cerebral inflammatory response. Moreover, astrocytes increased in MSC-treated HS rats when compared with the untreated ones. This may suggest a potential mechanism for HS prevention and therapy through MSC administration.
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Affiliation(s)
- Yu Zhang
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Zihui Deng
- Biochemistry Department of Graduate School, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Yun Li
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Rui Yuan
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Mengmeng Yang
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Yan Zhao
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Lu Wang
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Feihu Zhou
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, General Hospital of the Chinese People's Liberation Army, Beijing, China
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Lin CH, Chen SH, Chang CP, Lin KC. Hypothalamic impairment underlying heat intolerance in pregnant mice. Mol Cell Endocrinol 2019; 492:110439. [PMID: 31071379 DOI: 10.1016/j.mce.2019.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 11/18/2022]
Abstract
Pregnant women are vulnerable to heat stroke reactions caused by high environmental temperatures. Heat intolerance is associated with hypothalamic impairment. Here, we aim to ascertain whether pregnancy causes heat intolerance by inducing hypothalamic impairment in mice. In the heated groups, mice were exposed to whole body heating (WBH; 41.2 °C for 1 h) in an environment-controlled chamber. Then, they were returned to normal room temperature (26 °C) immediately after WBH. In the hyperbaric oxygen therapy (HBO2T) groups, mice were exposed to 100% O2 at 2.0 atm absolute (ATA) for 4 h immediately post-WBH. Mice that survived after 4 h of WBH were considered survivors. Here, we show that when pregnant mice underwent non-HBO2T (21% O2 at 1.0 ATA for 4 h) after WBH, the survival rate was 4/20, and the core temperature at 4 h post-WBH was 31.2 ± 0.2 °C. Both the survival rate and core temperature of HBO2T pregnant mice (10/10 and 35.2 ± 0.3 °C, respectively) were significantly greater than those in non-HBO2T pregnant mice. Compared to non-HBO2T heated mice, the HBO2T heated mice exhibited lower neurological severity scores, reduced hypothalamic neuronal damage, fewer apoptotic cells, reduced multiorgan damage scores, and lower hypothalamic levels of proinflammatory cytokines and nitrogen and oxygen radical species. Compared to non-HBO2T heated mice, the HBO2T-treated heated mice had significantly higher hypothalamic-pituitary-adrenal axis activity (evidenced by higher serum levels of both adrenocorticotrophic hormone and corticosterone). In conclusion, pregnancy induces heat intolerance by inducing hypothalamic impairment in mice. Additionally, HBO2T protects against heat intolerance in pregnant mice by preserving hypothalamic integrity.
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Affiliation(s)
- Cheng-Hsien Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | | | - Ching-Ping Chang
- Department of Medical Research, Chi Mei Medical Center, Tainan City, Taiwan.
| | - Kao-Chang Lin
- Department of Neurology, Chi Mei Medical Center, Tainan City, Taiwan.
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Schosserer M, Banks G, Dogan S, Dungel P, Fernandes A, Marolt Presen D, Matheu A, Osuchowski M, Potter P, Sanfeliu C, Tuna BG, Varela-Nieto I, Bellantuono I. Modelling physical resilience in ageing mice. Mech Ageing Dev 2018; 177:91-102. [PMID: 30290161 PMCID: PMC6445352 DOI: 10.1016/j.mad.2018.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
Geroprotectors, a class of drugs targeting multiple deficits occurring with age, necessitate the development of new animal models to test their efficacy. The COST Action MouseAGE is a European network whose aim is to reach consensus on the translational path required for geroprotectors, interventions targeting the biology of ageing. In our previous work we identified frailty and loss of resilience as a potential target for geroprotectors. Frailty is the result of an accumulation of deficits, which occurs with age and reduces the ability to respond to adverse events (physical resilience). Modelling frailty and physical resilience in mice is challenging for many reasons. There is no consensus on the precise definition of frailty and resilience in patients or on how best to measure it. This makes it difficult to evaluate available mouse models. In addition, the characterization of those models is poor. Here we review potential models of physical resilience, focusing on those where there is some evidence that the administration of acute stressors requires integrative responses involving multiple tissues and where aged mice showed a delayed recovery or a worse outcome then young mice in response to the stressor. These models include sepsis, trauma, drug- and radiation exposure, kidney and brain ischemia, exposure to noise, heat and cold shock.
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Affiliation(s)
- Markus Schosserer
- University of Natural Resources and Life Sciences, Vienna, Department of Biotechnology, Vienna, Austria
| | - Gareth Banks
- Mammalian Genetics Unit, MRC Harwell Institute, Harwell Campus, Oxfordshire, OX11 0RD, United Kingdom
| | - Soner Dogan
- Department of Medical Biology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Peter Dungel
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Adelaide Fernandes
- Neuron-Glia Biology in Health and Disease, iMed.ULisboa, Research Institute for Medicines, Department of Biochemistry and Human Biology, Faculty of Pharmacy, Universidade de Lisboa, Lisboa, Portugal
| | - Darja Marolt Presen
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Ander Matheu
- Oncology Department, Biodonostia Research Institute, San Sebastián, Spain
| | - Marcin Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Paul Potter
- Mammalian Genetics Unit, MRC Harwell Institute, Harwell Campus, Oxfordshire, OX11 0RD, United Kingdom
| | - Coral Sanfeliu
- Institute of Biomedical Research of Barcelona (IIBB) CSIC, IDIBAPS, CIBERESP, Barcelona, Spain
| | - Bilge Guvenc Tuna
- Department of Medical Biophysics, School of Medicine, Yeditepe University, Istanbul, Turkey
| | | | - Ilaria Bellantuono
- MRC/Arthritis Research-UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Department of Oncology and Metabolism, The Medical School, Beech Hill Road, Sheffield, S10 2RX, United Kingdom.
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Theanine supplementation prevents liver injury and heat shock response by normalizing hypothalamic-pituitaryadrenal axis hyperactivity in mice subjected to whole body heat stress. J Funct Foods 2018. [DOI: 10.1016/j.jff.2018.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Hsuan YCY, Lin CH, Chang CP, Lin MT. Mesenchymal stem cell-based treatments for stroke, neural trauma, and heat stroke. Brain Behav 2016; 6:e00526. [PMID: 27781140 PMCID: PMC5064338 DOI: 10.1002/brb3.526] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/05/2016] [Accepted: 06/08/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mesenchymal stem cell (MSC) transplantation has been reported to improve neurological function following neural injury. Many physiological and molecular mechanisms involving MSC therapy-related neuroprotection have been identified. METHODS A review is presented of articles that pertain to MSC therapy and diverse brain injuries including stroke, neural trauma, and heat stroke, which were identified using an electronic search (e.g., PubMed), emphasize mechanisms of MSC therapy-related neuroprotection. We aim to discuss neuroprotective mechanisms that underlie the beneficial effects of MSCs in treating stroke, neural trauma, and heatstroke. RESULTS MSC therapy is promising as a means of augmenting brain repair. Cell incorporation into the injured tissue is not a prerequisite for the beneficial effects exerted by MSCs. Paracrine signaling is believed to be the most important mediator of MSC therapy in brain injury. The multiple mechanisms of action of MSCs include enhanced angiogenesis and neurogenesis, immunomodulation, and anti-inflammatory effects. Microglia are the first source of the inflammatory cascade during brain injury. Cytokines, including tumor necrosis factor-α, interleukin-1β, and interleukin-6, are significantly produced by microglia in the brain after experimental brain injury. The proinflammatory M1 phenotype of microglia is associated with tissue destruction, whereas the anti-inflammatory M2 phenotype of microglia facilitates repair and regeneration. MSC therapy may improve outcomes of ischemic stroke, neural trauma, and heatstroke by inhibiting the activity of M1 phenotype of microglia but augmenting the activity of M2 phenotype of microglia. CONCLUSION This review offers a testable platform for targeting microglial-mediated cytokines in clinical trials based upon the rational design of MSC therapy in the future. MSCs that are derived from the placenta provide a great choice for stem cell therapy. Although targeting the microglial activation is an important approach to reduce the burden of the injury, it is not the only one. This review focuses on this specific aspect.
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Affiliation(s)
| | | | - Ching-Ping Chang
- Department of Medical Research Chi Mei Medical Center Tainan Taiwan
| | - Mao-Tsun Lin
- Department of Medical Research Chi Mei Medical Center Tainan Taiwan
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