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Galeano AC, Rincón-Rodríguez CJ, Gil F, Valderrama-Beltrán S. Association between CD4 lymphocyte count and the incidence of comorbidities in Human immunodeficiency virus positive patients with virological suppression after antiretroviral treatment. Int J STD AIDS 2024; 35:884-893. [PMID: 39030669 DOI: 10.1177/09564624241264041] [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] [Indexed: 07/21/2024]
Abstract
BACKGROUND The incidence of comorbidities is higher in HIV-positive patients than in the general population due to factors, such as HIV-related chronic inflammation. There is no consensus on whether a low CD4 lymphocyte count after virological suppression at long-term follow-up increases the risk of comorbidities. This study evaluates the association between CD4 lymphocyte count and the incidence of comorbidities during the first 5 years of virological suppression after highly active antiretroviral treatment. METHODS We conducted a cohort study of HIV-positive adults who achieved virological suppression in an HIV program between 2002 and 2016 in Colombia. A generalized equation estimation model was used to estimate the association between CD4 lymphocyte count and the incidence of comorbidities. RESULTS A follow-up period of at least 1 year was completed in 921 HIV-positive patients with virological suppression. We found 71 comorbidities during a maximum of 5 years of follow-up; 41 (59%) were AIDS-defining comorbidities and 19 (46%) of them occurred during the first semester. Thirty cases of non-AIDS- defining comorbidities were diagnosed.We did not find any association between CD4 lymphocyte count and the incidence of comorbidities (OR 0.92, CI 95% 0.45 -1.91 for CD4 201-499 cells/µL vs CD4 ≤200 cells/µL, and OR 0.55, 95% CI 0.21-1.44 for CD4 ≥500 cells/µL vs CD4 ≤200 cells/µL). CONCLUSION No association was found between CD4 lymphocyte count and the incidence of AIDS-defining or non-AIDS-defining comorbidities in patients with virological suppression. Further studies are needed to assess the risk of comorbidities in this population to design interventions aimed at improving their prognosis.
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Affiliation(s)
- Adriana C Galeano
- School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - C J Rincón-Rodríguez
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Fabián Gil
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - S Valderrama-Beltrán
- Division of Infectious Diseases, Hospital Universitario San Ignacio, Bogotá, DC, Colombia
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Ward RA, Aghaeepour N, Bhattacharyya RP, Clish CB, Gaudillière B, Hacohen N, Mansour MK, Mudd PA, Pasupneti S, Presti RM, Rhee EP, Sen P, Spec A, Tam JM, Villani AC, Woolley AE, Hsu JL, Vyas JM. Harnessing the Potential of Multiomics Studies for Precision Medicine in Infectious Disease. Open Forum Infect Dis 2021; 8:ofab483. [PMID: 34805429 PMCID: PMC8598922 DOI: 10.1093/ofid/ofab483] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
The field of infectious diseases currently takes a reactive approach and treats infections as they present in patients. Although certain populations are known to be at greater risk of developing infection (eg, immunocompromised), we lack a systems approach to define the true risk of future infection for a patient. Guided by impressive gains in "omics" technologies, future strategies to infectious diseases should take a precision approach to infection through identification of patients at intermediate and high-risk of infection and deploy targeted preventative measures (ie, prophylaxis). The advances of high-throughput immune profiling by multiomics approaches (ie, transcriptomics, epigenomics, metabolomics, proteomics) hold the promise to identify patients at increased risk of infection and enable risk-stratifying approaches to be applied in the clinic. Integration of patient-specific data using machine learning improves the effectiveness of prediction, providing the necessary technologies needed to propel the field of infectious diseases medicine into the era of personalized medicine.
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Affiliation(s)
- Rebecca A Ward
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, California, USA
| | - Roby P Bhattacharyya
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Clary B Clish
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Brice Gaudillière
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cancer for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Philip A Mudd
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shravani Pasupneti
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
| | - Rachel M Presti
- Division of Infectious Diseases, Department of lnternal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Center for Vaccines and Immunity to Microbial Pathogens, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eugene P Rhee
- The Nephrology Division and Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pritha Sen
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of lnternal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jenny M Tam
- Harvard Medical School, Boston, Massachusetts, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts, USA
| | - Alexandra-Chloé Villani
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ann E Woolley
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joe L Hsu
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
| | - Jatin M Vyas
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Atkinson A, Zwahlen M, Barger D, d’Arminio Monforte A, De Wit S, Ghosn J, Girardi E, Svedhem V, Morlat P, Mussini C, Noguera-Julian A, Stephan C, Touloumi G, Kirk O, Mocroft A, Reiss P, Miro JM, Carpenter JR, Furrer H. Withholding Primary Pneumocystis Pneumonia Prophylaxis in Virologically Suppressed Patients With Human Immunodeficiency Virus: An Emulation of a Pragmatic Trial in COHERE. Clin Infect Dis 2021; 73:195-202. [PMID: 32448894 PMCID: PMC8516510 DOI: 10.1093/cid/ciaa615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/19/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Using data from the COHERE collaboration, we investigated whether primary prophylaxis for pneumocystis pneumonia (PcP) might be withheld in all patients on antiretroviral therapy (ART) with suppressed plasma human immunodeficiency virus (HIV) RNA (≤400 copies/mL), irrespective of CD4 count. METHODS We implemented an established causal inference approach whereby observational data are used to emulate a randomized trial. Patients taking PcP prophylaxis were eligible for the emulated trial if their CD4 count was ≤200 cells/µL in line with existing recommendations. We compared the following 2 strategies for stopping prophylaxis: (1) when CD4 count was >200 cells/µL for >3 months or (2) when the patient was virologically suppressed (2 consecutive HIV RNA ≤400 copies/mL). Patients were artificially censored if they did not comply with these stopping rules. We estimated the risk of primary PcP in patients on ART, using the hazard ratio (HR) to compare the stopping strategies by fitting a pooled logistic model, including inverse probability weights to adjust for the selection bias introduced by the artificial censoring. RESULTS A total of 4813 patients (10 324 person-years) complied with eligibility conditions for the emulated trial. With primary PcP diagnosis as an endpoint, the adjusted HR (aHR) indicated a slightly lower, but not statistically significant, different risk for the strategy based on viral suppression alone compared with the existing guidelines (aHR, .8; 95% confidence interval, .6-1.1; P = .2). CONCLUSIONS This study suggests that primary PcP prophylaxis might be safely withheld in confirmed virologically suppressed patients on ART, regardless of their CD4 count.
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Affiliation(s)
- Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Diana Barger
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
| | | | - Stephane De Wit
- Department of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jade Ghosn
- APHP, Nord-Université de Paris, Service des Maladies Infectieuses et Tropicales, Hôpital Bichat, Paris, France
- INSERM UMR 1137 IAME, Université de Paris, Faculté de Médecine, Paris, France
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases L. Spallanzani–IRCCS, Rome, Italy
| | - Veronica Svedhem
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Philippe Morlat
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux (CHU), Services de Médecine Interne et Maladies Infectieuses, Bordeaux, France
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d´Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
- Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Christoph Stephan
- Infectious Diseases Unit at Medical Center No. 2, Frankfurt University Hospital, Goethe University, Frankfurt, Germany
| | - Giota Touloumi
- Department of Hygiene, Epidemiology, and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling, and Evaluation (CREME), Institute for Global Health, University College London, London, United Kingdom
| | - Peter Reiss
- HIV Monitoring Foundation, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic–IDIBAPS, University of Barcelona, Barcelona, Spain
| | - James R Carpenter
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Atkinson A, Miro JM, Mocroft A, Reiss P, Kirk O, Morlat P, Ghosn J, Stephan C, Mussini C, Antoniadou A, Doerholt K, Girardi E, De Wit S, Kraus D, Zwahlen M, Furrer H. No need for secondary Pneumocystis jirovecii pneumonia prophylaxis in adult people living with HIV from Europe on ART with suppressed viraemia and a CD4 cell count greater than 100 cells/µL. J Int AIDS Soc 2021; 24:e25726. [PMID: 34118121 PMCID: PMC8196713 DOI: 10.1002/jia2.25726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/31/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Since the beginning of the HIV epidemic in resource-rich countries, Pneumocystis jirovecii pneumonia (PjP) is one of the most frequent opportunistic AIDS-defining infections. The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) has shown that primary Pneumocystis jirovecii Pneumonia (PjP) prophylaxis can be safely withdrawn in patients with CD4 counts of 100 to 200 cells/µL if plasma HIV-RNA is suppressed on combination antiretroviral therapy. Whether this holds true for secondary prophylaxis is not known, and this has proved difficult to determine due to the much lower population at risk. METHODS We estimated the incidence of secondary PjP by including patient data collected from 1998 to 2015 from the COHERE cohort collaboration according to time-updated CD4 counts, HIV-RNA and use of PjP prophylaxis in persons >16 years of age. We fitted a Poisson generalized additive model in which the smoothed effect of CD4 was modelled by a restricted cubic spline, and HIV-RNA was stratified as low (<400), medium (400 to 10,000) or high (>10,000copies/mL). RESULTS There were 373 recurrences of PjP during 74,295 person-years (py) in 10,476 patients. The PjP incidence in the different plasma HIV-RNA strata differed significantly and was lowest in the low stratum. For patients off prophylaxis with CD4 counts between 100 and 200 cells/µL and HIV-RNA below 400 copies/mL, the incidence of recurrent PjP was 3.9 (95% CI: 2.0 to 5.8) per 1000 py, not significantly different from patients on prophylaxis in the same stratum (1.9, 95% CI: 0.1 to 3.7). CONCLUSIONS HIV viraemia importantly affects the risk of recurrent PjP. In virologically suppressed patients on ART with CD4 counts of 100 to 200/µL, the incidence of PjP off prophylaxis is below 10/1000 py. Secondary PjP prophylaxis may be safely withheld in such patients. While European guidelines recommend discontinuing secondary PjP prophylaxis only if CD4 counts rise above 200 cells/mL, the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load. Our results strengthen and support this US recommendation.
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Affiliation(s)
- Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, UCL, London, UK
| | - Peter Reiss
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, and HIV Monitoring Foundation, Amsterdam, The Netherlands
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Philippe Morlat
- Internal Medicine and Infectious Diseases Department, University Hospital of Bordeaux, Bordeaux, France
| | - Jade Ghosn
- Service des Maladies Infectieuses et Tropicales, Groupe Hospitalier Universitaire Bichat-Claude Bernard, Paris, France.,INSERM U 1137 IAME, Université de Paris, Paris, France
| | - Christoph Stephan
- Infectious Diseases Unit at Medical Center no.2, Frankfurt University Hospital, Goethe University, Frankfurt, Germany
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Anastasia Antoniadou
- Fourth Department of Internal Medicine, ATTIKON University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katja Doerholt
- Paediatric Infectious Diseases Unit, St. George's University Hospital, London, UK
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases L. Spallanzani-IRCCS, Rome, Italy
| | - Stéphane De Wit
- Department of Infectious Diseases, St Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Kraus
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.,Department of Mathematics and Statistics, Masaryk University, Brno, Czech Republic
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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5
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Huang YS, Yang JJ, Lee NY, Chen GJ, Ko WC, Sun HY, Hung CC. Treatment of Pneumocystis jirovecii pneumonia in HIV-infected patients: a review. Expert Rev Anti Infect Ther 2017; 15:873-892. [PMID: 28782390 DOI: 10.1080/14787210.2017.1364991] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pneumocystis pneumonia is a potentially life-threatening pulmonary infection that occurs in immunocompromised individuals and HIV-infected patients with a low CD4 cell count. Trimethoprim-sulfamethoxazole has been used as the first-line agent for treatment, but mutations within dihydropteroate synthase gene render potential resistance to sulfamide. Despite advances of combination antiretroviral therapy (cART), Pneumocystis pneumonia continues to occur in HIV-infected patients with late presentation for cART or virological and immunological failure after receiving cART. Areas covered: This review summarizes the diagnosis and first-line and alternative treatment and prophylaxis for Pneumocystis pneumonia in HIV-infected patients. Articles for this review were identified through searching PubMed. Search terms included: 'Pneumocystis pneumonia', 'Pneumocystis jirovecii pneumonia', 'Pneumocystis carinii pneumonia', 'trimethoprim-sulfamethoxazole', 'primaquine', 'trimetrexate', 'dapsone', 'pentamidine', 'atovaquone', 'echinocandins', 'human immunodeficiency virus infection', 'acquired immunodeficiency syndrome', 'resistance to sulfamide' and combinations of these terms. We limited the search to English language papers that were published between 1981 and March 2017. We screened all identified articles and cross-referenced studies from retrieved articles. Expert commentary: Trimethoprim-sulfamethoxazole will continue to be the first-line agent for Pneumocystis pneumonia given its cost, availability of both oral and parenteral formulations, and effectiveness or efficacy in both treatment and prophylaxis. Whether resistance due to mutations within dihydropteroate synthase gene compromises treatment effectiveness remains controversial. Continued search for effective alternatives with better safety profiles for Pneumocystis pneumonia is warranted.
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Affiliation(s)
- Yu-Shan Huang
- a Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsin-Chu , Taiwan
| | - Jen-Jia Yang
- b Department of Internal Medicine , Po Jen General Hospital , Taipei , Taiwan
| | - Nan-Yao Lee
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Guan-Jhou Chen
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Wen-Chien Ko
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Hsin-Yun Sun
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Chien-Ching Hung
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan.,f Department of Parasitology , National Taiwan University College of Medicine , Taipei , Taiwan.,g Department of Medical Research , China Medical University Hospital , Taichung , Taiwan.,h China Medical University , Taichung , Taiwan
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