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Granai M, Warm V, Vogelsberg A, Milla J, Greif K, Vogel U, Bakchoul T, Rosenberger P, Quintanilla-Martinez L, Schürch CM, Klingel K, Fend F, Bösmüller H. Impact of P-selectin-PSGL-1 Axis on Platelet-Endothelium-Leukocyte Interactions in Fatal COVID-19. J Transl Med 2023; 103:100179. [PMID: 37224922 PMCID: PMC10202465 DOI: 10.1016/j.labinv.2023.100179] [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: 01/13/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023] Open
Abstract
In critically ill patients infected with SARS-CoV-2, early leukocyte recruitment to the respiratory system was found to be orchestrated by leukocyte trafficking molecules accompanied by massive secretion of proinflammatory cytokines and hypercoagulability. Our study aimed to explore the interplay between leukocyte activation and pulmonary endothelium in different disease stages of fatal COVID-19. Our study comprised 10 COVID-19 postmortem lung specimens and 20 control lung samples (5 acute respiratory distress syndrome, 2 viral pneumonia, 3 bacterial pneumonia, and 10 normal), which were stained for antigens representing the different steps of leukocyte migration: E-selectin, P-selectin, PSGL-1, ICAM1, VCAM1, and CD11b. Image analysis software QuPath was used for quantification of positive leukocytes (PSGL-1 and CD11b) and endothelium (E-selectin, P-selectin, ICAM1, VCAM1). Expression of IL-6 and IL-1β was quantified by RT-qPCR. Expression of P-selectin and PSGL-1 was strongly increased in the COVID-19 cohort compared with all control groups (COVID-19:Controls, 17:23, P < .0001; COVID-19:Controls, 2:75, P < .0001, respectively). Importantly, P-selectin was found in endothelial cells and associated with aggregates of activated platelets adherent to the endothelial surface in COVID-19 cases. In addition, PSGL-1 staining disclosed positive perivascular leukocyte cuffs, reflecting capillaritis. Moreover, CD11b showed a strongly increased positivity in COVID-19 compared with all controls (COVID-19:Controls, 2:89; P = .0002), indicating a proinflammatory immune microenvironment. Of note, CD11b exhibited distinct staining patterns at different stages of COVID-19 disease. Only in cases with very short disease course, high levels of IL-1β and IL-6 mRNA were observed in lung tissue. The striking upregulation of PSGL-1 and P-selectin reflects the activation of this receptor-ligand pair in COVID-19, increasing the efficiency of initial leukocyte recruitment, thus promoting tissue damage and immunothrombosis. Our results show that endothelial activation and unbalanced leukocyte migration play a central role in COVID-19 involving the P-selectin-PSGL-1 axis.
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Affiliation(s)
- Massimo Granai
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Verena Warm
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Antonio Vogelsberg
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Jakob Milla
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Karen Greif
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrich Vogel
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine Tübingen ZKT gGmbH, University of Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | | | - Christian M Schürch
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Karin Klingel
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Falko Fend
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany.
| | - Hans Bösmüller
- Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
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Zhou G, Verweij S, Bijlsma MJ, de Vos S, Oude Rengerink K, Pasmooij AMG, van Baarle D, Niesters HGM, Mol P, Vonk JM, Hak E. Repurposed drug studies on the primary prevention of SARS-CoV-2 infection during the pandemic: systematic review and meta-analysis. BMJ Open Respir Res 2023; 10:e001674. [PMID: 37640510 PMCID: PMC10462970 DOI: 10.1136/bmjresp-2023-001674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Current evidence on the effectiveness of SARS-CoV-2 prophylaxis is inconclusive. We aimed to systematically evaluate published studies on repurposed drugs for the prevention of laboratory-confirmed SARS-CoV-2 infection and/or COVID-19 among healthy adults. DESIGN Systematic review. ELIGIBILITY Quantitative experimental and observational intervention studies that evaluated the effectiveness of repurposed drugs for the primary prevention of SARS-CoV-2 infection and/or COVID-19 disease. DATA SOURCE PubMed and Embase (1 January 2020-28 September 2022). RISK OF BIAS Cochrane Risk of Bias 2.0 and Risk of Bias in Non-Randomised Studies of Interventions tools were applied to assess the quality of studies. DATA ANALYSIS Meta-analyses for each eligible drug were performed if ≥2 similar study designs were available. RESULTS In all, 65 (25 trials, 40 observational) and 29 publications were eligible for review and meta-analyses, respectively. Most studies pertained to hydroxychloroquine (32), ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) (11), statin (8), and ivermectin (8). In trials, hydroxychloroquine prophylaxis reduced laboratory-confirmed SARS-CoV-2 infection (risk ratio: 0.82 (95% CI 0.74 to 0.90), I2=48%), a result largely driven by one clinical trial (weight: 60.5%). Such beneficial effects were not observed in observational studies, nor for prognostic clinical outcomes. Ivermectin did not significantly reduce the risk of SARS-CoV-2 infection (RR: 0.35 (95% CI 0.10 to 1.26), I2=96%) and findings for clinical outcomes were inconsistent. Neither ACEi or ARB were beneficial in reducing SARS-CoV-2 infection. Most of the evidence from clinical trials was of moderate quality and of lower quality in observational studies. CONCLUSIONS Results from our analysis are insufficient to support an evidence-based repurposed drug policy for SARS-CoV-2 prophylaxis because of inconsistency. In the view of scarce supportive evidence on repurposing drugs for COVID-19, alternative strategies such as immunisation of vulnerable people are warranted to prevent the future waves of infection. PROSPERO REGISTRATION NUMBER CRD42021292797.
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Affiliation(s)
- Guiling Zhou
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Stefan Verweij
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Maarten J Bijlsma
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Stijn de Vos
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | | | | | - Debbie van Baarle
- Virology and Immunology Research Group, Department of Medical Microbiology and Infection Prevention, University Medical Centre, Groningen, The Netherlands
| | - Hubert G M Niesters
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, Groningen, The Netherlands
| | - Peter Mol
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre, Groningen, The Netherlands
| | - Judith M Vonk
- Groningen Research Institute for Asthma and COPD, University Medical Centre, Groningen, The Netherlands
- Department of Epidemiology, University Medical Centre, Groningen, The Netherlands
| | - Eelko Hak
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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Visos-Varela I, Zapata-Cachafeiro M, Pintos-Rodríguez S, Bugarín-González R, González-Barcala FJ, Herdeiro MT, Piñeiro-Lamas M, Figueiras A, Salgado-Barreira Á. Outpatient atorvastatin use and severe COVID-19 outcomes: A population-based study. J Med Virol 2023; 95:e28971. [PMID: 37486310 DOI: 10.1002/jmv.28971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/09/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023]
Abstract
Evidence of the effect of statins on patients with coronavirus disease (2019) COVID-19 is inconsistent. The aim of this study was to evaluate the association between chronic use of statins-both overall and by active ingredient-and severe outcomes of COVID-19 (risk of hospitalization and mortality), progression to severe outcomes, and susceptibility to the virus. We conducted a population-based case-control study with data from electronic records to assess the risk of (1) hospitalization: cases were patients admitted due to COVID-19 and controls were subjects without COVID-19; (2) mortality: cases were hospitalized patients who died due to COVID-19 and controls were subjects without COVID-19; (3) progression: cases were hospitalized COVID-19 subjects and controls were nonhospitalized COVID-19 patients; and (4) susceptibility: cases were patients with COVID-19 (both hospitalized and nonhospitalized) and controls were subjects without COVID-19. We collected data on 2821 hospitalized cases, 26 996 nonhospitalized cases, and 52 318 controls. Chronic use of atorvastatin was associated with a decreased risk of hospitalization (adjusted odds ratios [aOR] = 0.83; 95% confidence interval [CI]: 0.74-0.92) and mortality (aOR = 0.70; 95% CI: 0.53-0.93), attributable in part to a lower risk of susceptibility to the virus (aOR = 0.91; 95% CI: 0.86-0.96). Simvastatin was associated with a reduced risk of mortality (aOR = 0.59; 95% CI: 0.40-0.87). The wide degree of heterogeneity observed in the estimated odds ratios (ORs) of the different statins suggests that there is no class effect. The results of this real-world study suggest that chronic use of atorvastatin (and to a lesser degree, of simvastatin) is associated with a decrease in risk of severe COVID-19 outcomes.
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Affiliation(s)
- Irene Visos-Varela
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Samuel Pintos-Rodríguez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Rosendo Bugarín-González
- Monforte de Lemos Health Center, Health Area of Lugo, A Mariña and Monforte de Lemos, SERGAS, Monforte de Lemos, Lugo, Spain
| | - Francisco Javier González-Barcala
- Spanish Biomedical Research Networking Centre-CIBERES, Santiago de Compostela, Spain
- Pneumoloxy Department, Santiago de Compostela University Hospital Complex, Santiago de Compostela, Spain
| | - Maria T Herdeiro
- Department of Medical Sciences, iBiMED-Institute of Biomedicine, University of Aveiro, Aveiro, Portugal
| | - María Piñeiro-Lamas
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Ángel Salgado-Barreira
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
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Wang LK, Kuo YF, Westra J, Raji MA, Albayyaa M, Allencherril J, Baillargeon J. Association of Cardiovascular Medications With Adverse Outcomes in a Matched Analysis of a National Cohort of Patients With COVID-19. AMERICAN JOURNAL OF MEDICINE OPEN 2023; 9:100040. [PMID: 37207280 PMCID: PMC10032048 DOI: 10.1016/j.ajmo.2023.100040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/22/2023] [Accepted: 03/14/2023] [Indexed: 03/24/2023]
Abstract
Background The use of statins, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), and anticoagulants may be associated with fewer adverse outcomes in COVID-19 patients. Methods Nested within a cohort of 800,913 patients diagnosed with COVID-19 between April 1, 2020 and June 24, 2021 from the Optum COVID-19 database, three case-control studies were conducted. Cases-defined as persons who: (1) were hospitalized within 30 days of COVID-19 diagnosis (n = 88,405); (2) were admitted to the intensive care unit (ICU)/received mechanical ventilation during COVID-19 hospitalization (n = 22,147); and (3) died during COVID-19 hospitalization (n = 2300)-were matched 1:1 using demographic/clinical factors with controls randomly selected from a pool of patients who did not experience the case definition/event. Medication use was based on prescription ≤90 days before COVID-19 diagnosis. Results Statin use was associated with decreased risk of hospitalization (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.69, 0.75) and ICU admission/mechanical ventilation (aOR, 0.90; 95% CI, 0.84, 0.97). ACEI/ARB use was associated with decreased risk of hospitalization (aOR, 0.67; 95% CI, 0.65, 0.70), ICU admission/mechanical ventilation (aOR, 0.92; 95% CI, 0.86, 0.99), and death (aOR, 0.60; 95% CI, 0.47, 0.78). Anticoagulant use was associated with decreased risk of hospitalization (aOR, 0.94; 95% CI, 0.89, 0.99) and death (aOR, 0.56; 95% CI, 0.41, 0.77). Interaction effects-in the model predicting hospitalization-were statistically significant for statins and ACEI/ARBs (P < .0001), statins and anticoagulants (P = .003), ACEI/ARBs and anticoagulants (P < .0001). An interaction effect-in the model predicting ventilator use/ICU-was statistically significant for statins and ACEI/ARBs (P = .002). Conclusions Statins, ACEI/ARBs, and anticoagulants were associated with decreased risks of the adverse outcomes under study. These findings may provide clinically relevant information regarding potential treatment for patients with COVID-19.
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Affiliation(s)
- Leonard K. Wang
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Jordan Westra
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
| | - Mukaila A. Raji
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Mohanad Albayyaa
- Institute for Translational Sciences, University of Texas Medical Branch
| | - Joseph Allencherril
- Texas Heart Institute, Houston
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Jacques Baillargeon
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
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Fung KW, Baye F, Baik SH, Zheng Z, McDonald CJ. Prevalence and characteristics of long COVID in elderly patients: An observational cohort study of over 2 million adults in the US. PLoS Med 2023; 20:e1004194. [PMID: 37068113 PMCID: PMC10150975 DOI: 10.1371/journal.pmed.1004194] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 05/01/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Incidence of long COVID in the elderly is difficult to estimate and can be underreported. While long COVID is sometimes considered a novel disease, many viral or bacterial infections have been known to cause prolonged illnesses. We postulate that some influenza patients might develop residual symptoms that would satisfy the diagnostic criteria for long COVID, a condition we call "long Flu." In this study, we estimate the incidence of long COVID and long Flu among Medicare patients using the World Health Organization (WHO) consensus definition. We compare the incidence, symptomatology, and healthcare utilization between long COVID and long Flu patients. METHODS AND FINDINGS This is a cohort study of Medicare (the US federal health insurance program) beneficiaries over 65. ICD-10-CM codes were used to capture COVID-19, influenza, and residual symptoms. Long COVID was identified by (a) the designated long COVID code B94.8 (code-based definition), or (b) any of 11 symptoms identified in the WHO definition (symptom-based definition), from 1 to 3 months post-infection. A symptom would be excluded if it occurred in the year prior to infection. Long Flu was identified in influenza patients from the combined 2018 and 2019 Flu seasons by the same symptom-based definition for long COVID. Long COVID and long Flu were compared in 4 outcome measures: (a) hospitalization (any cause); (b) hospitalization (for long COVID symptom); (c) emergency department (ED) visit (for long COVID symptom); and (d) number of outpatient encounters (for long COVID symptom), adjusted for age, sex, race, region, Medicare-Medicaid dual eligibility status, prior-year hospitalization, and chronic comorbidities. Among 2,071,532 COVID-19 patients diagnosed between April 2020 and June 2021, symptom-based definition identified long COVID in 16.6% (246,154/1,479,183) and 29.2% (61,631/210,765) of outpatients and inpatients, respectively. The designated code gave much lower estimates (outpatients 0.49% (7,213/1,479,183), inpatients 2.6% (5,521/210,765)). Among 933,877 influenza patients, 17.0% (138,951/817,336) of outpatients and 24.6% (18,824/76,390) of inpatients fit the long Flu definition. Long COVID patients had higher incidence of dyspnea, fatigue, palpitations, loss of taste/smell, and neurocognitive symptoms compared to long Flu. Long COVID outpatients were more likely to have any-cause hospitalization (31.9% (74,854/234,688) versus 26.8% (33,140/123,736), odds ratio 1.06 (95% CI 1.05 to 1.08, p < 0.001)), and more outpatient visits than long Flu outpatients (mean 2.9(SD 3.4) versus 2.5(SD 2.7) visits, incidence rate ratio 1.09 (95% CI 1.08 to 1.10, p < 0.001)). There were less ED visits in long COVID patients, probably because of reduction in ED usage during the pandemic. The main limitation of our study is that the diagnosis of long COVID in is not independently verified. CONCLUSIONS Relying on specific long COVID diagnostic codes results in significant underreporting. We observed that about 30% of hospitalized COVID-19 patients developed long COVID. In a similar proportion of patients, long COVID-like symptoms (long Flu) can be observed after influenza, but there are notable differences in symptomatology between long COVID and long Flu. The impact of long COVID on healthcare utilization is higher than long Flu.
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Affiliation(s)
- Kin Wah Fung
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, United States of America
| | - Fitsum Baye
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, United States of America
| | - Seo H. Baik
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, United States of America
| | - Zhaonian Zheng
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, United States of America
| | - Clement J. McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, United States of America
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Lao US, Law CF, Baptista-Hon DT, Tomlinson B. Systematic Review and Meta-Analysis of Statin Use and Mortality, Intensive Care Unit Admission and Requirement for Mechanical Ventilation in COVID-19 Patients. J Clin Med 2022; 11:5454. [PMID: 36143101 PMCID: PMC9501062 DOI: 10.3390/jcm11185454] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/04/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
There is mounting evidence that statin use is beneficial for COVID-19 outcomes. We performed a systematic review and meta-analysis to evaluate the association between statin use and mortality, intensive care unit (ICU) admission and mechanical ventilation in COVID-19 patients, on studies which provided covariate adjusted effect estimates, or performed propensity score matching. We searched PubMed, Embase, Web of Science and Scopus for studies and extracted odds or hazard ratios for specified outcome measures. Data synthesis was performed using a random-effects inverse variance method. Risk of bias, heterogeneity and publication bias were analyzed using standard methods. Our results show that statin use was associated with significant reductions in mortality (OR = 0.72, 95% CI: 0.67-0.77; HR = 0.74, 95% CI: 0.69, 0.79), ICU admission (OR = 0.94, 95% CI: 0.89-0.99; HR = 0.76, 95% CI: 0.60-0.96) and mechanical ventilation (OR = 0.84, 95% CI: 0.78-0.92; HR = 0.67, 95% CI: 0.47-0.97). Nevertheless, current retrospective studies are based on the antecedent use of statins prior to infection and/or continued use of statin after hospital admission. The results may not apply to the de novo commencement of statin treatment after developing COVID-19 infection. Prospective studies are lacking and necessary.
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Affiliation(s)
- Ut-Sam Lao
- Center for Biomedicine and Innovations, Faculty of Medicine, Macau University Science and Technology, Taipa, Macau SAR 999078, China
| | - Chak-Fun Law
- Center for Biomedicine and Innovations, Faculty of Medicine, Macau University Science and Technology, Taipa, Macau SAR 999078, China
| | - Daniel T. Baptista-Hon
- Center for Biomedicine and Innovations, Faculty of Medicine, Macau University Science and Technology, Taipa, Macau SAR 999078, China
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee DD1 4HN, UK
| | - Brian Tomlinson
- Center for Biomedicine and Innovations, Faculty of Medicine, Macau University Science and Technology, Taipa, Macau SAR 999078, China
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