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Tan Y, Jing X, Wang J, Zhou L, Wang Y, Zhang H, Yang Q. Vitamin D Deficiency in the Acute Phase of Stroke May Predict Post-stroke Depression: A Systematic Review and Meta-Analysis. J Geriatr Psychiatry Neurol 2024:8919887241275044. [PMID: 39179523 DOI: 10.1177/08919887241275044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
OBJECTIVE To conduct the association between vitamin D levels in the acute phase of stroke and post-stroke depression (PSD) in stroke patients. METHODS Five international databases (PubMed, Web of Science, Embase, Ovid MEDLINE(R), Cochrane Library) and one Chinese database (Wanfang Data) were searched for observational studies in any language reporting on PSD and vitamin D levels tested in the acute phase of stroke in stroke patients from inception to May 2024. Data extraction and study quality assessment were conducted by two authors independently. Qualitative and quantitative analyses of data were performed. The meta-analysis was registered in the PROSPERO database (CRD42023398581). RESULTS We included 7 studies containing 3537 participants in the systematic review and meta-analysis. All studies that met the inclusion and exclusion criteria were conducted in China. Vitamin D levels in the acute phase of stroke were lower in PSD patients compared with non-PSD patients (weighted mean difference = -14.97 nmol/L; 95% confidence interval = -19.54, -10.40). Stroke patients with vitamin D deficiency (<50 nmol/L) had an increased risk of PSD compared with stroke patients with vitamin D sufficiency (≥75 nmol/L) (odds ratio = 3.59; 95% confidence interval = 2.05, 6.27). However, the association between vitamin D insufficiency (50-75 nmol/L) and PSD were not statistically significant (odds ratio = 4.15; 95% confidence interval = 0.87, 19.78). CONCLUSION Vitamin D deficiency in the acute phase of stroke may be a risk factor for PSD.
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Affiliation(s)
- Yongjun Tan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaojun Jing
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiani Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Zhou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yilin Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Chen IW, Lin HJ, Hung KC. Letter to the Editor Regarding "Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis". World Neurosurg 2024; 185:471-472. [PMID: 38741310 DOI: 10.1016/j.wneu.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 05/16/2024]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Hsiu-Jung Lin
- Department of Anesthesiology, E-Da Cancer Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan.
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3
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Chen IW, Kao CL, Hung KC. The Impact of Helicobacter pylori on Laparoscopic Sleeve Gastrectomy Postoperative Complications: Insights and Limitations. Obes Surg 2024; 34:1384-1385. [PMID: 38358453 DOI: 10.1007/s11695-024-07098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Chia-Li Kao
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, No.901, ChungHwa Road, YungKung Dist, Tainan City, 71004, Taiwan.
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Chen IW, Wang WT, Hung KC. Comment on effect of virtual reality technology as intervention for people with kinesiophobia. J Clin Nurs 2024; 33:1588-1589. [PMID: 38243681 DOI: 10.1111/jocn.16991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
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Chen IW, Chang LC, Hung KC. Letter to the Editor Regarding "Supratotal Resection: An Emerging Concept of Glioblastoma Multiforme Surgery-Systematic Review And Meta-Analysis". World Neurosurg 2024; 183:262-263. [PMID: 38468167 DOI: 10.1016/j.wneu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/04/2023] [Indexed: 03/13/2024]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Li-Chen Chang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan.
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Chen IW, Kao CL, Hung KC. Comment to: should routine surgical wound drainage after ventral hernia repair be avoided? Hernia 2024; 28:283-284. [PMID: 37715826 DOI: 10.1007/s10029-023-02888-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/08/2023] [Indexed: 09/18/2023]
Affiliation(s)
- I-W Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan
| | - C-L Kao
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung city, Taiwan
| | - K-C Hung
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, ChungHwa Road, YungKung Dist, Tainan city, 71004, Taiwan.
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Kim MS, Lee JS, Chung SJ, Soh Y. Association between Vitamin D and Short-Term Functional Outcomes in Acute Ischemic Stroke. Nutrients 2023; 15:4957. [PMID: 38068815 PMCID: PMC10708110 DOI: 10.3390/nu15234957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
Vitamin D (Vit D) affects musculoskeletal performance and central nervous system neuroprotection. We aimed to investigate the association between serum Vit D levels and short-term functional outcomes in patients with acute ischemic stroke. This study involved patients with acute ischemic stroke confirmed on brain MRI. The National Institutes of Health Stroke Scale (NIHSS) was used to assess initial stroke severity upon admission. We evaluated the functional outcomes using the Berg Balance Scale (BBS), Manual Function Test (MFT), Korean Mini-Mental State Examination (K-MMSE), Korean version of the modified Barthel Index (K-MBI) within three weeks from the onset of stroke, and modified Rankin Scale (mRS) score at discharge. Overall, 192 patients were finally included and divided into three groups: Vit D sufficient (n = 28), insufficient (n = 49), and deficient (n = 115). Multivariate analysis showed that the Vit D deficient group presented with a higher risk of initially severe stroke (p = 0.025) and poor functional outcomes on the BBS (p = 0.048), MFT (p = 0.017), K-MMSE (p = 0.001), K-MBI (p = 0.003), and mRS (p = 0.032) compared to the Vit D sufficient group. Vit D deficiency may be associated with severe initial stroke and poor short-term post-stroke functional outcomes.
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Affiliation(s)
- Min-Su Kim
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (M.-S.K.); (S.J.C.)
| | - Jin San Lee
- Department of Neurology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea;
| | - Sung Joon Chung
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (M.-S.K.); (S.J.C.)
| | - Yunsoo Soh
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (M.-S.K.); (S.J.C.)
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Ciobanu AM, Petrescu C, Anghele C, Manea MC, Ciobanu CA, Petrescu DM, Antonia MO, Riga S. Severe Vitamin D Deficiency-A Possible Cause of Resistance to Treatment in Psychiatric Pathology. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2056. [PMID: 38138159 PMCID: PMC10744484 DOI: 10.3390/medicina59122056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/24/2023]
Abstract
In the last few years, vitamin D functions have been studied progressively, and along with their main role in regulating calcium homeostasis, the potential function in the nervous system and the link between different psychiatric disorders and vitamin D deficiency have been revealed. The discovery of vitamin D receptors in multiple brain structures, like the hippocampus, led to the hypothesis that vitamin D deficiency could be responsible for treatment resistance in psychiatric diseases. The aim of this study was to analyze the current knowledge in the literature regarding vitamin D deficiency among individuals afflicted with psychiatric disorders and assess the potential therapeutic benefits of vitamin D supplementation. A systematic search was conducted on the PubMed database for articles published in the last five years (2016-2022) in English, focusing on human subjects. Results show that vitamin D deficiency has implications for numerous psychiatric disorders, affecting mood and behavior through its influence on neurotransmitter release, neurotrophic factors, and neuroprotection. It also plays a role in modulating inflammation, which is often elevated in psychiatric disorders. In conclusion, vitamin D deficiency is prevalent and has far-reaching implications for mental health. This review underscores the importance of exploring the therapeutic potential of vitamin D supplementation in individuals with psychiatric disorders and highlights the need for further research in this complex field.
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Affiliation(s)
- Adela Magdalena Ciobanu
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.M.C.); (C.P.); (C.A.); (M.C.M.)
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania
| | - Cristian Petrescu
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.M.C.); (C.P.); (C.A.); (M.C.M.)
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania
| | - Cristina Anghele
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.M.C.); (C.P.); (C.A.); (M.C.M.)
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania
| | - Mihnea Costin Manea
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.M.C.); (C.P.); (C.A.); (M.C.M.)
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania
| | | | - Diana Mihaela Petrescu
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Mihalache Oana Antonia
- Neurology Clinic, “Fundeni” Clinical Institute, 022328 Bucharest, Romania
- Department of Stress Research and Prophylaxis, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania;
| | - Sorin Riga
- Department of Stress Research and Prophylaxis, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania;
- Romanian Academy of Medical Sciences, 927180 Bucharest, Romania
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Zhan Q, Kong F. Mechanisms associated with post-stroke depression and pharmacologic therapy. Front Neurol 2023; 14:1274709. [PMID: 38020612 PMCID: PMC10651767 DOI: 10.3389/fneur.2023.1274709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Stroke is one of the most common cerebrovascular diseases, which is the cause of long-term mental illness and physical disability, Post-stroke depression (PSD) is the most common neuropsychiatric complication after stroke, and its mechanisms are characterized by complexity, plurality, and diversity, which seriously affects the quality of survival and prognosis of patients. Studies have focused on and recognized neurotransmitter-based mechanisms and selective serotonin-reuptake inhibitors (SSRIs) can be used to treat PSD. Neuroinflammation, neuroendocrinology, neurotrophic factors, and the site of the stroke lesion may affect neurotransmitters. Thus the mechanisms of PSD have been increasingly studied. Pharmacological treatment mainly includes SSRIs, noradrenergic and specific serotonergic antidepressant (NaSSA), anti-inflammatory drugs, vitamin D, ect, which have been confirmed to have better efficacy by clinical studies. Currently, there is an increasing number of studies related to the mechanisms of PSD. However, the mechanisms and pharmacologic treatment of PSD is still unclear. In the future, in-depth research on the mechanisms and treatment of PSD is needed to provide a reference for the prevention and treatment of clinical PSD.
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Affiliation(s)
- Qingyang Zhan
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Fanyi Kong
- Neurosurgery, Affiliated First Hospital, Harbin Medical University, Harbin, China
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Chen IW, Wang WT, Hung KC. The Influence of Gender on the Association Between Total Weight Loss and Biliopancreatic Limb Length. Obes Surg 2023; 33:3681-3683. [PMID: 37731090 DOI: 10.1007/s11695-023-06820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/22/2023]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan.
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11
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Chen IW, Wang WT, Hung KC. Association between resistance training duration and change in fasting insulin or homeostatic model assessment for insulin resistance: A meta-regression. Obes Res Clin Pract 2023; 17:539-541. [PMID: 37777399 DOI: 10.1016/j.orcp.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 10/02/2023]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan.
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Komba S, Hase M, Kotake-Nara E. Organic Synthesis of New Secosteroids from Fucosterol, Its Intestinal Absorption by Caco-2 Cells, and Simulation of the Biological Activities of Vitamin D. Mar Drugs 2023; 21:540. [PMID: 37888475 PMCID: PMC10608315 DOI: 10.3390/md21100540] [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: 09/22/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
We previously examined the cellular uptake of six types of vitamin D in human intestinal Caco-2 cells. Since vitamins D5-D7 were commercially unavailable, we synthesized these compounds organically before studying them. This process led us to understand that new secosteroids could be generated as vitamin D candidates, depending on the sterol used as the starting material. We obtained two new secosteroids-compounds 3 and 4-from fucosterol in the current study. We investigated the intestinal absorption of these compounds using Caco-2 cells cultured in Transwells and compared the results with vitamin D3, a representative secosteroid. The intestinal absorption of compound 4 was comparable to that of vitamin D3. Compound 3 showed similar uptake levels but transported about half as much as vitamin D3. These compounds demonstrated intestinal absorption at the cellular level. Vitamin D is known for its diverse biological activities manifest after intestinal absorption. Using PASS online simulation, we estimated the biological activity of compound 3's activated form. In several items indicated by PASS, compound 3 exhibited stronger biological activity than vitamins D2-D7 and was also predicted to have unique biological activities.
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Affiliation(s)
- Shiro Komba
- Institute of Food Research, National Agriculture and Food Research Organization, 2-1-12 Kannondai, Tsukuba 305-8642, Ibaraki, Japan
| | - Megumi Hase
- Institute of Food Research, National Agriculture and Food Research Organization, 2-1-12 Kannondai, Tsukuba 305-8642, Ibaraki, Japan
| | - Eiichi Kotake-Nara
- Institute of Food Research, National Agriculture and Food Research Organization, 2-1-12 Kannondai, Tsukuba 305-8642, Ibaraki, Japan
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Yiu CY, Liu CC, Wu JY, Tsai WW, Liu PH, Cheng WJ, Chen JY, Hung KC. Efficacy of the Geriatric Nutritional Risk Index for Predicting Overall Survival in Patients with Head and Neck Cancer: A Meta-Analysis. Nutrients 2023; 15:4348. [PMID: 37892423 PMCID: PMC10610298 DOI: 10.3390/nu15204348] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Head and neck cancer (HNC) is a prevalent malignancy with a poor prognosis, necessitating the identification of prognostic biomarkers to guide management. The geriatric nutritional risk index (GNRI), calculated from serum albumin and body weight, may predict survival in patients with HNC. We performed a systematic review and meta-analysis to clarify this relationship. Databases were searched for studies examining the association between pretreatment GNRI and overall survival in patients with HNC. Ten studies with 2793 patients were included. Meta-analysis demonstrated that low GNRI was associated with significantly worse overall survival compared to high GNRI (hazard ratio [HR]:2.84, 95% CI 2.07-3.91, p < 0.00001). Older age (HR:1.73; 95% CI, 1.35-2.22; p < 0.0001), male sex (HR:1.7; 95% CI, 1.12-2.6; p = 0.01), advanced tumor stage (HR: 2.5; 95% CI, 1.72-3.63; p < 0.00001), and higher T-/N-stage (HR = 1.69 and 1.98, respectively) were also predictive of unfavorable outcomes. The GNRI had the highest HR, suggesting potent predictive ability. Despite limitations, including retrospective design and potential publication bias, our study indicates that low pretreatment GNRI predicts poor overall survival in patients with HNC. The GNRI is an inexpensive, routinely available biomarker that could improve prognostication and guide management decisions. Additional research is warranted to validate these findings.
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Affiliation(s)
- Ching-Yi Yiu
- Department of Otolaryngology, Chi Mei Medical Center, Liouying, Tainan City 73657, Taiwan
- Department of Dental Laboratory Technology, Min-Hwei Junior College of Health Care Management, Liouying, Tainan City 73658, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City 82445, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
- School of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Wen-Wen Tsai
- Department of Neurology, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Ping-Hsin Liu
- Department of Anesthesiology, E-Da Dachang Hospital, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Wan-Jung Cheng
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City 73657, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City 804201, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City 804201, Taiwan
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