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Rossi I, Mignogna C, Del Rio D, Mena P. Health effects of 100% fruit and vegetable juices: evidence from human subject intervention studies. Nutr Res Rev 2024; 37:194-238. [PMID: 37655747 DOI: 10.1017/s095442242300015x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The health effects of 100% fruit and vegetable juices (FVJ) represent a controversial topic. FVJ contain notable amounts of free sugars, but also vitamins, minerals, and secondary compounds with proven biological activities like (poly)phenols and carotenoids. The review aimed to shed light on the potential impact of 100% FVJ on human subject health, comprehensively assessing the role each type of juice may have in specific health outcomes for a particular target population, as reported in dietary interventions. The effects of a wide range of FVJ (orange, grapefruit, mandarin, lemon, apple, white, red, and Concord grapes, pomegranate, cranberry, chokeberry, blueberry, other minor berries, sweet and tart cherry, plum, tomato, carrot, beetroot, and watermelon, among others) were evaluated on a series of outcomes (anthropometric parameters, body composition, blood pressure and vascular function, lipid profile, glucose homeostasis, biomarkers of inflammation and oxidative stress, cognitive function, exercise performance, gut microbiota composition and bacterial infections), providing a thorough picture of the contribution of each FVJ to a health outcome. Some juices demonstrated their ability to exert potential preventive effects on some outcomes while others on other health outcomes, emphasising how the differential composition in bioactive compounds defines juice effects. Research gaps and future prospects were discussed. Although 100% FVJ appear to have beneficial effects on some cardiometabolic health outcomes, cognition and exercise performance, or neutral effects on anthropometric parameters and body composition, further efforts are needed to better understand the impact of 100% FVJ on human subject health.
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Affiliation(s)
- Irene Rossi
- Human Nutrition Unit, Department of Food and Drug, University of Parma, Parma, Italy
| | - Cristiana Mignogna
- Human Nutrition Unit, Department of Food and Drug, University of Parma, Parma, Italy
| | - Daniele Del Rio
- Human Nutrition Unit, Department of Food and Drug, University of Parma, Parma, Italy
| | - Pedro Mena
- Human Nutrition Unit, Department of Food and Drug, University of Parma, Parma, Italy
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2
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Pârvǎnescu CD, Bǎrbulescu AL, Dinescu ŞC, Bițǎ CE, Firulescu SC, Traşcǎ BA, Dascǎlu RC, Sandu RE, Vreju FA. Subclinical Atherosclerosis in a Gout Cohort: Prevalence and Associations. CURRENT HEALTH SCIENCES JOURNAL 2024; 50:274-282. [PMID: 39371056 PMCID: PMC11447497 DOI: 10.12865/chsj.50.02.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/16/2024] [Indexed: 10/08/2024]
Abstract
The current observational, prospective study enrolled 65 patients with gout, diagnosed according to 2015 ACR/EULAR criteria [17], evaluated in Rheumatology Clinic, Emergency County Hospital Craiova, and 40 healthy subjects. This research aimed to determine the presence of subclinical carotid atherosclerosis, revealed by an increased intima media thickness and carotid plaques in gout patients, by US examination. Secondary, we aimed to search for the possible correlations displayed between the presence of subclinical carotid atherosclerosis and several disease variables. CCAIMT over 0.9mm was identified for 19 patients (29.23%), percentage statistically significant different compared to controls (7; 17.5%), p=0,0428. For 23 patients (35.38%) carotid plaques were present at US examination, more prevalent compared to controls (19; 29.23%), p=0.002. Using multivariate logistic regression, we pointed out that SUA (OR 2,103; p=0.0002), age (OR=1,051; p<0.001), disease duration (OR=1.740; p=0.0039) and LDLc (OR=1,003; p=0.0029) were independently associated to an increased IMT in patients with gout, similar results being obtained for carotid plaques. MSKUS was performed for all patients, with important results. The presence of deposits associated with an increased risk of a thick IMT; similar results were obtained for double contour sign, aggregates and tophi. A statistically significant risk was noticed for the presence of deposits (p=0.002). Regarding the presence of carotid atheroma plaques, a higher risk was associated to deposits identification, double contour sign, aggregates, tophi and PD signal. Our results sustain that carotid ultrasound is an easily accessible imagistic method that offers important predictors of atherosclerotic status.
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Affiliation(s)
| | | | | | - Cristina Elena Bițǎ
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, Romania
| | | | | | | | - Raluca Elena Sandu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, Romania
| | - Florentin Ananu Vreju
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, Romania
- Rheumatology Department, Emergency County Hospital Craiova, Romania
- Ecomed Clinic, Craiova, Romania
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3
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Faustino C, Duarte N, Pinheiro L. Triterpenes Drug Delivery Systems, a Modern Approach for Arthritis Targeted Therapy. Pharmaceuticals (Basel) 2023; 17:54. [PMID: 38256888 PMCID: PMC10819636 DOI: 10.3390/ph17010054] [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: 10/27/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Arthritis is a major cause of disability. Currently available anti-arthritic drugs, such as disease-modifying anti-rheumatic drugs (DMARDs), have serious side-effects associated with long-term use. Triterpenoids are natural products with known anti-inflammatory properties, and many have revealed efficiency against arthritis both in vitro and in vivo in several animal models, with negligible cytotoxicity. However, poor bioavailability due to low water solubility and extensive metabolism upon oral administration hinder the therapeutic use of anti-arthritic triterpenoids. Therefore, drug delivery systems (DDSs) able to improve the pharmacokinetic profile of triterpenoids and achieve sustained drug release are useful alternatives for targeted delivery in arthritis treatment. Several DDSs have been described in the literature for triterpenoid delivery, including microparticulate and nanoparticulate DDSs, such as polymeric micro and nanoparticles (NPs), polymeric micelles, liposomes, micro and nanoemulsions, and hydrogels. These systems have shown superior therapeutic effects in arthritis compared to the free drugs and are similar to currently available anti-arthritic drugs without significant side-effects. This review focuses on nanocarriers for triterpenoid delivery in arthritis therapy, including osteoarthritis (OA), rheumatoid arthritis (RA) and gout that appeared in the literature in the last ten years.
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Affiliation(s)
| | - Noélia Duarte
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Prof. Gama Pinto, 1649-003 Lisbon, Portugal;
| | - Lídia Pinheiro
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Prof. Gama Pinto, 1649-003 Lisbon, Portugal;
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Yang ML, Yang HD, Tang ZS, Hu XH, Zhou R, Xue TT, Ma K, Ji C, Xu HB. Lignan and Phthalide Derivatives from the Rhizome of Ligusticum chuanxiong ( Rhizoma chuanxiong) and Evaluation of Their anti-Xanthine Oxidase Activities. ACS OMEGA 2023; 8:39855-39864. [PMID: 37901529 PMCID: PMC10601418 DOI: 10.1021/acsomega.3c06172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023]
Abstract
The previous research results showed that the extracts of ethyl acetate of the rhizome of Ligusticum chuanxiong (Rhizoma chuanxiong) possessed significant antigout effects in model mice. To explore the active ingredients responsible for the effects, phytochemical studies were performed, which led to the isolation of three rare 8', 9-linked neolignans, ligusticumins A-C (1-3), together with two novel phthalide-phenylpropanoid heterodimers, ligusticumalides A-B (4 and 5). It is noteworthy that 4 possesses an unprecedented 7-styryl phthalide skeleton. The structures and absolute configurations of 1-5 were elucidated by one-dimensional (1D) and two-dimensional (2D) NMR spectroscopy and electron-capture detector (ECD) spectroscopic methods. The bioassay results showed that compounds 1, 2, 3, and 5 presented moderate inhibitory activities against xanthine oxidase (XO) and 4 possessed a significant XO inhibitory effect with an IC50 value of 93.88 μM. This is the first time to investigate the anti-XO active ingredients of R. chuanxiong, which provides valuable information for searching for new antigout agents from natural products.
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Affiliation(s)
- Man-Li Yang
- Nanjing
University of Chinese Medicine, Nanjing 210023, People’s Republic of China
| | - Hao-Dong Yang
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Zhi-Shu Tang
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
- China
Academy of Chinese Medical Sciences, Beijing 100700, People’s Republic of China
| | - Xiao-Hui Hu
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Rui Zhou
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Tao-Tao Xue
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Kang Ma
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Chun Ji
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
| | - Hong-Bo Xu
- Shaanxi
Collaborative Innovation Center of Chinese Medicine Resources Industrialization,
State Key Laboratory of Research & Development of Characteristic
Qin Medicine Resources (Cultivation), Shaanxi Innovative Drug Research
Center, Shaanxi University of Chinese Medicine, Xianyang 712046, People’s Republic of China
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5
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Zamudio-Cuevas Y, Martínez-López V, López-Macay A, Montaño-Armendáriz N, Lozada-Pérez CA, Martínez-Flores K, Hernández-Valencia CG, Sánchez-Sánchez R, Gimeno M, Fernández-Torres J. Antiphagocytic Properties of Polygallic Acid with Implications in Gouty Inflammation. Inflammation 2023; 46:1952-1965. [PMID: 37470914 DOI: 10.1007/s10753-023-01852-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023]
Abstract
Polygallic acid (PGAL) has been used in vitro to protect synoviocytes from monosodium urate (MSU) crystals due to its anti-inflammatory properties. However, MSU crystals can also activate other cells of the synovial fluid (SF). We studied the impact of PGAL on the phagocytosis of MSU crystals, inflammation, and oxidative stress using an in vitro model with SF leukocytes and THP-1 monocyte cells. SF leukocytes were stimulated with PGAL and MSU crystals, proinflammatory cytokines and phagocytosis were assessed. In THP-1 cells, the effect of PGAL on the phagocytosis of MSU crystals and the levels of IL-1β, IL-6, TNF-α, and reactive oxygen species (ROS) was evaluated. PGAL was added to THP-1 cultures 24 h before MSU crystal addition as a pre-treatment, and IL-1β was measured. One-way ANOVA with Tukey's post hoc test was performed, and a P value < 0.05 was considered statistically significant. PGAL (100 µg/mL) decreased phagocytosis in SF leukocytes by 14% compared to cells exposed to crystals without PGAL. In THP-1 cells, 100 and 200 µg/mL PGAL reduced phagocytosis by 17% and 15%, respectively. In SF cells, there was a tendency to decrease IL-1β and IL-6. In THP-1 cells, decreases in IL-1β and TNF-α, as well as a slight decrease in ROS, were identified. PGAL pre-treatment resulted in a reduction of IL-1β. PGAL inhibits MSU phagocytosis by exerting an anti-inflammatory effect on cells exposed to crystals. The use of PGAL before an acute attack of gout suggests an important protective factor to control the inflammation.
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Affiliation(s)
- Yessica Zamudio-Cuevas
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Valentín Martínez-López
- Unidad de Ingeniería de Tejidos Terapia Celular y Medicina Regenerativa, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Ambar López-Macay
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Nathalie Montaño-Armendáriz
- División de Reconstrucción Articular de Cadera y Rodilla, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Carlos Alberto Lozada-Pérez
- División de Reumatología, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Karina Martínez-Flores
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
| | - Carmen G Hernández-Valencia
- Unidad de Ingeniería de Tejidos Terapia Celular y Medicina Regenerativa, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
- Departamento de Alimentos y Biotecnología, Facultad de Química, UNAM, Mexico City, Mexico
| | - Roberto Sánchez-Sánchez
- Unidad de Ingeniería de Tejidos Terapia Celular y Medicina Regenerativa, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico
- Escuela de Ingeniería y Ciencias, Departamento de Bioingeniería, Instituto Tecnólogico de Monterrey, C. Puente No 222, Colonia Arboledas Sur, 14380, Tlalpan, Mexico City, Mexico
| | - Miquel Gimeno
- Departamento de Alimentos y Biotecnología, Facultad de Química, UNAM, Mexico City, Mexico
| | - Javier Fernández-Torres
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra", Mexico City, Mexico.
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Kakagia DD, Karadimas EJ, Stouras IA, Papanas N. The Ageing Foot. INT J LOW EXTR WOUND 2023:15347346231203279. [PMID: 37750199 DOI: 10.1177/15347346231203279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Feet suffer significant stress throughout a lifetime and undergo ageing-associated problems due to gradual tissue degeneration affecting the skin, connective tissue, and nerves. Oxygen supply to the tissues may be diminished. The skin gets dry and calluses, ulcers and fungal infections of the skin and nails are not uncommon. Ligaments and tendons degenerate and, without proper prevention, deformities including claw toes, hammer toes, tendonitis, and bursitis may occur. Skeletal toe deformities such as bunions, bony spurs, and hallux valgus may increase discomfort, while stress fractures may have an adverse impact on the patients' quality of life. The ageing foot pathology may add up to common age-related problems, such as crystal deposition arthropathies, diabetes mellitus, peripheral circulatory disorders, and peripheral edema, increasing morbidity. This review summarizes ageing-related feet problems, focusing on prevention and treatment. Foot health has a paramount role in overall wellbeing, therefore prevention, proper foot care, and prompt diagnosis and management of ageing-related changes are vital for maintaining a healthy, active status.
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Affiliation(s)
- Despoina D Kakagia
- Department of Plastic Surgery, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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Kang HS, Lee NE, Yoo DM, Han KM, Hong JY, Choi HG, Lim H, Kim JH, Kim JH, Cho SJ, Nam ES, Park HY, Kim NY, Baek SU, Lee JY, Kwon MJ. An elevated likelihood of stroke, ischemic heart disease, or heart failure in individuals with gout: a longitudinal follow-up study utilizing the National Health Information database in Korea. Front Endocrinol (Lausanne) 2023; 14:1195888. [PMID: 37680887 PMCID: PMC10482324 DOI: 10.3389/fendo.2023.1195888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/13/2023] [Indexed: 09/09/2023] Open
Abstract
Objective Accumulating evidence from other countries indicates potential associations between gout and cardiovascular diseases; however, the associations of gout with cardiovascular diseases, particularly stroke, ischemic heart disease, and heart failure, remain ambiguous in the Korean population. We hypothesized that individuals with gout are at a higher likelihood of stroke, ischemic heart disease, or heart failure. This study expands upon previous research by ensuring a comparable baseline between patient and control groups and analyzing 16 years of data derived from an extensive healthcare database. Methods We selected 22,480 patients with gout and 22,480 control individuals from the Korean National Health Insurance Service-Health Screening Cohort database (2002-2019), and matched them at a 1:1 ratio according to sex, age, income, and residence. A Cox proportional hazard model with weighted overlap was employed to examine the relationship between gout and the risk of stroke, ischemic heart disease, or heart failure after adjustment for several covariates. Results The incidences of stroke, ischemic heart disease, or heart failure in participants with gout were slightly higher than those in controls (stroke: 9.84 vs. 8.41 per 1000 person-years; ischemic heart disease: 9.77 vs. 7.15 per 1000 person-years; heart failure: 2.47 vs. 1.46 per 1000 person-years). After adjustment, the gout group had an 11% (95% confidence interval [CI] = 1.04-1.19), 28% (95% CI = 1.19-1.37), or 64% (95% CI = 1.41-1.91) higher likelihood of experiencing stroke, ischemic heart disease, or heart failure, respectively, than the control group. Conclusion The present findings suggest that individuals with gout in the Korean population, particularly those aged ≥ 60 years, were more likely to have stroke, ischemic heart disease, or heart failure.
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Affiliation(s)
- Ho Suk Kang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Na-Eun Lee
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Dae Myoung Yoo
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Kyeong Min Han
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Ji Yeon Hong
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Hyo Geun Choi
- Department of Otorhinolaryngology, Suseo Seoul E.N.T. Clinic, Seoul, Republic of Korea
- MD Analytics, Seoul, Republic of Korea
| | - Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Joo-Hee Kim
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Seong-Jin Cho
- Department of Pathology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Eun Sook Nam
- Department of Pathology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ha Young Park
- Department of Pathology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Nan Young Kim
- Hallym Institute of Translational Genomics and Bioinformatics, Hallym University Medical Center, Anyang, Republic of Korea
| | - Sung Uk Baek
- Department of Ophthalmology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Joo Yeon Lee
- Department of Ophthalmology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
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Liu GT, Kuo CY. Bioactives and Inflammation. Curr Issues Mol Biol 2023; 45:5824-5829. [PMID: 37504284 PMCID: PMC10377902 DOI: 10.3390/cimb45070368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Inflammation is one of the body's most complex physiological defense mechanisms against harmful substances [...].
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Affiliation(s)
- Guan-Ting Liu
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
| | - Chan-Yen Kuo
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
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