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O'Reilly S, Tsou PS, Varga J. Senescence and tissue fibrosis: opportunities for therapeutic targeting. Trends Mol Med 2024:S1471-4914(24)00134-5. [PMID: 38890028 DOI: 10.1016/j.molmed.2024.05.012] [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: 04/10/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024]
Abstract
Cellular senescence is a key hallmark of aging. It has now emerged as a key mediator in normal tissue turnover and is associated with a variety of age-related diseases, including organ-specific fibrosis and systemic sclerosis (SSc). This review discusses the recent evidence of the role of senescence in tissue fibrosis, with an emphasis on SSc, a systemic autoimmune rheumatic disease. We discuss the physiological role of these cells, their role in fibrosis, and that targeting these cells specifically could be a new therapeutic avenue in fibrotic disease. We argue that targeting senescent cells, with senolytics or senomorphs, is a viable therapeutic target in fibrotic diseases which remain largely intractable.
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Affiliation(s)
- Steven O'Reilly
- Bioscience Department, Durham University, South Road, Durham, UK.
| | - Pei-Suen Tsou
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John Varga
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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2
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D'Agnano V, Mariniello DF, Pagliaro R, Far MS, Schiattarella A, Scialò F, Stella G, Matera MG, Cazzola M, Bianco A, Perrotta F. Sirtuins and Cellular Senescence in Patients with Idiopathic Pulmonary Fibrosis and Systemic Autoimmune Disorders. Drugs 2024; 84:491-501. [PMID: 38630364 PMCID: PMC11189987 DOI: 10.1007/s40265-024-02021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 06/22/2024]
Abstract
The sirtuin family is a heterogeneous group of proteins that play a critical role in many cellular activities. Several degenerative diseases have recently been linked to aberrant sirtuin expression and activity because of the involvement of sirtuins in maintaining cell longevity and their putative antiaging function. Idiopathic pulmonary fibrosis and progressive pulmonary fibrosis associated with systemic autoimmune disorders are severe diseases characterized by premature and accelerated exhaustion and failure of alveolar type II cells combined with aberrant activation of fibroblast proliferative pathways leading to dramatic destruction of lung architecture. The mechanisms underlying alveolar type II cell exhaustion in these disorders are not fully understood. In this review, we have focused on the role of sirtuins in the pathogenesis of idiopathic and secondary pulmonary fibrosis and their potential as biomarkers in the diagnosis and management of fibrotic interstitial lung diseases.
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Affiliation(s)
- Vito D'Agnano
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Domenica Francesca Mariniello
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Mehrdad Savabi Far
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Angela Schiattarella
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Filippo Scialò
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Giulia Stella
- Unit of Respiratory System Diseases, Department of Medical Sciences and Infectious Diseases, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome 'Tor Vergata', Rome, Italy.
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy
- U.O.C. Clinica Pneumologica L. Vanvitelli, A.O. dei Colli, Monaldi Hospital, Naples, Italy
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3
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Jones DP. Redox organization of living systems. Free Radic Biol Med 2024; 217:179-189. [PMID: 38490457 DOI: 10.1016/j.freeradbiomed.2024.03.008] [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: 12/31/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/17/2024]
Abstract
Redox organization governs an underlying simplicity in living systems. Critically, redox reactions enable the essential characteristics of life: extraction of energy from the environment, use of energy to support metabolic and structural organization, use of dynamic redox responses to defend against environmental threats, and use of redox mechanisms to direct differentiation of cells and organ systems essential for reproduction. These processes are sustained through a redox context in which electron donor/acceptor couples are poised at substantially different steady-state redox potentials, some with relatively reducing steady states and others with relatively oxidizing steady states. Redox-sensitive thiols of the redox proteome, as well as low molecular weight redox-active molecules, are maintained individually by the kinetics of oxidation-reduction within this redox system. Recent research has revealed opposing network interactions of the metallome, redox proteome, metabolome and transcriptome, which appear to be an evolved redox response structure to maintain stability of an organism in the presence of variable oxidative environments. Considerable opportunity exists to improve human health through detailed understanding of these redox networks so that targeted interventions can be developed to support new avenues for redox medicine.
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Affiliation(s)
- Dean P Jones
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Whitehead Biomedical Research Building, 615 Michael St, RM205P, Atlanta, GA, 30322, USA.
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Mari YM, Fraix MP, Agrawal DK. Pulmonary Fibrosis and Diabetes Mellitus: Two coins with the same face. ARCHIVES OF INTERNAL MEDICINE RESEARCH 2024; 7:53-70. [PMID: 38576768 PMCID: PMC10994216 DOI: 10.26502/aimr.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Idiopathic pulmonary fibrosis (IPF) constitutes a long-term disease with a complex pathophysiology composed of multiple molecular actors that lead to the deposition of extracellular matrix, the loss of pulmonary function and ultimately the patient's death. Despite the approval of pirfenidone and nintedanib for the treatment of the disease, lung transplant is the only long-term solution to fully recover the respiratory capacity and gain quality of life. One of the risk factors for the development of IPF is the pre-existing condition of diabetes mellitus. Both, IPF and diabetes mellitus, share similar pathological damage mechanisms, including inflammation, endoplasmic reticulum stress, mitochondrial failure, oxidative stress, senescence and signaling from glycated proteins through receptors. In this critical review article, we provide information about this interrelationship, examining molecular mediators that play an essential role in both diseases and identify targets of interest for the development of potential drugs. We review the findings of clinical trials examining the progression of IPF and how novel molecules may be used to stop this process. The results highlight the importance of early detection and addressing multiple therapeutic targets simultaneously to achieve better therapeutic efficacy and potentially reverse lung fibrosis.
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Affiliation(s)
- Yssel Mendoza Mari
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
| | - Marcel P Fraix
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
| | - Devendra K Agrawal
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
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Mohanan A, Washimkar KR, Mugale MN. Unraveling the interplay between vital organelle stress and oxidative stress in idiopathic pulmonary fibrosis. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2024; 1871:119676. [PMID: 38242330 DOI: 10.1016/j.bbamcr.2024.119676] [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: 08/06/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 01/21/2024]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive lung disease characterized by excessive accumulation of extracellular matrix, leading to irreversible fibrosis. Emerging evidence suggests that endoplasmic reticulum (ER) stress, mitochondrial stress, and oxidative stress pathways play crucial roles in the pathogenesis of IPF. ER stress occurs when the protein folding capacity of the ER is overwhelmed, triggering the unfolded protein response (UPR) and contributing to protein misfolding and cellular stress in IPF. Concurrently, mitochondrial dysfunction involving dysregulation of key regulators, including PTEN-induced putative kinase 1 (PINK1), Parkin, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), and sirtuin 3 (SIRT3), disrupts mitochondrial homeostasis and impairs cellular energy metabolism. This leads to increased reactive oxygen species (ROS) production, release of pro-fibrotic mediators, and activation of fibrotic pathways, exacerbating IPF progression. The UPR-induced ER stress further disrupts mitochondrial metabolism, resulting in altered mitochondrial mechanisms that increase the generation of ROS, resulting in further ER stress, creating a feedback loop that contributes to the progression of IPF. Oxidative stress also plays a pivotal role in IPF, as ROS-mediated activation of TGF-β, NF-κB, and MAPK pathways promotes inflammation and fibrotic responses. This review mainly focuses on the links between ER stress, mitochondrial dysfunctions, and oxidative stress with different signaling pathways involved in IPF. Understanding these mechanisms and targeting key molecules within these pathways may offer promising avenues for intervention.
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Affiliation(s)
- Anushree Mohanan
- Division of Toxicology and Experimental Medicine, CSIR-Central Drug Research Institute (CSIR-CDRI), Lucknow 226031, India
| | - Kaveri R Washimkar
- Division of Toxicology and Experimental Medicine, CSIR-Central Drug Research Institute (CSIR-CDRI), Lucknow 226031, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Madhav Nilakanth Mugale
- Division of Toxicology and Experimental Medicine, CSIR-Central Drug Research Institute (CSIR-CDRI), Lucknow 226031, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
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Jia M, Sayed K, Kapetanaki MG, Dion W, Rosas L, Irfan S, Valenzi E, Mora AL, Lafyatis RA, Rojas M, Zhu B, Benos PV. LEF1 isoforms regulate cellular senescence and aging. Aging Cell 2023; 22:e14024. [PMID: 37961030 PMCID: PMC10726832 DOI: 10.1111/acel.14024] [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: 08/10/2023] [Revised: 10/11/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023] Open
Abstract
The study of aging and its mechanisms, such as cellular senescence, has provided valuable insights into age-related pathologies, thus contributing to their prevention and treatment. The current abundance of high-throughput data combined with the surge of robust analysis algorithms has facilitated novel ways of identifying underlying pathways that may drive these pathologies. For the purpose of identifying key regulators of lung aging, we performed comparative analyses of transcriptional profiles of aged versus young human subjects and mice, focusing on the common age-related changes in the transcriptional regulation in lung macrophages, T cells, and B immune cells. Importantly, we validated our findings in cell culture assays and human lung samples. Our analysis identified lymphoid enhancer binding factor 1 (LEF1) as an important age-associated regulator of gene expression in all three cell types across different tissues and species. Follow-up experiments showed that the differential expression of long and short LEF1 isoforms is a key regulatory mechanism of cellular senescence. Further examination of lung tissue from patients with idiopathic pulmonary fibrosis, an age-related disease with strong ties to cellular senescence, revealed a stark dysregulation of LEF1. Collectively, our results suggest that LEF1 is a key factor of aging, and its differential regulation is associated with human and murine cellular senescence.
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Affiliation(s)
- Minxue Jia
- Department of Computational and Systems BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Joint Carnegie Mellon University‐University of Pittsburgh Ph.D. Program in Computational BiologyPittsburghPennsylvaniaUSA
| | - Khaled Sayed
- Department of Computational and Systems BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of Electrical & Computer Engineering and Computer ScienceUniversity of New HavenWest HavenConnecticutUSA
| | - Maria G. Kapetanaki
- Department of Computational and Systems BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of EpidemiologyUniversity of FloridaGainesvilleFloridaUSA
| | - William Dion
- Aging Institute of UPMCUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Lorena Rosas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Saad Irfan
- Aging Institute of UPMCUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Eleanor Valenzi
- Department of RheumatologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Ana L. Mora
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Robert A. Lafyatis
- Department of RheumatologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Mauricio Rojas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Bokai Zhu
- Aging Institute of UPMCUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
- Pittsburgh Liver Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Panayiotis V. Benos
- Department of Computational and Systems BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Joint Carnegie Mellon University‐University of Pittsburgh Ph.D. Program in Computational BiologyPittsburghPennsylvaniaUSA
- Department of EpidemiologyUniversity of FloridaGainesvilleFloridaUSA
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Wan R, Wang L, Zhu M, Li W, Duan Y, Yu G. Cellular Senescence: A Troy Horse in Pulmonary Fibrosis. Int J Mol Sci 2023; 24:16410. [PMID: 38003600 PMCID: PMC10671822 DOI: 10.3390/ijms242216410] [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: 10/19/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Pulmonary fibrosis (PF) is a chronic interstitial lung disease characterized by myofibroblast abnormal activation and extracellular matrix deposition. However, the pathogenesis of PF remains unclear, and treatment options are limited. Epidemiological studies have shown that the average age of PF patients is estimated to be over 65 years, and the incidence of the disease increases with age. Therefore, PF is considered an age-related disease. A preliminary study on PF patients demonstrated that the combination therapy of the anti-senescence drugs dasatinib and quercetin improved physical functional indicators. Given the global aging population and the role of cellular senescence in tissue and organ aging, understanding the impact of cellular senescence on PF is of growing interest. This article systematically summarizes the causes and signaling pathways of cellular senescence in PF. It also objectively analyzes the impact of senescence in AECs and fibroblasts on PF development. Furthermore, potential intervention methods targeting cellular senescence in PF treatment are discussed. This review not only provides a strong theoretical foundation for understanding and manipulating cellular senescence, developing new therapies to improve age-related diseases, and extending a healthy lifespan but also offers hope for reversing the toxicity caused by the massive accumulation of senescence cells in humans.
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Affiliation(s)
- Ruyan Wan
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
| | - Lan Wang
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
| | - Miaomiao Zhu
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
| | - Wenwen Li
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
| | - Yudi Duan
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
| | - Guoying Yu
- Henan International Joint Laboratory of Pulmonary Fibrosis, Henan Center for Outstanding Overseas Scientists of Pulmonary Fibrosis, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang 453007, China; (R.W.); (L.W.); (M.Z.); (W.L.); (Y.D.)
- State Key Laboratory Cell Differentiation and Regulation, Henan Normal University, Xinxiang 453007, China
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Tseng CC, Sung YW, Chen KY, Wang PY, Yen CY, Sung WY, Wu CC, Ou TT, Tsai WC, Liao WT, Chen CJ, Lee SC, Chang SJ, Yen JH. The Role of Macrophages in Connective Tissue Disease-Associated Interstitial Lung Disease: Focusing on Molecular Mechanisms and Potential Treatment Strategies. Int J Mol Sci 2023; 24:11995. [PMID: 37569370 PMCID: PMC10419312 DOI: 10.3390/ijms241511995] [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: 04/20/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Connective tissue disease-associated interstitial lung disease (CTD-ILD) is a severe manifestation of CTD that leads to significant morbidity and mortality. Clinically, ILD can occur in diverse CTDs. Pathologically, CTD-ILD is characterized by various histologic patterns, such as nonspecific interstitial pneumonia, organizing pneumonia, and usual interstitial pneumonia. Abnormal immune system responses have traditionally been instrumental in its pathophysiology, and various changes in immune cells have been described, especially in macrophages. This article first briefly overviews the epidemiology, clinical characteristics, impacts, and histopathologic changes associated with CTD-ILD. Next, it summarizes the roles of various signaling pathways in macrophages or products of macrophages in ILD, helped by insights gained from animal models. In the following sections, this review returns to studies of macrophages in CTD-ILD in humans for an overall picture of the current understanding. Finally, we direct attention to potential therapies targeting macrophages in CTD-ILD in investigation or in clinical trials, as well as the future directions regarding macrophages in the context of CTD-ILD. Although the field of macrophages in CTD-ILD is still in its infancy, several lines of evidence suggest the potential of this area.
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Affiliation(s)
- Chia-Chun Tseng
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Ya-Wen Sung
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Kuan-Yu Chen
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Pin-Yi Wang
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Chang-Yi Yen
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wan-Yu Sung
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Cheng-Chin Wu
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Tsan-Teng Ou
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wen-Chan Tsai
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wei-Ting Liao
- Department of Biotechnology, College of Life Science, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Chung-Jen Chen
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 801, Taiwan
| | - Su-Chen Lee
- Laboratory Diagnosis of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Shun-Jen Chang
- Department of Kinesiology, Health and Leisure Studies, National University of Kaohsiung, Kaohsiung 811, Taiwan
| | - Jeng-Hsien Yen
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
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