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Song Y, Sun N, Jiang Y, Zhu H, Yu Y, Lai G, Yang X. High Hydrophilic and Antibacterial Efficient UV-Curable Silicone-Containing Choline Chloride Quaternary Ammonium Salts Functionalized Materials. Macromol Rapid Commun 2024; 45:e2400300. [PMID: 38950172 DOI: 10.1002/marc.202400300] [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: 05/03/2024] [Revised: 06/15/2024] [Indexed: 07/03/2024]
Abstract
Antibacterial materials with high hydrophobicity have drawbacks such as protein adsorption, bacterial contamination, and biofilm formation, which are responsible for some serious adverse health events. Therefore, antibacterial materials with high hydrophilicity are highly desired. In this paper, UV-curable antibacterial materials are prepared from silicone-containing Choline chloride (ChCl) functionalized hyperbranched quaternary ammonium salts (QAS) and tri-hydroxylethyl acrylate phosphate (TAEP). The materials show high hydrophilic performance because their water contact angle is as low as 19.3°. The materials also exhibit quite high antibacterial efficiency against S. aureus over 95.6%, fairly high transmittance over 90%, and good mechanical performance with tensile strength as high as 6.5 MPa. It reveals that it is a feasible strategy to develop antibacterial materials with low hydrophobicity from silicone-modified ChCl-functionalized hyperbranched QAS.
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Affiliation(s)
- Yan Song
- College of Material, Chemistry and Chemical Engineering, Key Laboratory of Organosilicon Chemistry and Material Technology of Ministry of Education, Key Laboratory of Silicone Materials Technology of Zhejiang Province, Hangzhou Normal University, Zhejiang, 311121, China
| | - Nana Sun
- College of Material, Chemistry and Chemical Engineering, Key Laboratory of Organosilicon Chemistry and Material Technology of Ministry of Education, Key Laboratory of Silicone Materials Technology of Zhejiang Province, Hangzhou Normal University, Zhejiang, 311121, China
| | - Yaohuang Jiang
- College of Life and Environmental Sciences, Hangzhou Normal University, Zhejiang, 311121, China
| | - Hongyu Zhu
- College of Material, Chemistry and Chemical Engineering, Key Laboratory of Organosilicon Chemistry and Material Technology of Ministry of Education, Key Laboratory of Silicone Materials Technology of Zhejiang Province, Hangzhou Normal University, Zhejiang, 311121, China
| | - Yanchun Yu
- College of Life and Environmental Sciences, Hangzhou Normal University, Zhejiang, 311121, China
| | - Guoqiao Lai
- College of Material, Chemistry and Chemical Engineering, Key Laboratory of Organosilicon Chemistry and Material Technology of Ministry of Education, Key Laboratory of Silicone Materials Technology of Zhejiang Province, Hangzhou Normal University, Zhejiang, 311121, China
| | - Xiongfa Yang
- College of Material, Chemistry and Chemical Engineering, Key Laboratory of Organosilicon Chemistry and Material Technology of Ministry of Education, Key Laboratory of Silicone Materials Technology of Zhejiang Province, Hangzhou Normal University, Zhejiang, 311121, China
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Ma T, Zhang J, Liu X, Sun S, Wu J. Effects of combined modification of sulfonation, oxygen plasma and silane on the bond strength of PEEK to resin. Dent Mater 2024; 40:e1-e11. [PMID: 38365456 DOI: 10.1016/j.dental.2024.02.001] [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: 08/21/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE This study aimed to evaluate the combined effects of sulfonation, non-thermal oxygen plasma and silane on the shear bond strength (SBS) of PEEK to resin materials. MATERIALS AND METHODS Two hundred and eighty specimens were randomly divided into four groups: (A) untreated; (B) sulfonation for 60 s; (C) oxygen plasma for 20 min; (D) sulfonation for 60 s and oxygen plasma for 20 min. According to the instructions, 120 samples (N = 30) were coated with silane, adhesive, and resin composites. Each group of bonding specimens was divided into two subgroups (n = 15) to measure immediate and post-aging SBS. The surface morphology and the interface between the samples and adhesive were analyzed through SEM. Physicochemical characteristics of the surface and mechanical properties were determined through XPS, FTIR, light interferometry, contact angle measurement, and three-point bending tests. RESULTS Sulfonation produced a porous layer of approximately 20 µm thickness on the surface, and the oxygen plasma increased the O/C ratio and oxygen-containing groups of the sample surface. After coating with silane, the SBS values of sulfonated PEEK and plasma-treated PEEK increased (9.96 and 10.72 MPa, respectively), and dual-modified PEEK exhibited the highest SBS value (20.99 MPa), which was significantly higher than that of blank group (p > 0.01). After 10,000 thermal cycles, the dual-modified PEEK still displayed a favorable SBS (18.68 MPa). SIGNIFICANCE Sulfonation strengthened the mechanical interlocking between PEEK and the resin while oxygen plasma established a chemical bonding between silane and PEEK. This dual modification of the surface microstructure and chemical state synergistically improved the bond strength of PEEK to resin and resulted in considerable long-term effects.
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Affiliation(s)
- Tongtong Ma
- Department of Prosthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Research Center of Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral Diseases, No. 44-1 Wenhua Road West, 250012, Jinan, Shandong, China
| | - Jiajia Zhang
- Department of Prosthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Research Center of Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral Diseases, No. 44-1 Wenhua Road West, 250012, Jinan, Shandong, China
| | - Xueye Liu
- Department of Prosthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Research Center of Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral Diseases, No. 44-1 Wenhua Road West, 250012, Jinan, Shandong, China
| | - Shuoyao Sun
- Department of Prosthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Research Center of Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral Diseases, No. 44-1 Wenhua Road West, 250012, Jinan, Shandong, China
| | - Junling Wu
- Department of Prosthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Research Center of Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral Diseases, No. 44-1 Wenhua Road West, 250012, Jinan, Shandong, China.
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Shi Y, Lai Y, Guo Y, Cai Z, Mao C, Lu M, Ren C, Ong JL, Chen W. Aspirin/amoxicillin loaded chitosan microparticles and polydopamine modified titanium implants to combat infections and promote osteogenesis. Sci Rep 2024; 14:7624. [PMID: 38561345 PMCID: PMC10984998 DOI: 10.1038/s41598-024-57156-1] [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: 12/09/2023] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
It is known that titanium (Ti) implant surfaces exhibit poor antibacterial properties and osteogenesis. In this study, chitosan particles loaded with aspirin, amoxicillin or aspirin + amoxicillin were synthesized and coated onto implant surfaces. In addition to analysing the surface characteristics of the modified Ti surfaces, the effects of the modified Ti surfaces on the adhesion and viability of rat bone marrow-derived stem cells (rBMSCs) were evaluated. The metabolic activities of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) biofilms on the modified Ti surfaces were also measured in vitro. Moreover, S. aureus was tested for its antibacterial effect by coating it in vivo. Using water as the droplet medium, the contact angles of the modified Ti surfaces increased from 44.12 ± 1.75° to 58.37 ± 4.15°. In comparison to those of the other groups tested, significant increases in rBMSC adhesion and proliferation were observed in the presence of aspirin + amoxicillin-loaded microspheres, whereas a significant reduction in the metabolic level of biofilms was observed in the presence of aspirin + amoxicillin-loaded microspheres both in vitro and in vivo. Aspirin and amoxicillin could be used in combination to coat implant surfaces to mitigate bacterial activities and promote osteogenesis.
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Affiliation(s)
- Yun Shi
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Yongzhen Lai
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Yan Guo
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Zhiyu Cai
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Chuanqing Mao
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Meng Lu
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Chengyan Ren
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Joo L Ong
- Department of Biomedical Engineering and Chemical Engineering, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA.
| | - Weihui Chen
- Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
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Zhou W, Liang J, Huang X, Weir MD, Masri R, Oates TW, Xu HHK, Cheng L. Novel antibacterial titanium implant healing abutment with dimethylaminohexadecyl methacrylate to combat implant-related infections. Dent Mater 2024; 40:244-253. [PMID: 37981511 DOI: 10.1016/j.dental.2023.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Implant-related infections from the adhesion and proliferation of dental plaque are a major challenge for dental implants. The objectives of this study were to: (1) develop novel antibacterial titanium (Ti) healing abutment; (2) investigate the inhibition of implant infection-related pathogenic bacteria and saliva-derived biofilm, and evaluate the biocompatibility of the new material for the first time. METHODS Dimethylaminohexadecyl methacrylate (DMAHDM) and hydroxyapatite (HAP) were polymerized via polydopamine (PDA) on Ti. Staphylococcus aureus (S. aureus), Streptococcus sanguinis (S. sanguinis) and human saliva-derived biofilms were tested. After 4 weeks of DMAHDM release, the antibacterial efficacy of the DMAHDM remaining on Ti surface and the DMADHM in medium was tested. Biocompatibility was determined using human gingival fibroblasts (HGFs) and periodontal ligament stem cells (PDLSCs). RESULTS The DMAHDM-loaded coating filled into the nano-voids in Ti surfaces. The modified Ti showed potent antibacterial activity, reducing the CFU of S. aureus, S. sanguinis and saliva-derived biofilms by 8, 7 and 4 log, respectively (P < 0.05). After 4 weeks of release, the modified Ti was still able to reduce S. aureus and S. sanguinis biofilm CFU by 1-3 log (P < 0.05). This provided strong antibacterial function for more than 4 weeks, which were the high-risk period for implant infections. The new material showed excellent biocompatibility when compared to control (P > 0.05). CONCLUSION Novel DMAHDM-loaded Ti healing abutment had strong antibacterial effects, reducing biofilm CFUs by orders of magnitude, and lasting for over four weeks to cover the high-risk period for implant infections. The novel antibacterial Ti is promising to combat implant-related infections in dental, craniofacial and orthopedic applications.
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Affiliation(s)
- Wen Zhou
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China; State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Jingou Liang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Xiaoyu Huang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA; Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, China
| | - Michael D Weir
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Radi Masri
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Thomas W Oates
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Hockin H K Xu
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA.
| | - Lei Cheng
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China.
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Liang X, Yu B, Ye L, Lin D, Zhang W, Zhong HJ, He J. Recent Advances in Quaternary Ammonium Monomers for Dental Applications. MATERIALS (BASEL, SWITZERLAND) 2024; 17:345. [PMID: 38255513 PMCID: PMC10820831 DOI: 10.3390/ma17020345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/30/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024]
Abstract
Resin-based dental materials have been one of the ideal choices among various materials in the treatment of dental caries. However, resin-based dental materials still have some drawbacks, such as the lack of inherent antibacterial activity. Extensive research has been conducted on the use of novel quaternary ammonium monomers (QAMs) to impart antibacterial activity to dental materials. This review provides a comprehensive overview of the recent advances in quaternary ammonium monomers (QAMs) for dental applications. The current progress and limitations of QAMs are discussed based on the evolution of their structures. The functional diversification and enhancement of QAMs are presented. QAMs have the potential to provide long-term antibacterial activity in dental resin composites, thereby prolonging their service life. However, there is a need to balance antibacterial performance with other material properties and the potential impact on the oral microbiome and general health. Finally, the necessity for further scientific progress in the development of novel quaternary ammonium monomers and the optimization of dental resin formulations is emphasized.
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Affiliation(s)
- Xiaoxu Liang
- Foundation Department, Guangzhou Maritime University, Guangzhou 510725, China;
| | - Biao Yu
- School of Chemistry and Chemical Engineering, Lingnan Normal University, Zhanjiang 524048, China;
| | - Liuqi Ye
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), College of Pharmacy, Jinan University, Guangzhou 510632, China; (L.Y.); (D.L.); (W.Z.)
| | - Danlei Lin
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), College of Pharmacy, Jinan University, Guangzhou 510632, China; (L.Y.); (D.L.); (W.Z.)
| | - Wen Zhang
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), College of Pharmacy, Jinan University, Guangzhou 510632, China; (L.Y.); (D.L.); (W.Z.)
| | - Hai-Jing Zhong
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), College of Pharmacy, Jinan University, Guangzhou 510632, China; (L.Y.); (D.L.); (W.Z.)
| | - Jingwei He
- School of Materials Science and Engineering, South China University of Technology, Guangzhou 510641, China
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Saverina EA, Frolov NA, Kamanina OA, Arlyapov VA, Vereshchagin AN, Ananikov VP. From Antibacterial to Antibiofilm Targeting: An Emerging Paradigm Shift in the Development of Quaternary Ammonium Compounds (QACs). ACS Infect Dis 2023; 9:394-422. [PMID: 36790073 DOI: 10.1021/acsinfecdis.2c00469] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
In a previous development stage, mostly individual antibacterial activity was a target in the optimization of biologically active compounds and antiseptic agents. Although this targeting is still valuable, a new trend has appeared since the discovery of superhigh resistance of bacterial cells upon their aggregation into groups. Indeed, it is now well established that the great majority of pathogenic germs are found in the environment as surface-associated microbial communities called biofilms. The protective properties of biofilms and microbial resistance, even to high concentrations of biocides, cause many chronic infections in medical settings and lead to serious economic losses in various areas. A paradigm shift from individual bacterial targeting to also affecting more complex cellular frameworks is taking place and involves multiple strategies for combating biofilms with compounds that are effective at different stages of microbiome formation. Quaternary ammonium compounds (QACs) play a key role in many of these treatments and prophylactic techniques on the basis of both the use of individual antibacterial agents and combination technologies. In this review, we summarize the literature data on the effectiveness of using commercially available and newly synthesized QACs, as well as synergistic treatment techniques based on them. As an important focus, techniques for developing and applying antimicrobial coatings that prevent the formation of biofilms on various surfaces over time are discussed. The information analyzed in this review will be useful to researchers and engineers working in many fields, including the development of a new generation of applied materials; understanding biofilm surface growth; and conducting research in medical, pharmaceutical, and materials sciences. Although regular studies of antibacterial activity are still widely conducted, a promising new trend is also to evaluate antibiofilm activity in a comprehensive study in order to meet the current requirements for the development of highly needed practical applications.
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Affiliation(s)
- Evgeniya A Saverina
- Tula State University, Lenin pr. 92, 300012 Tula, Russia.,N. D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky pr. 47, 119991 Moscow, Russia
| | - Nikita A Frolov
- N. D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky pr. 47, 119991 Moscow, Russia
| | | | | | - Anatoly N Vereshchagin
- N. D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky pr. 47, 119991 Moscow, Russia
| | - Valentine P Ananikov
- N. D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky pr. 47, 119991 Moscow, Russia
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Zhou W, Wang X, Huang X. Cold atmospheric pressure plasmas applications in dentistry. PLASMA PROCESSES AND POLYMERS 2022; 19. [DOI: 10.1002/ppap.202200024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/13/2022] [Indexed: 01/05/2025]
Abstract
AbstractCold atmospheric pressure plasmas (CAP) is widely used for various therapeutic applications in health care. With the enormous progress in the understanding of plasma physics and development of plasma devices, the application of CAP is greatly promoted in dentistry. The reactive chemical species and electromagnetic radiation generated by CAP can activate and control various biochemical procedures. Therefore, CAP showed promising usage in surface modification of dental materials, biofilm removal, disinfection, endodontic therapy, periodontitis treatment, wound healing, and head and neck cancer control. Therefore, the objective of the present review is to present recently published studies on CAP in dentistry.
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Affiliation(s)
- Wen Zhou
- Postdoctoral Workstation, School and Hospital of Stomatology Fujian Medical University Fuzhou China
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key lab of Fujian College and University, School and Hospital of Stomatology Fujian Medical University Fuzhou China
| | - Xiuqing Wang
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key lab of Fujian College and University, School and Hospital of Stomatology Fujian Medical University Fuzhou China
| | - Xiaojing Huang
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key lab of Fujian College and University, School and Hospital of Stomatology Fujian Medical University Fuzhou China
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