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Fukatsu-Chikumoto A, Hirano T, Takahashi S, Ishida T, Yasuda K, Donishi T, Suga K, Doi K, Oishi K, Ohata S, Murata Y, Yamaji Y, Asami-Noyama M, Edakuni N, Kakugawa T, Matsunaga K. Correlation between frailty and reduction in cortical thickness in patients with chronic obstructive pulmonary disease. Sci Rep 2024; 14:6106. [PMID: 38480723 PMCID: PMC10937661 DOI: 10.1038/s41598-024-53933-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 02/06/2024] [Indexed: 03/17/2024] Open
Abstract
Physical inactivity and cognitive impairment in patients with chronic obstructive pulmonary disease (COPD) can lead to frailty and poor prognoses. However, little is known regarding the association between frailty and the human brain. We hypothesized that the brain structure could change according to frailty in patients with COPD and focused on cortical thickness. Cortical thickness measured by magnetic resonance imaging and frailty scores using the Kihon Checklist (KCL) were assessed in 40 patients with stable COPD and 20 healthy controls. Among the 34 regions assessed, multiple regions were thinner in patients with COPD than in healthy individuals (p < 0.05). We found significant negative correlations between the eight regions and the KCL scores only in patients with COPD. After adjusting for age and cognitive impairment, the association between the left and six right regions remained statistically significant. The correlation coefficient was the strongest in the bilateral superior frontal gyrus (left: ρ = - 0.5319, p = 0.0006) (right: ρ = - 0.5361, p = 0.0005). Interestingly, among the KCL scores, the daily activity domain showed the strongest correlation (sensitivity, 90%; specificity, 73%) with the bottom quartile of the reduction in the superior frontal gyrus. Frailty in patients with COPD is associated with a thickness reduction in the cortical regions, reflecting social vulnerability.
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Affiliation(s)
- Ayumi Fukatsu-Chikumoto
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan.
| | - Shun Takahashi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, 565-0871, Japan
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
- Graduate School of Rehabilitation Science, Osaka Metropolitan University, Habikino, 583-8555, Japan
- Clinical Research and Education Center, Asakayama General Hospital, Sakai, 590-0018, Japan
| | - Takuya Ishida
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Kasumi Yasuda
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Tomohiro Donishi
- Department of System Neurophysiology, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Kazuyoshi Suga
- Department of Radiology, St. Hill Hospital, Ube, 755-0155, Japan
| | - Keiko Doi
- Department of Pulmonology and Gerontology, Graduate School of Medicine, Yamaguchi University, Ube, 755-8505, Japan
| | - Keiji Oishi
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Shuichiro Ohata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Yoriyuki Murata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Tomoyuki Kakugawa
- Department of Pulmonology and Gerontology, Graduate School of Medicine, Yamaguchi University, Ube, 755-8505, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
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Abstract
Growth differentiation factor 15 (GDF15), a member of the transforming growth factor-beta superfamily, is expressed in several human organs. In particular, it is highly expressed in the placenta, prostate, and liver. The expression of GDF15 increases under cellular stress and pathological conditions. Although numerous transcription factors directly up-regulate the expression of GDF15, the receptors and downstream mediators of GDF15 signal transduction in most tissues have not yet been determined. Glial cell-derived neurotrophic factor family receptor α-like protein was recently identified as a specific receptor that plays a mediating role in anorexia. However, the specific receptors of GDF15 in other tissues and organs remain unclear. As a marker of cell stress, GDF15 appears to exert different effects under different pathological conditions. Cell senescence may be an important pathogenetic process and could be used to assess the progression of various lung diseases, including COVID-19. As a key member of the senescence-associated secretory phenotype protein repertoire, GDF15 seems to be associated with mitochondrial dysfunction, although the specific molecular mechanism linking GDF15 expression with ageing remains to be elucidated. Here, we focus on research progress linking GDF15 expression with the pathogenesis of various chronic lung diseases, including neonatal bronchopulmonary dysplasia, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, and pulmonary hypertension, suggesting that GDF15 may be a key biomarker for diagnosis and prognosis. Thus, in this review, we aimed to provide new insights into the molecular biological mechanism and emerging clinical data associated with GDF15 in lung-related diseases, while highlighting promising research and clinical prospects.
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Affiliation(s)
- Yang Wan
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jianhua Fu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.
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Kim HR, Kim MJ, Jeon JW, Ham YR, Na KR, Park H, Kim JJ, Choi DE. Association between Serum GDF-15 and Cognitive Dysfunction in Hemodialysis Patients. Biomedicines 2024; 12:358. [PMID: 38397960 PMCID: PMC10887297 DOI: 10.3390/biomedicines12020358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Cognitive dysfunction is more frequent in end-stage renal disease (ESRD) patients undergoing hemodialysis compared with the healthy population, emphasizing the need for early detection. Interest in serum markers that reflect cognitive function has recently increased. Elevated serum growth differentiation factor 15 (GDF-15) levels are known to be associated with an increased risk of decreased renal function and cognitive dysfunction. This study investigated the relationship between GDF-15 and cognitive dysfunction in hemodialysis patients using a retrospective analysis of 92 individuals aged ≥ 18 years. Cognitive function was assessed using the Korean version of the Mini-Mental Status Examination (K-MMSE), categorizing patients into normal (≥24 points) and cognitive dysfunction (<24 points). As a result, serum GDF-15 concentrations were at significantly higher levels in the cognitive dysfunction group (7500.42 pg/mL, p = 0.001). Logistic regression indicated an increased risk of K-MMSE scores < 24 points when serum GDF-15 exceeded 5408.33 pg/mL. After indoxyl sulfate exposure in HT22 cells, HT22 cells survival was decreased and GDF-15 expression in HT22 cells was increased. Similarly, exposure to indoxyl sulfate in mouse brain tissue resulted in an increased expression of GDF-15. This study highlights the potential of serum GDF-15 as a marker for cognitive dysfunction in hemodialysis patients, offering a valuable screening tool. Serum GDF-15 is related to cognitive dysfunction in hemodialysis patients and may be helpful in screening for cognitive dysfunction in hemodialysis patients.
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Affiliation(s)
- Hae Ri Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (H.R.K.); (M.J.K.); (J.W.J.)
| | - Moo Jun Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (H.R.K.); (M.J.K.); (J.W.J.)
| | - Jae Wan Jeon
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (H.R.K.); (M.J.K.); (J.W.J.)
| | - Young Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (Y.R.H.); (K.R.N.); (J.-J.K.)
| | - Ki Ryang Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (Y.R.H.); (K.R.N.); (J.-J.K.)
| | - Hyerim Park
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea;
| | - Jwa-Jin Kim
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (Y.R.H.); (K.R.N.); (J.-J.K.)
| | - Dae Eun Choi
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (Y.R.H.); (K.R.N.); (J.-J.K.)
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea;
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Qiu P, Chen M, Lv S, Xie J, Wu J. The association between walking pace and hand grip strength with the risk of chronic obstructive pulmonary disease: a bidirectional Mendelian randomization study. BMC Pulm Med 2023; 23:450. [PMID: 37986176 PMCID: PMC10658936 DOI: 10.1186/s12890-023-02759-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) currently ranks as the third leading cause of mortality worldwide, imposing substantial burdens on societal and individual health. Amongst health research tools, walking pace (WP) and hand grip strength (HGS) are cornerstones, extensively associated with diverse health conditions. However, the intricate interplay between these factors and COPD risk remains ambiguous. This study aims to elucidate the causal association of WP, HGS, with COPD risk through a bidirectional Mendelian randomization (MR) approach. METHODS Bidirectional MR analysis was performed using Genome-wide association study (GWAS) data of European individuals for WP, HGS, and COPD. Inverse Variance Weighted (IVW) served as the primary MR analysis approach. To supplement the IVW findings, four additional MR methods [MR-Egger, weighted median, maximum likelihood, simple median] were used. To assess heterogeneity and pleiotropy, sensitivity analyses were performed. In addition, multivariate MR (MVMR) analysis was used to assess causality after adjustment for potential confounders. RESULTS IVW method results show a significant negative association between WP and COPD risk in both initial (genome-wide threshold, odds ratio (OR) = 0.21, 95% confidence interval (CI) 0.09-0.51, P = 5.06 × 10- 4) and secondary (locus-wide threshold, OR = 0.27, 95%CI: 0.18-0.41, P = 4.88 × 10- 10) MR analysis. The reverse MR analysis suggested that COPD also diminishes WP. Additionally, a causal risk reduction for COPD with right HGS (OR = 0.74, 95% CI: 0.58-0.94, P = 1.44 × 10- 2) was only found in secondary MR analysis. The outcomes of the four additional MR methods also suggested similar causal relationships, and sensitivity analyses endorsed their robustness. Lastly, the MVMR analysis demonstrated that the WP's effect on reducing COPD risk persisted independently of potential confounding variables. CONCLUSION A bidirectional causal relationship exists between typical WP and COPD risk. Conversely, a decrease in right HGS is unidirectionally associated with an increased risk of COPD. The study suggests that WP may serve as a predictive factor for COPD or as a simple evaluative indicator for prognosis.
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Affiliation(s)
- Peng Qiu
- Department of Rehabilitation, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mingxian Chen
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Shuaibing Lv
- School of Physical Education, Shanghai University of Sport, Shanghai, China
| | - Juanjuan Xie
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Junyu Wu
- School of Physical Education, Shanghai University of Sport, Shanghai, China.
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Li J, Sun Q, Zhang H, Li B, Zhang C, Zhao Y, Lu J, Ma X. Serum-Creatinine-to-Cystatin C-to-Waist-Circumference Ratios as an Indicator of Severe Airflow Limitation in Older Adults. J Clin Med 2023; 12:7116. [PMID: 38002727 PMCID: PMC10672224 DOI: 10.3390/jcm12227116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/17/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between the serum-creatinine-to-cystatin C-to-waist-circumference (CCR/WC) ratio with lung function and severe airflow limitation (SAL). METHODS The data were derived from the China Health and Retirement Longitudinal Study. Peak expiratory flow (PEF) was used as a measure of lung function parameter. Logistic and linear regression were utilized separately to evaluate the relationship between the CCR/WC ratio with PEF and SAL in baseline. Restricted cubic spline was used to explore potential non-linear associations between the CCR/WC ratio and SAL. Cox proportional-hazards models were used to assess the association between CCR/WC quartiles and the risk of new-onset SAL. RESULTS A total of 6105 participants were included. This study revealed a positive association between the CCR/WC ratio and lung function (PEF: β [partial coefficient]: 25.95, 95%CI: 12.72 to 39.18, p < 0.001; PEF/PEF prediction: β = 0.08, 95%CI: 0.05 to 0.12, p < 0.001) and an inverse association relationship with SAL (OR [odds ratio]: 0.64, 95% confidence interval [CI]: 0.47 to 0.85, p = 0.003). Subgroup analysis showed a significant association between the CCR/WC ratio and SAL in males (OR: 0.58, 95% CI: 0.37 to 0.90, p = 0.017) but not in females (p = 0.059). Cox regression analysis revealed a decreased risk of SAL in the quartiles (Q2-4) compared to the first quartile of the CCR/WC ratio (hazard ratios [HRs]: 0.49 to 0.73, all p < 0.05). CONCLUSIONS This study highlights a positive association between the CCR/WC ratio and lung function, with a potential protective effect against SAL.
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Affiliation(s)
- Jinxuan Li
- China-Japan Friendship School of Clinical Medicine, Capital Medical University, Beijing 100029, China;
| | - Qi Sun
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pediatrics, China-Japan Friendship Hospital, Beijing 100029, China;
| | - Hongguang Zhang
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
| | - Bingjie Li
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
| | - Chaoyu Zhang
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
| | - Yixin Zhao
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
| | - Jianbo Lu
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
| | - Xu Ma
- National Human Genetic Resources Center, National Research Institute for Family Planning, Beijing 100081, China; (H.Z.); (B.L.); (C.Z.); (Y.Z.)
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Lv Z, Liang G, Cheng M. Predictive Value of GDF-15 and sST2 for Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 18:2431-2438. [PMID: 37955023 PMCID: PMC10637188 DOI: 10.2147/copd.s429334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
Objective To confirm whether growth differentiation factor-15 (GDF-15) and soluble suppression of tumorigenicity 2 (sST2) are indicators of pulmonary hypertension in acute exacerbation of chronic obstructive pulmonary disease (AECOPD-PH). Methods All patients admitted to the hospital with AECOPD between July 2020 and October 2021 were enrolled. The patients were then categorized into AECOPD and AECOPD-PH groups according to PH probability, and the differences in GDF-15 and sST2 serum levels in the AECOPD and AECOPD-PH groups were compared. Correlation analysis was carried out to explore the association between GDF-15 and sST2 serum levels and the length of hospital stay of patients with AECOPD-PH. Receiver operating characteristic curve analysis was used to assess the clinical significance of GDF-15 and sST2 in predicting patients with AECOPD-PH. Results Included in this study were 126 patients with AECOPD, including 69 with AECOPD and 57 with AECOPD-PH. The serum levels of GDF-15 and sST2 in the AECOPD-PH group were significantly higher than those in the AECOPD group (P < 0.05). There was no significant correlation between the length of hospital stay in AECOPD-PH patients and GDF-15 and sST2 serum levels (P > 0.05). The area under the curves of GDF-15, sST2, and GDF-15 + sST2 for predicting AECOPD-PH and AECOPD-PH patients with poor prognosis were >0.60 and 0.70, respectively. The optimal cutoff values of GDF-15 and sST2 for predicting AECOPD-PH were 1125.33 pg/mL and 80.68 ng/mL and 1309.72 pg/mL and 59.10 ng/mL for predicting AECOPD-PH patients with poor prognosis, respectively. Conclusion GDF-15 and sST2 levels may be useful in the prediction of AECOPD-PH.
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Affiliation(s)
- Zhigan Lv
- Department of Anesthesiology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China
- Department of Anesthesiology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Guohua Liang
- Department of Intensive Care Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Mengyu Cheng
- Department of Respiratory and Critical Care Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
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Zou RH, Nouraie SM, Karoleski C, Zhang Y, Sciurba FC, Forman DE, Bon J. Incident low muscle mass is associated with greater lung disease and lower circulating leptin in a tobacco-exposed longitudinal cohort. Respir Res 2023; 24:224. [PMID: 37737171 PMCID: PMC10515430 DOI: 10.1186/s12931-023-02521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Muscle loss is prevalent in chronic obstructive pulmonary disease (COPD). Prior studies evaluating musculoskeletal dysfunction in COPD have focused on individuals with baseline low muscle mass. Currently, there is limited data evaluating clinical characteristics and outcomes associated with progression to incident low muscle mass in a tobacco-exposed cohort of individuals with baseline normal muscle mass. METHODS We evaluated 246 participants from a single-center longitudinal tobacco-exposed cohort with serial spirometry, thoracic imaging, dual energy x-ray absorptiometry (DXA) measurements, walk testing, and plasma adipokine measurements. DXA-derived fat free mass index (FFMI) and appendicular skeletal mass index (ASMI) were used as surrogates for muscle mass. Participants with incident low muscle mass (LM) at follow-up were characterized by FFMI < 18.4 kg/m2 in males and < 15.4 kg/m2 in females and/or ASMI < 7.25 kg/m2 in males and < 5.67 kg/m2 in females. RESULTS Twenty-five (10%) participants progressed to incident low muscle mass at follow-up. At baseline, the LM subgroup had greater active smoking prevalence (60% v. 38%, p = 0.04), lower FFMI (17.8 ± 1.7 kg/m2 v. 19.7 ± 2.9 kg/m2, p = 0.002), lower ASMI (7.3 ± 0.9 kg/m2 v. 8.2 ± 1.2 kg/m2, p = 0.0003), and lower plasma leptin (14.9 ± 10.1 ng/mL v. 24.0 ± 20.9 ng/mL, p = 0.04). At follow-up, the LM subgroup had higher COPD prevalence (68% v. 43%, p = 0.02), lower FEV1/FVC (0.63 ± 0.12 v. 0.69 ± 0.12, p = 0.02), lower %DLco (66.5 ± 15.9% v. 73.9 ± 16.8%, p = 0.03), and higher annual rate of FFMI decline (-0.17 kg/m2/year v. -0.04 kg/m2/year, p = 0.006). There were no differences in age, gender distribution, pack years smoking history, or walk distance. CONCLUSIONS We identified a subgroup of tobacco-exposed individuals with normal baseline muscle mass who progressed to incident DXA-derived low muscle mass. This subgroup demonstrated synchronous lung disease and persistently low circulating leptin levels. Our study suggests the importance of assessing for muscle loss in conjunction with lung function decline when evaluating individuals with tobacco exposure.
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Affiliation(s)
- Richard H Zou
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - S Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chad Karoleski
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Frank C Sciurba
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Forman
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Geriatrics, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jessica Bon
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Emphysema COPD Research Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- UPMC Montefiore Hospital, NW628 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Rani S, Shelyag S, Angelova M. Patterns of sedentary behaviour in adults with acute insomnia derived from actigraphy data. PLoS One 2023; 18:e0291095. [PMID: 37733680 PMCID: PMC10513233 DOI: 10.1371/journal.pone.0291095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Sleep disorders, such as insomnia, have been associated with extended periods of inactive, sedentary behaviour. Many factors contribute to insomnia, including stress, irregular sleep patterns, mental health issues, inadequate sleeping schedules, diseases, neurological disorders and prescription medications. OBJECTIVES Identification of the patterns of sedentary time and its duration in adults with acute insomnia and healthy controls to determine the statistically significant sedentary bouts; comparison of the sedentary behaviour patterns in acute insomnia adults with healthy controls. METHODS We investigate the daytime actigraphy data and identify temporal patterns of inactivity among adults with acute insomnia and healthy adults. Seven days of actigraphy data were utilised to calculate sedentary time and bouts of variable duration based on a threshold of activity counts (<100 counts per minute). Statistical analysis was applied to investigate sedentary bouts and total sedentary time during weekdays and weekend. A logistic regression model has been used to determine the significance of sedentary bouts. RESULTS We found that individuals with acute insomnia accumulate a significant amount of their sedentary time in medium (6-30 minutes and 31-60 minutes) and longer (more than 60 minutes) duration bouts in comparison to healthy adults. Furthermore, a low p value for total sedentary time (2.54 ⋅ 10-4) association with acute insomnia supports the finding that acute insomnia individuals are significantly more engaged in sedentary activities compared to healthy controls. Also, as shown by the weekend vs weekday analysis, the physical and sedentary activity patterns of acute insomnia adults demonstrate higher variability during the weekdays in comparison to the weekend. CONCLUSION The results of the present study demonstrate that adults with acute insomnia spend more time in low-intensity daily physical activities compared to healthy adults.
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Affiliation(s)
- Sunita Rani
- School of IT, Deakin University, Melbourne, Victoria, Australia
| | - Sergiy Shelyag
- School of IT, Deakin University, Melbourne, Victoria, Australia
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Maia Angelova
- School of IT, Deakin University, Melbourne, Victoria, Australia
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Nakahara Y, Mabu S, Hirano T, Murata Y, Doi K, Fukatsu-Chikumoto A, Matsunaga K. Neural Network Approach to Investigating the Importance of Test Items for Predicting Physical Activity in Chronic Obstructive Pulmonary Disease. J Clin Med 2023; 12:4297. [PMID: 37445332 DOI: 10.3390/jcm12134297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Contracting COPD reduces a patient's physical activity and restricts everyday activities (physical activity disorder). However, the fundamental cause of physical activity disorder has not been found. In addition, costly and specialized equipment is required to accurately examine the disorder; hence, it is not regularly assessed in normal clinical practice. In this study, we constructed a machine learning model to predict physical activity using test items collected during the normal care of COPD patients. In detail, we first applied three types of data preprocessing methods (zero-padding, multiple imputation by chained equations (MICE), and k-nearest neighbor (kNN)) to complement missing values in the dataset. Then, we constructed several types of neural networks to predict physical activity. Finally, permutation importance was calculated to identify the importance of the test items for prediction. Multifactorial analysis using machine learning, including blood, lung function, walking, and chest imaging tests, was the unique point of this research. From the experimental results, it was found that the missing value processing using MICE contributed to the best prediction accuracy (73.00%) compared to that using zero-padding (68.44%) or kNN (71.52%), and showed better accuracy than XGBoost (66.12%) with a significant difference (p < 0.05). For patients with severe physical activity reduction (total exercise < 1.5), a high sensitivity (89.36%) was obtained. The permutation importance showed that "sex, the number of cigarettes, age, and the whole body phase angle (nutritional status)" were the most important items for this prediction. Furthermore, we found that a smaller number of test items could be used in ordinary clinical practice for the screening of physical activity disorder.
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Affiliation(s)
- Yoshiki Nakahara
- Graduate School of Sciences and Technology for Innovation, Yamaguchi University, Yamaguchi 7558611, Japan
| | - Shingo Mabu
- Graduate School of Sciences and Technology for Innovation, Yamaguchi University, Yamaguchi 7558611, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital, Yamaguchi 7558505, Japan
| | - Yoriyuki Murata
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital, Yamaguchi 7558505, Japan
| | - Keiko Doi
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital, Yamaguchi 7558505, Japan
| | - Ayumi Fukatsu-Chikumoto
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital, Yamaguchi 7558505, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital, Yamaguchi 7558505, Japan
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Yamaji Y, Hirano T, Ogawa H, Fukatsu-Chikumoto A, Matsuda K, Hamada K, Ohata S, Suetake R, Murata Y, Oishi K, Asami-Noyama M, Edakuni N, Kakugawa T, Matsunaga K. Utility of the Shortness of Breath in Daily Activities Questionnaire (SOBDA-Q) to Detect Sedentary Behavior in Patients with Chronic Obstructive Pulmonary Disease (COPD). J Clin Med 2023; 12:4105. [PMID: 37373800 DOI: 10.3390/jcm12124105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Sedentary behavior has been shown to be an independent predictor of mortality in patients with chronic obstructive pulmonary disease (COPD). However, physicians have difficulty ascertaining patients' activity levels because they tend to avoid shortness of breath. The reformed shortness of breath (SOB) in the daily activities questionnaire (SOBDA-Q) specifies the degree of SOB by measuring low-intensity activity behavior in everyday living. Therefore, we aimed to explore the utility of the SOBDA-Q in detecting sedentary COPD. We compared the modified Medical Research Council dyspnea scale (mMRC), COPD assessment test (CAT), and SOBDA-Q with physical activity levels (PAL) in 17 healthy patients, 32 non-sedentary COPD patients (PAL ≥ 1.5 METs·h), and 15 sedentary COPD patients (PAL < 1.5 METs·h) in this cross-sectional study. CAT and all domains of the SOBDA-Q in all patients are significantly correlated with PAL, even after adjusting for age. The dietary domain has the highest specificity, and the outdoor activity domain has the highest sensitivity for detecting sedentary COPD. Combining these domains helped determine patients with sedentary COPD (AUC = 0.829, sensitivity = 1.00, specificity = 0.55). The SOBDA-Q is associated with PAL and could be a useful tool for determining patients with sedentary COPD. Moreover, eating and outing inactivity claims reflect sedentary behavior in patients with COPD.
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Affiliation(s)
- Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Hiromasa Ogawa
- Department of Occupational Health, Graduate School of Medicine, Tohoku University, Sendai 980-8575, Japan
| | - Ayumi Fukatsu-Chikumoto
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Kazuki Matsuda
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Kazuki Hamada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Shuichiro Ohata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Ryo Suetake
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Yoriyuki Murata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Keiji Oishi
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Tomoyuki Kakugawa
- Department of Pulmonology and Gerontology, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan
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Kanezaki M, Tamaki A, Terada K, Ebihara S. Linguistic Validation of the Japanese Version of the Multidimensional Dyspnea Profile and Relation to Physical Activity in Patients with COPD. Int J Chron Obstruct Pulmon Dis 2022; 17:223-230. [PMID: 35087271 PMCID: PMC8789226 DOI: 10.2147/copd.s339285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to develop a linguistically validated Japanese translation of the multidimensional dyspnea profile (MDP) and assess whether worsening of dyspnea’s sensory and affective domains during exercise had detrimental effects on physical activity in stable outpatients with chronic obstructive pulmonary disease (COPD). Materials and Methods The Japanese version of the MDP was prepared in collaboration with Mapi Research Trust (Lyon, France) after the approval of the developer. Physical activity was assessed using a 3-axis accelerometer. Dyspnea upon exertion was investigated using a 3-minute step test. Results The Japanese version of the MDP was obtained and validated linguistically. Air-hunger was significantly associated with total calories from walking (r = − 0.47, p < 0.05), while anxiety and depression were significantly correlated with both the amount and intensity of physical activity (r = − 0.49, p < 0.05, and r = − 0.46, p < 0.05, respectively). Conclusion The Japanese version of the MDP was suggested to reflect both pulmonary functions, ventilatory response during exercise, and intensity and amount of physical activity in patients with COPD.
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Affiliation(s)
- Masashi Kanezaki
- Department of Physical Therapy, School of Health Sciences, Tokyo International University, Kawagoe, Saitama, 350-1197, Japan
- Correspondence: Masashi Kanezaki Department of Physical Therapy, School of Health Sciences, Tokyo International University, 1-13-1 Matobakita, Kawagoe, Saitama, 350-1197, JapanTel +81-49-232-1111Fax +81-49-232-1119 Email
| | - Akira Tamaki
- Department of Physical Therapy, School of Rehabilitation, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Kunihiko Terada
- Terada Clinic, Respiratory Medicine and General Practice, Himeji, Hyogo, Japan
| | - Satoru Ebihara
- Department of Rehabilitation Medicine, Graduate School of Medicine, Toho University, Tokyo, Japan
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Takahashi S, Hirano T, Yasuda K, Donishi T, Suga K, Doi K, Oishi K, Ohata S, Murata Y, Yamaji Y, Asami-Noyama M, Edakuni N, Matsunaga K. Impact of Frailty on Hippocampal Volume in Patients with Chronic Obstructive Pulmonary Disease. Biomedicines 2021; 9:1103. [PMID: 34572291 DOI: 10.3390/biomedicines9091103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 12/11/2022] Open
Abstract
Brain frailty may be related to the pathophysiology of poor clinical outcomes in chronic obstructive pulmonary disease (COPD). This study examines the relationship between hippocampal subfield volumes and frailty and depressive symptoms, and their combined association with quality of life (QOL) in patients with COPD. The study involved 40 patients with COPD. Frailty, depressive symptoms and QOL were assessed using Kihon Checklist (KCL), Hospital Anxiety and Depression Scale (HADS), and World Health Organization Quality of Life Assessment (WHO/QOL-26). Anatomical MRI data were acquired, and volumes of the hippocampal subfields were obtained using FreeSurfer (version 6.0). Statistically, HADS score had significant association with WHO/QOL-26 and KCL scores. KCL scores were significantly associated with volumes of left and right whole hippocampi, presubiculum and subiculum, but HADS score had no significant association with whole hippocampi or hippocampal subfield volumes. Meanwhile, WHO/QOL-26 score was significantly associated with volume of the left CA1. There was a significant association between frailty, depression, and QOL. Hippocampal pathology was related to frailty and, to some extent, with QOL in patients with COPD. Our results suggest the impact of frailty on hippocampal volume and their combined associations with poor QOL in COPD.
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Al-Mudares F, Reddick S, Ren J, Venkatesh A, Zhao C, Lingappan K. Role of Growth Differentiation Factor 15 in Lung Disease and Senescence: Potential Role Across the Lifespan. Front Med (Lausanne) 2020; 7:594137. [PMID: 33344478 PMCID: PMC7744305 DOI: 10.3389/fmed.2020.594137] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
Growth Differentiation Factor 15 (GDF15) is a divergent member of transforming growth factor-beta (TGF-β) superfamily and is ubiquitously expressed, under normal physiological conditions. GDF15 expression increases during many pathological states and serves a marker of cellular stress. GDF15 has multiple and even paradoxical roles within a pathological condition, as its effects can be dose- and time-dependent and vary based on the targeted tissues and downstream pathways. GDF15 has emerged as one of the most recognized proteins as part of the senescence associated secretory phenotype. Cellular senescence plays a major role in many lung diseases across the life-span from bronchopulmonary dysplasia in the premature neonate to COPD and idiopathic pulmonary fibrosis in aged adults. GDF15 levels have been reported to be as a useful biomarker in chronic obstructive pulmonary disease, lung fibrosis and pulmonary arterial hypertension and predict disease severity, decline in lung function and mortality. Glial-cell-line-derived neurotrophic factor family receptor alpha-like (GFRAL) in the brain stem has been identified as the only validated GDF15 receptor and mediates GDF15-mediated anorexia and wasting. The mechanisms and pathways by which GDF15 exerts its pulmonary effects are being elucidated. GDF15 may also have an impact on the lung based on the changes in circulating levels or through the central action of GDF15 activating peripheral metabolic changes. This review focuses on the role of GDF15 in different lung diseases across the lifespan and its role in cellular senescence.
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Affiliation(s)
- Faeq Al-Mudares
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | | | - Jenny Ren
- Baylor College of Medicine, Houston, TX, United States
| | | | - Candi Zhao
- Rice University, Houston, TX, United States
| | - Krithika Lingappan
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
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Oishi K, Matsunaga K, Harada M, Suizu J, Murakawa K, Chikumoto A, Ohteru Y, Matsuda K, Uehara S, Hamada K, Ohata S, Murata Y, Yamaji Y, Asami-Noyama M, Edakuni N, Kakugawa T, Hirano T. A New Dyspnea Evaluation System Focusing on Patients' Perceptions of Dyspnea and Their Living Disabilities: The Linkage between COPD and Frailty. J Clin Med 2020; 9:E3580. [PMID: 33172080 DOI: 10.3390/jcm9113580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As much as there are unmet needs for brief frailty assessment in patients with chronic obstructive pulmonary disease (COPD), the lack of a simplified and comprehensive dyspnea evaluation system that focuses on the patients' perceptions of dyspnea and their COPD living disabilities remains a major challenge. We developed patient-reported outcome measures for dyspnea-related behavior and activity limitation (PROMs-D), which consisted of the Activity-limit Dyspnea Scale (ADS) and Self-Limit Dyspnea Scale (SDS), while investigated the usefulness of PROMs-D in identifying frailty. METHODS We administered PROMs-D and frailty status evaluations in 128 outpatients. RESULTS We classified 30 (23.4%), 50 (39.0%), and 48 (37.5%) patients as robust, prefrail, and frail, respectively. There was a positive correlation between SDS and ADS (ρ = 0.67, p < 0.001), and both ADS and SDS had high accuracies for detecting frailty (AUC, 0.82 and 0.78, respectively). Moreover, a PROMs-D score that consisted of the sum of ADS and SDS was more effective in stratifying frailty (cutoff value, 2; AUC, 0.85; sensitivity, 60%; specificity, 95%). CONCLUSIONS PROMs-D could be used as the first step for frailty screening in patients with COPD, and we propose the importance of capturing the troublesome nature of living behaviors due to dyspnea in daily clinical practice.
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Matsunaga K, Harada M, Suizu J, Oishi K, Asami-Noyama M, Hirano T. Comorbid Conditions in Chronic Obstructive Pulmonary Disease: Potential Therapeutic Targets for Unmet Needs. J Clin Med 2020; 9:E3078. [PMID: 32987778 PMCID: PMC7598716 DOI: 10.3390/jcm9103078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/18/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022] Open
Abstract
The management of chronic obstructive pulmonary disease (COPD) has improved significantly due to advances in therapeutic agents, but it has also become apparent that there are issues that remain difficult to solve with the current treatment algorithm. COPD patients face a number of unmet needs concerning symptoms, exacerbations, and physical inactivity. There are various risk factors and triggers for these unmet needs, which can be roughly divided into two categories. One is the usual clinical characteristics for COPD patients, and the other is specific clinical characteristics in patients with comorbid conditions, such as asthma, cardiovascular disease, and bronchiectasis. These comorbidities, which are also associated with the diversity of COPD, can cause unmet needs resistance to usual care. However, treatable conditions that are not recognized as therapeutic targets may be latent in patients with COPD. We again realized that treatable traits should be assessed and treated as early as possible. In this article, we categorize potential therapeutic targets from the viewpoint of pulmonary and systemic comorbid conditions, and address recent data concerning the pathophysiological link with COPD and the impact of intervention on comorbid conditions in order to obtain evidence that could enable us to provide personalized COPD management.
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Affiliation(s)
- Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Misa Harada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Junki Suizu
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan;
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
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