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Grosso A, Cerveri I, Cazzoletti L, Zanolin ME, Mattioli V, Piloni D, Gini E, Albicini F, Ronzoni V, Jarvis D, Janson C, Corsico AG. Inhaled corticosteroids and risk of osteoporosis in late-middle-aged subjects: a multicenter European cohort study. Minerva Med 2023; 114:15-21. [PMID: 34114441 DOI: 10.23736/s0026-4806.21.07431-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled corticosteroids have been widely used for the regular treatment of asthma and chronic obstructive pulmonary diseases (COPD) over the past few decades. To date, studies investigating the effects of inhaled corticosteroids (ICS) on bone in populations including asthma and COPD patients, show conflicting results. The skeletal effects of ICS remain poorly understood. We assessed the association between ICS exposure and self-reported osteoporosis diagnosis in a European cohort study. METHODS The analysis was carried out by using clinical and questionnaire data available for subjects participating in the ECRHS III (European Community Respiratory Health Survey) with age >55 years. RESULTS Among the 3004 enrolled subjects, 245 were ICS users with an exposure ≥12 months. Osteoporosis was reported by 16 subjects in the ICS group (6.5%) and by 167 in the not exposed group (6.1%). The adjusted risk of osteoporosis in ICS users (≥12 months) was not greater in exposed subjects when compared with the unexposed ones (OR=1.02, 95CI%: 0.51, 2.03). The same result was observed even when considering in the analysis a longer exposure to the ICS use (≥36.5 months, the median ICS exposure for all subjects). History of COPD, use of oral corticosteroids, Body Mass Index, smoking and physical activity did not show any evidence of an association with osteoporosis. CONCLUSIONS Our study did not show any significant association between long- term ICS use and self-reported diagnosis of osteoporosis in subjects aged >55 years. To explore the real effect of ICS on bone status, further studies are needed, especially in the long-term ICS exposure.
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Affiliation(s)
- Amelia Grosso
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy -
| | - Isa Cerveri
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Lucia Cazzoletti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria E Zanolin
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Veronica Mattioli
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Erica Gini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Federica Albicini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Vanessa Ronzoni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Debbie Jarvis
- Department of Population Health and Occupational Diseases, National Heart and Lung Institute, Imperial College London, London, UK
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Angelo G Corsico
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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Duan H, Liang L, Liu X, Xie S, Wang C. PARC/CCL18 is Associated with Inflammation, Emphysema Severity and Application of Inhaled Corticosteroids in Hospitalized COPD Patients. Int J Chron Obstruct Pulmon Dis 2021; 16:1287-1297. [PMID: 34007168 PMCID: PMC8121623 DOI: 10.2147/copd.s304488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background Pulmonary and activation-regulated chemokine (PARC) also named CC-chemokine ligand 18 (CCL18) is a lung-predominant inflammatory protein that is found in serum. The relationship of PARC/CCL18 with the chronic obstructive pulmonary disease (COPD) is not fully understood. The aim of the present study is to analyze the expression of PARC/CCL18 in COPD. Methods Ninety-eight hospitalized COPD patients and 60 healthy volunteers from January 2019 to December 2019 were recruited in this retrospective study. Gender, age, height, weight, disease duration, smoking status, blood cell classification and count, length of hospital stay (LOS), symptom score, including COPD Assessment Test (CAT) score, modified British Medical Research Council (mMRC) score, lung function and therapy were recorded and serum PARC/CCL18 was analyzed by ELISA. The correlation between symptom score, blood cell classification and count, CRP, lung function parameters and serum levels of PARC/CCL18 and ROC curves of PARC/CCL18 levels and inhaled corticosteroids (ICS) were accessed. Results It was found that serum PARC/CCL18 level in hospitalized COPD population was significantly higher than that in healthy people (p=0.003). COPD patients with emphysema had significantly higher serum level of PARC/CCL18 than those without emphysema (p=0.049). Total lung capacity (TLC) and residual volume (RV)/TLC had positive correlation with serum level of PARC/CCL18 (p=0.001, 0.020, respectively). Furthermore, serum PARC/CCL18 level was predictive for the application ICS (p=0.003) and related to C-reactive protein (p <0.0001) in hospitalized COPD patients. Conclusion PARC/CCL18 is associated with the severity of inflammation and emphysema in COPD. Furthermore, PARC/CCL18 is a predictor of ICS application in the treatment of hospitalized COPD patients.
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Affiliation(s)
- Hongxia Duan
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Long Liang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xinyang Liu
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Shuanshuan Xie
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Changhui Wang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Loundagin LL, Haider IT, Cooper DM, Edwards WB. Association between intracortical microarchitecture and the compressive fatigue life of human bone: A pilot study. Bone Rep 2020; 12:100254. [PMID: 32258250 PMCID: PMC7110329 DOI: 10.1016/j.bonr.2020.100254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/26/2020] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Many mechanical properties of cortical bone are largely governed by the underlying microarchitecture; however, the influence of microarchitecture on the fatigue life of bone is poorly understood. Furthermore, imaging-based studies investigating intracortical microarchitecture may expose bone samples to large doses of radiation that may compromise fatigue resistance. The purpose of this pilot study was to 1) investigate the relationship between intracortical microarchitecture and the fatigue life of human bone in compression and 2) examine the effects of synchrotron irradiation on fatigue life measurements. Cortical samples were prepared from the femoral and tibial shafts of three cadaveric donors. A subset of samples was imaged using synchrotron X-ray microCT to quantify microarchitecture, including porosity, canal diameter, lacunar density, lacunar volume, and lacunar orientation. A second group of control samples was not imaged and used only for mechanical testing. Fatigue life was quantified by cyclically loading both groups in zero-compression until failure. Increased porosity and larger canal diameter were both logarithmically related to a shorter fatigue life, whereas lacunar density demonstrated a positive linear relationship with fatigue life (r2 = 45–73%, depending on measure). Irradiation from microCT scanning reduced fatigue life measurements by 91%, but relationships with microarchitecture measurements remained. Additional research is needed to support the findings of this pilot study and fully establish the relationship between intracortical microarchitecture and the compressive fatigue life of bone. Increased porosity and larger canal diameters were associated with a shorter compressive fatigue life. A higher lacunar density was related to a longer compressive fatigue life. Irradiation from synchrotron X-ray microCT scanning reduced fatigue life by 91%. The influence of microarchitecture on fatigue life exhibited similar trends for both irradiated and non-irradiated bone.
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Affiliation(s)
- Lindsay L. Loundagin
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
- Corresponding author at: Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
| | - Ifaz T. Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
| | - David M.L. Cooper
- Department of Anatomy, Physiology and Pharmacology, University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2, Canada
| | - W. Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
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Christmann V, van der Putten ME, Rodwell L, Steiner K, Gotthardt M, van Goudoever JB, van Heijst AFJ. Effect of early nutritional intake on long-term growth and bone mineralization of former very low birth weight infants. Bone 2018; 108:89-97. [PMID: 29289790 DOI: 10.1016/j.bone.2017.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 12/11/2017] [Accepted: 12/21/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preterm infants are at risk for impaired bone mineralization and growth in length later in life due to inadequate nutritional intake in the early postnatal period. OBJECTIVE To investigate whether increased nutritional supplementation of calcium, phosphate and protein in Very Low Birth Weight (VLBW) infants during the first 14days after birth was associated with improvement in length and bone development until 9-10years of age. DESIGN Observational follow-up study of VLBW infants (birth weight<1500g or gestational age<32weeks) born in two consecutive years (eligible infants: 2004 n: 63 and 2005: n: 66). Cohort 2005 received higher intake of calcium, phosphate and protein with parenteral nutrition compared to Cohort 2004. Anthropometric data were collected during standard follow-up visits until five years, and additionally at 9-10years of age including measurements of bone mineral content, bone mineral density of the whole body and lumbar spine determined by dual-energy X-ray absorptiometry. Long-term growth trajectories of both cohorts were evaluated separately for participants born appropriate (AGA) and small for gestational age (SGA), stratified by gender. Multivariate linear regression was used to examine the effect of nutritional intake and clinical covariates on length and bone mineralization. RESULTS Both cohorts achieved a catch-up in length to SDS within the normal range by 6months (length SDS: estimated mean (95% confidence interval (CI): 6months: Cohort 2004: -0.7 (-1.1, -0.3) Cohort 2005: -0.5 (-0.8, -0.2)). Bone mineral content and density were within the normal range and not different between the cohorts. SGA children achieved a catch-up in length at 5years with bone mineralization comparable to AGA children. Only for girls birth weight was significantly associated with length SDS (per gram: β 0.001; 95% CI (0.000, 0.003); p=0.03) There was no evidence of an association between early nutritional intake and bone mineralization. CONCLUSION Children born as appropriate or small for gestational age preterm infants are able to catch up in length after the postnatal period, and achieve a normal length and bone mineralization at age nine-ten years. An improvement of calcium and phosphate intake during the first 14days after birth was not associated with improvement in length and bone development.
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Affiliation(s)
- V Christmann
- Department of Pediatrics, Subdivision of Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - M E van der Putten
- Department of Pediatrics, Subdivision of Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands; Department of Pediatrics, Subdivision of Neonatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - L Rodwell
- Department for Health Evidence, Radboud Institute for Health Science, Subdivision of Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K Steiner
- Department of Pediatrics, Subdivision of Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - M Gotthardt
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J B van Goudoever
- Department of Pediatrics, VU University Medical Center Amsterdam, Amsterdam, The Netherlands; Department of Pediatrics, Emma Children's Hospital - AMC Amsterdam, Amsterdam, The Netherlands
| | - A F J van Heijst
- Department of Pediatrics, Subdivision of Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
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Paschalis EP, Gamsjaeger S, Dempster D, Jorgetti V, Borba V, Boguszewski CL, Klaushofer K, Moreira CA. Fragility Fracture Incidence in Chronic Obstructive Pulmonary Disease (COPD) Patients Associates With Nanoporosity, Mineral/Matrix Ratio, and Pyridinoline Content at Actively Bone-Forming Trabecular Surfaces. J Bone Miner Res 2017; 32:165-171. [PMID: 27490957 DOI: 10.1002/jbmr.2933] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/22/2016] [Accepted: 07/12/2016] [Indexed: 11/05/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with low areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) and altered microstructure by bone histomorphometry and micro-computed tomography. Nevertheless, not all COPD patients sustain fragility fractures. In the present study, we used Raman microspectroscopic analysis to determine bone compositional properties at actively forming trabecular surfaces (based on double fluorescent labels) in iliac crest biopsies from 19 postmenopausal COPD patients (aged 62.1 ± 7.3 years). Additionally, we analyzed trabecular geometrical centers, representing tissue much older than the forming surfaces. Eight of the patients had sustained fragility fractures, and 13 had received treatment with inhaled glucocorticoids. None of the patients had taken oral glucocorticoids. The monitored parameters were mineral/matrix ratio (MM), nanoporosity, and relative glycosaminoglycan (GAG), lipid, and pyridinoline contents (PYD). There were no significant differences between the glucocorticoid-treated patients and those who did not receive any. On the other hand, COPD patients sustaining fragility fractures had significantly lower nanoporosity and higher MM and PYD values compared with COPD patients without fragility fractures. To the best of our knowledge, this is the first study to discriminate between fracture and non-fracture COPD patients based on differences in the material properties of bone matrix. Given that these bone material compositional differences are evident close to the cement line (a major bone interface), they may contribute to the inferior bone toughness and coupled with the lower lumbar spine bone mineral density values result in the fragility fractures prevalent in these patients. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Eleftherios P Paschalis
- Ludwig Boltzmann Institute of Osteology, the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Sonja Gamsjaeger
- Ludwig Boltzmann Institute of Osteology, the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - David Dempster
- Departments of Medicine and Pathology, College of Physicians and Surgeons of Columbia University, New York, New York, USA
| | - Vanda Jorgetti
- Department of Nephrology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Victoria Borba
- Endocrinology Division, Federal University of Parana, Curitiba, Brazil
| | | | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology, the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Carolina A Moreira
- Endocrinology Division, Federal University of Parana, Curitiba, Brazil.,LAB PRO, Bone Histomorphometry Division, Pro Renal Foundation, Curitiba, Brazil
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A randomized, controlled multicentric study of inhaled budesonide and intravenous methylprednisolone in the treatment on acute exacerbation of chronic obstructive pulmonary disease. Respir Med 2016; 121:39-47. [PMID: 27888990 DOI: 10.1016/j.rmed.2016.10.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/17/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Almost all international guidelines recommend corticosteroids for management of exacerbations of chronic obstructive pulmonary disease (COPD), because it leads to improved outcomes of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Nevertheless, due to its side effects, there are still concerns regarding the use of systemic corticosteroid (SC). Inhaled corticosteroids (IC) can be used as an alternative to SC, while reducing the risk of occurrence of side effects. PURPOSE To measure the clinical efficacy and side effects of nebulized budesonide and systemic methylprednisolone in AECOPD. METHODS Valid data from 410 AECOPD patients in 10 hospitals was collected. Patients were randomly divided into 2 groups; budesonide group, treated with nebulized budesonide (2 mg 3 times/day); and methylprednisolone group, treated with intravenously injected methylprednisolone (40 mg/day). COPD assessment test (CAT), arterial blood gas analysis, hospitalization days, adverse effects, fasting blood glucose, serum creatinine, alanine aminotransferase levels, and blood drug were measured and analyzed in both groups. RESULTS Symptoms, pulmonary function and arterial blood gas analysis were significantly improved after treatment in both groups (P < 0.05), with no significant differences between them (P > 0.05), while incidence of adverse events in the budesonide group was lower (P < 0.05). No significant differences in CAT score, days of admission, blood gas analysis results and physiological and biochemical indexes were found between the two groups. Patients treated with methylprednisolone showed a higher degree of PaO2 level improvement. CONCLUSION Results show that inhalation of budesonide (2 mg 3 times/day) and systemic methylprednisolone (40 mg/day) had similar clinical outcome in AECOPD. In conclusion, inhaled budesonide is an alternative to systemic corticosteroids in AECOPD treatment.
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Rittweger J, Debevec T, Frings-Meuthen P, Lau P, Mittag U, Ganse B, Ferstl PG, Simpson EJ, Macdonald IA, Eiken O, Mekjavic IB. On the combined effects of normobaric hypoxia and bed rest upon bone and mineral metabolism: Results from the PlanHab study. Bone 2016; 91:130-8. [PMID: 27443510 DOI: 10.1016/j.bone.2016.07.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/29/2016] [Accepted: 07/17/2016] [Indexed: 01/10/2023]
Abstract
Bone losses are common as a consequence of unloading and also in patients with chronic obstructive pulmonary disease (COPD). Although hypoxia has been implicated as an important factor to drive bone loss, its interaction with unloading remains unresolved. The objective therefore was to assess whether human bone loss caused by unloading could be aggravated by chronic hypoxia. In a cross-over designed study, 14 healthy young men underwent 21-day interventions of bed rest in normoxia (NBR), bed rest in hypoxia (HBR), and hypoxic ambulatory confinement (HAmb). Hypoxic conditions were equivalent to 4000m altitude. Bone metabolism (NTX, P1NP, sclerostin, DKK1) and phospho-calcic homeostasis (calcium and phosphate serum levels and urinary excretion, PTH) were assessed from regular blood samples and 24-hour urine collections, and tibia and femur bone mineral content was assessed by peripheral quantitative computed tomography (pQCT). Urinary NTX excretion increased (P<0.001) to a similar extent in NBR and HBR (P=0.69) and P1NP serum levels decreased (P=0.0035) with likewise no difference between NBR and HBR (P=0.88). Serum total calcium was increased during bed rest by 0.059 (day D05, SE 0.05mM) to 0.091mM (day D21, P<0.001), with no additional effect by hypoxia during bed rest (P=0.199). HAmb led, at least temporally, to increased total serum calcium, to reduced serum phosphate, and to reduced phosphate and calcium excretion. In conclusion, hypoxia did not aggravate bed rest-induced bone resorption, but led to changes in phospho-calcic homeostasis likely caused by hyperventilation. Whether hyperventilation could have mitigated the effects of hypoxia in this study remains to be established.
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Affiliation(s)
- Jörn Rittweger
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany; Department of Pediatrics and Adolescent Medicine, University of Cologne, Cologne, Germany.
| | - Tadej Debevec
- Department of Automation, Biocybernetics and Robotics, Jozef Stefan Institute, Ljubljana, Slovenia
| | - Petra Frings-Meuthen
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany
| | - Patrick Lau
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany
| | - Uwe Mittag
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany
| | - Bergita Ganse
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany
| | - Philip G Ferstl
- Medizinische Klinik I, University of Frankfurt, Frankfurt, Germany
| | - Elizabeth J Simpson
- MRC/Arthritis UK Centre for Musculoskeletal Aging Research, University of Nottingham Medical School, School of Life Sciences, Queen's Medical Centre, Nottingham, United Kingdom
| | - Ian A Macdonald
- MRC/Arthritis UK Centre for Musculoskeletal Aging Research, University of Nottingham Medical School, School of Life Sciences, Queen's Medical Centre, Nottingham, United Kingdom
| | - Ola Eiken
- Department of Environmental Physiology, Swedish Aerospace Physiology Centre, Royal Institute of Technology, Stockholm, Sweden
| | - Igor B Mekjavic
- Department of Automation, Biocybernetics and Robotics, Jozef Stefan Institute, Ljubljana, Slovenia; Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
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