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Sari F, Pala GG, Oskay D, Tufan A. Investigating physical inactivity and associated health parameters in patients with systemic lupus erythematosus. Lupus 2024:9612033241273078. [PMID: 39120489 DOI: 10.1177/09612033241273078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
BACKGROUND Physical inactivity, which is highly prevalent in patients with systemic lupus erythematosus (SLE), is an independent risk factor for cardiovascular events and causes many complications. This study aimed to investigate the effect of objective measurement and physical activity level on peripheral muscle strength, exercise capacity, pain, dyspnea, fatigue, anxiety, and depression in patients with SLE. METHODS The present cross-sectional study analyzed 41 patients with SLE. Clinical and demographic characteristics of patients were recorded. Functional exercise capacity, peripheral muscle strength, dyspnea, pain, fatigue, anxiety, and depression were assessed. The physical activity level was assessed by a wearable activity tracker (Mi Band four smart band). RESULTS The number of steps measured by the activity tracker was 4384.43 ± 1558.21 steps per day in patients with SLE. Patients with physical activity levels below 5000 steps exhibited elevated levels of fatigue, along with diminished functional exercise capacity and knee muscle strength, in comparison to those who were above the 5000-step threshold. Physical activity levels correlated with functional exercise capacity (6MWT), physiological parameters (maximum heart rate, Δ heart rate, Δ dyspnea, QFM fatigue, Δ QFM fatigue), and knee extension muscle strength. The functional exercise capacity and knee extension were identified as significantly and dependently associated with physical activity levels in SLE patients. CONCLUSION Physical activity level is associated with functional exercise capacity and knee muscle strength in patients with SLE.
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Affiliation(s)
- Fulden Sari
- Department of Physiotherapy and Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Bingol University, Bingol, Turkey
| | - Gamze Gülsün Pala
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Amasya University, Amasya, Turkey
| | - Deran Oskay
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| | - Abdurrahman Tufan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
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Gavilán-Carrera B, Martínez-Rosales E, Palacios-Morenilla C, Díaz-Chamorro A, Soriano-Maldonado A, Vargas-Hitos JA. Associations of physical activity, sedentary time, and fitness with cardiovascular risk and atherosclerosis over 3 years in women with systemic lupus erythematosus. Med Clin (Barc) 2024:S0025-7753(24)00359-2. [PMID: 39030119 DOI: 10.1016/j.medcli.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Cardiovascular (CV) diseases are among the main causes of death in systemic lupus erythematosus (SLE). Physical activity (PA) and fitness are potential protective factors against the progression of CV risk factors and atherosclerosis. AIM To analyze trends over time in PA, sedentary time (ST) and physical fitness and their associations of with traditional and novel markers of CV risk and subclinical atherosclerosis in women with SLE over a 3-year follow-up period. METHODS In this exploratory study, 77 White Hispanic women with SLE (43.3±13.8 years) with mild disease activity were followed after 3 years (n=44). HDL and LDL cholesterol (blood samples), BMI and muscle mass (stadiometer and bioimpedance device), blood pressure (BP), pulse wave velocity (PWV, Mobil-O-Graph® monitor), carotid plaques and intima-media thickness (General Electric Medical Systems, LOGQ-6 model) were assessed. PA and ST were measured using triaxial accelerometers. Physical fitness was assessed with the back-scratch, handgrip strength, 30-s chair stand, and 6-min walk, tests. RESULTS After 3 years, LDL-c (estimated mean change [est]=13.77mg/dL) and PWV (0.13m/s) increased while diastolic BP (-2.80mmHG) decreased (all, p<0.05). In mixed models, 6-min walk test was positively associated with HDL-c (est=0.07); back scratch (est=0.33) and chair-stand (est=1.19) tests were positively associated with systolic BP (all, p<0.05). No other trends or associations over time were identified (all, p>0.05). CONCLUSIONS PA, ST, fitness, and most studied CV risk factors remained stable over time, with only marginal changes in LDL-c, PWV, and diastolic BP. Overall, PA and ST were not longitudinally associated with CV risk factors and subclinical atherosclerosis and contradictory weak associations were found for physical fitness.
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Affiliation(s)
- Blanca Gavilán-Carrera
- Department of Internal Medicine, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; PA-HELP "Physical Activity for HEaLth Promotion" Research Group, University of Granada, Granada, Spain; Sport and Health University Research Institute (iMUDS), University of Granada, Granada, Spain
| | - Elena Martínez-Rosales
- Department of Education, Faculty of Education Sciences, University of Almería, Almería, Spain; SPORT Research Group (CTS-1024), CIBIS (Centro de Investigación para el Bienestar y la Inclusión Social) Research Center, Univerisity of Almería, Almería, Spain
| | | | - Antonio Díaz-Chamorro
- Department of Internal Medicine, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Alberto Soriano-Maldonado
- Department of Education, Faculty of Education Sciences, University of Almería, Almería, Spain; SPORT Research Group (CTS-1024), CIBIS (Centro de Investigación para el Bienestar y la Inclusión Social) Research Center, Univerisity of Almería, Almería, Spain.
| | - José Antonio Vargas-Hitos
- Department of Internal Medicine, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
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Smaira FI, Mazzolani BC, Sieczkowska SM, Romero M, Ribeiro TT, Amarante MC, Pasoto S, Pinto ALDS, Lima FR, Benatti FB, Roschel H, Gualano B. Food consumption, physical activity and aerobic capacity in systemic lupus erythematosus patients with high cardiovascular risk. Clinics (Sao Paulo) 2024; 79:100418. [PMID: 39003927 DOI: 10.1016/j.clinsp.2024.100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 06/11/2024] [Indexed: 07/16/2024] Open
Abstract
Systemic Lupus Erythematosus (SLE) is a chronic, autoimmune and multisystemic rheumatic disease. Patients with SLE have decreased functional and aerobic capacity, as well as increased prevalence of Cardiovascular Diseases (CVD), which are the primary causes of morbimortality in this condition. Dietary intake and physical activity are well-known modifiable cardiovascular risk factors. The aim of this study is to describe food consumption, sedentary behavior, physical activity level, and functional and aerobic capacity in a sample of SLE patients with high cardiovascular risk. This was a cross-sectional study in which patients were assessed for (i) Demographic, anthropometric, and disease-related parameters; (ii) Food consumption; (iii) Physical activity level and sedentary behavior; (iv) Functional and aerobic capacity. Patients averaged 41.7 ± 9 years, and most were classified as overweight/obese (87%). Average macronutrient intake was within recommendations; however, fiber (16 ± 9g) and calcium (391 ± 217 mg) intakes were below, and sodium intake (2.9 ± 1.3 mg) was above recommendations. Besides, food consumption assessed by the Nova system showed a predominance of unprocessed foods (43.8 ± 14.0%TEI), although ultraprocessed food intake (20.0 ± 13.9%TEI) was slightly higher than that seen in the Brazilian population. Patients also exhibited high sedentary behavior (8.2 ± 2.2h) and only eighteen participants reached the minimum recommended amount of moderate-to-vigorous physical activity. Overall, patients had a low functional and aerobic capacity compared to the general population. Data from this study may help design dedicated clinical trials aiming to investigate the effects of lifestyle intervention to mitigate CVD in SLE.
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Affiliation(s)
- Fabiana Infante Smaira
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bruna Caruso Mazzolani
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Sofia Mendes Sieczkowska
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Marina Romero
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Thainá Toledo Ribeiro
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Milla Cordeiro Amarante
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Sandra Pasoto
- Rheumatology Division, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Ana Lúcia de Sá Pinto
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Rheumatology Division, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Fernanda Rodrigues Lima
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Rheumatology Division, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Fabiana Braga Benatti
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Hamilton Roschel
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group - Center of Lifestyle Medicine; Laboratory of Assessment and Conditioning in Rheumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Rheumatology Division, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
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Blaess J, Geneton S, Goepfert T, Appenzeller S, Bordier G, Davergne T, Fuentes Y, Haglo H, Hambly K, Kinnett-Hopkins D, Su KY, Legge A, Li L, Mak A, Padjen I, Sciascia S, Sheikh SZ, Soriano-Maldonado A, Ugarte-Gil MF, Md Yusof MY, Parodis I, Arnaud L. Recommendations for physical activity and exercise in persons living with Systemic Lupus Erythematosus (SLE): consensus by an international task force. RMD Open 2024; 10:e004171. [PMID: 38580348 PMCID: PMC11002419 DOI: 10.1136/rmdopen-2024-004171] [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: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 04/07/2024] Open
Abstract
OBJECTIVE This international task force aimed to provide healthcare professionals and persons living with systemic lupus erythematosus (SLE) with consensus-based recommendations for physical activity and exercise in SLE. METHODS Based on evidence from a systematic literature review and expert opinion, 3 overarching principles and 15 recommendations were agreed on by Delphi consensus. RESULTS The overarching principles highlight the importance of shared decision-making and the need to explain the benefits of physical activity to persons living with SLE and other healthcare providers. The 15 specific recommendations state that physical activity is generally recommended for all people with SLE, but in some instances, a medical evaluation may be needed to rule out contraindications. Pertaining to outdoor activity, photoprotection is necessary. Both aerobic and resistance training programmes are recommended, with a gradual increase in frequency and intensity, which should be adapted for each individual, and ideally supervised by qualified professionals. CONCLUSION In summary, the consensus reached by the international task force provides a valuable framework for the integration of physical activity and exercise into the management of SLE, offering a tailored evidence-based and eminence-based approach to enhance the well-being of individuals living with this challenging autoimmune condition.
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Affiliation(s)
- Julien Blaess
- Department of Physiology and Functional Exploration, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Sophie Geneton
- Department of Rheumatology, National Reference Center for Rare Autoimmune Diseases (RESO), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thibaut Goepfert
- Department of Rheumatology, National Reference Center for Rare Autoimmune Diseases (RESO), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Department of Sport Medicine, Unit of Physical and Rehabilitation Medicine, University Hospital of Martinique, Fort De France, Martinique
| | - Simone Appenzeller
- School of Medical Science, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil
| | | | - Thomas Davergne
- School of physiotherapy Boris Dolto, DUS2R, University of Paris Cité, Paris, France
| | - Yurilis Fuentes
- Departamento de Medicina, Universidad de Oriente, Ciudad Bolívar, Venezuela
| | - Håvard Haglo
- Treningsklinikken, Medical Rehabilitation Clinic, Trondheim, Norway
| | - Karen Hambly
- School of Sport and Exercise Sciences, University of Kent, Canterbury, UK
| | | | - Kuei-Ying Su
- Division of Allergy,Immunology and Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Alexandra Legge
- Division of Rheumatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Linda Li
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anselm Mak
- Division of Rheumatology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ivan Padjen
- School of Medicine, Division of Clinical Immunology and Rheumatology, National Referral Centre for SLE and Related Disorders, University of Zagreb, Zagreb, Croatia
- Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Saira Z Sheikh
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alberto Soriano-Maldonado
- Department of Education, Faculty of Education Sciences, and SPORT Research Group (CTS-1024), CIBIS (Centro de Investigación para el Bienestar y la Inclusión Social) Research Center, University of Almería, Almería, Spain
| | - Manuel F Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima Peru and Rheumatology Department, Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Peru
| | - Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health and Care Research (NIHR) Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Rare Autoimmune Diseases (RESO), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Ambler WG, Kaplan MJ. Vascular damage in systemic lupus erythematosus. Nat Rev Nephrol 2024; 20:251-265. [PMID: 38172627 DOI: 10.1038/s41581-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
Vascular disease is a major cause of morbidity and mortality in patients with systemic autoimmune diseases, particularly systemic lupus erythematosus (SLE). Although comorbid cardiovascular risk factors are frequently present in patients with SLE, they do not explain the high burden of premature vascular disease. Profound innate and adaptive immune dysregulation seems to be the primary driver of accelerated vascular damage in SLE. In particular, evidence suggests that dysregulation of type 1 interferon (IFN-I) and aberrant neutrophils have key roles in the pathogenesis of vascular damage. IFN-I promotes endothelial dysfunction directly via effects on endothelial cells and indirectly via priming of immune cells that contribute to vascular damage. SLE neutrophils are vasculopathic in part because of their increased ability to form immunostimulatory neutrophil extracellular traps. Despite improvements in clinical care, cardiovascular disease remains the leading cause of mortality among patients with SLE, and treatments that improve vascular outcomes are urgently needed. Improved understanding of the mechanisms of vascular injury in inflammatory conditions such as SLE could also have implications for common cardiovascular diseases, such as atherosclerosis and hypertension, and may ultimately lead to personalized therapeutic approaches to the prevention and treatment of this potentially fatal complication.
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Affiliation(s)
- William G Ambler
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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Sieczkowska SM, Smaira FI, Mazzolani BC, Romero M, Pasoto SG, de Sá Pinto AL, Lima FR, De Oliveira VR, Ueda S, Benatti FB, Roschel H, Gualano B. A randomized controlled trial of an intervention promoting physical activity and healthy eating recommendations in systemic lupus erythematosus: the protocol study "Living Well with Lupus". Rheumatol Int 2023; 43:1799-1810. [PMID: 37354245 DOI: 10.1007/s00296-023-05370-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/26/2023]
Abstract
There is a paucity of studies assessing multidisciplinary interventions focused on tackling physical inactivity/sedentary behavior and poor dietary habits in SLE. The Living well with Lupus (LWWL) is a randomized controlled trial to investigate whether a six-month lifestyle change intervention will improve cardiometabolic risk factors (primary outcome) among systemic lupus erythematosus (SLE) patients with low disease activity (SLEDAI score ≤ 4) and with high cardiovascular risk. As secondary goals, we will evaluate: (1) the intervention's safety, efficacy, and feasibility in promoting lifestyle changes, and (2) the effects of the intervention on secondary outcomes (i.e., clinical parameters, functional capacity, fatigue, psychological aspects, sleep quality and health-related quality of life). Patients will be randomly allocated to either a control (i.e., standard care) or a lifestyle intervention group using a simple randomization (1:1 ratio, blocks of 20). Mixed Model analyses will be conducted for comparing groups following an intention-to-treat approach. A per protocol analysis will also be conducted. This study has the potential to generate new, clinically relevant data able to refine the multidisciplinary management of SLE patients. Protocol version number: NCT04431167 (first version).
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Affiliation(s)
- Sofia Mendes Sieczkowska
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
| | - Fabiana Infante Smaira
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
| | - Bruna Caruso Mazzolani
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
| | - Marina Romero
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
- School of Applied Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, 13484-350, Brazil
| | - Sandra Gofinet Pasoto
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil
| | - Ana Lúcia de Sá Pinto
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil
| | - Fernanda Rodrigues Lima
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil
| | - Victor Rodrigues De Oliveira
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil
| | - Serli Ueda
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil
| | - Fabiana Braga Benatti
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
- School of Applied Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, 13484-350, Brazil
| | - Hamilton Roschel
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, Center of Lifestyle Medicine, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° Andar, São Paulo, SP, 01246-903, Brazil.
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 05403-900, Brazil.
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7
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Touil H, Mounts K, De Jager PL. Differential impact of environmental factors on systemic and localized autoimmunity. Front Immunol 2023; 14:1147447. [PMID: 37283765 PMCID: PMC10239830 DOI: 10.3389/fimmu.2023.1147447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/08/2023] [Indexed: 06/08/2023] Open
Abstract
The influence of environmental factors on the development of autoimmune disease is being broadly investigated to better understand the multifactorial nature of autoimmune pathogenesis and to identify potential areas of intervention. Areas of particular interest include the influence of lifestyle, nutrition, and vitamin deficiencies on autoimmunity and chronic inflammation. In this review, we discuss how particular lifestyles and dietary patterns may contribute to or modulate autoimmunity. We explored this concept through a spectrum of several autoimmune diseases including Multiple Sclerosis (MS), Systemic Lupus Erythematosus (SLE) and Alopecia Areata (AA) affecting the central nervous system, whole body, and the hair follicles, respectively. A clear commonality between the autoimmune conditions of interest here is low Vitamin D, a well-researched hormone in the context of autoimmunity with pleiotropic immunomodulatory and anti-inflammatory effects. While low levels are often correlated with disease activity and progression in MS and AA, the relationship is less clear in SLE. Despite strong associations with autoimmunity, we lack conclusive evidence which elucidates its role in contributing to pathogenesis or simply as a result of chronic inflammation. In a similar vein, other vitamins impacting the development and course of these diseases are explored in this review, and overall diet and lifestyle. Recent work exploring the effects of dietary interventions on MS showed that a balanced diet was linked to improvement in clinical parameters, comorbid conditions, and overall quality of life for patients. In patients with MS, SLE and AA, certain diets and supplements are linked to lower incidence and improved symptoms. Conversely, obesity during adolescence was linked with higher incidence of MS while in SLE it was associated with organ damage. Autoimmunity is thought to emerge from the complex interplay between environmental factors and genetic background. Although the scope of this review focuses on environmental factors, it is imperative to elaborate the interaction between genetic susceptibility and environment due to the multifactorial origin of these disease. Here, we offer a comprehensive review about the influence of recent environmental and lifestyle factors on these autoimmune diseases and potential translation into therapeutic interventions.
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Affiliation(s)
- Hanane Touil
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
| | - Kristin Mounts
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
| | - Philip Lawrence De Jager
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
- Columbia Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
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Ocagli H, Agarinis R, Azzolina D, Zabotti A, Treppo E, Francavilla A, Bartolotta P, Todino F, Binutti M, Gregori D, Quartuccio L. Physical activity assessment with wearable devices in rheumatic diseases: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1031-1046. [PMID: 36005834 DOI: 10.1093/rheumatology/keac476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/13/2022] [Accepted: 08/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In the management of rheumatic musculoskeletal disorders (RMDs), regular physical activity (PA) is an important recognized non-pharmacological intervention. This systematic review and meta-analysis aims to evaluate how the use of wearable devices (WDs) impacts physical activity in patients with noninflammatory and inflammatory rheumatic diseases. METHODS A comprehensive search of articles was performed in PubMed, Embase, CINAHL and Scopus. A random-effect meta-analysis was carried out on the number of steps and moderate-vigorous physical activity (MVPA). Univariable meta-regression models were computed to assess the possibility that the study characteristics may act as modifiers on the final meta-analysis estimate. RESULTS In the analysis, 51 articles were included, with a total of 7488 participants. Twenty-two studies considered MVPA outcome alone, 16 studies considered the number of steps alone, and 13 studies reported information on both outcomes. The recommended PA threshold was reached for MVPA (36.35, 95% CI 29.39, 43.31) but not for daily steps (-1092.60, -1640.42 to -544.77). Studies on patients with fibromyalgia report a higher number (6290, 5198.65-7381.62) of daily steps compared with other RMDs. Patients affected by chronic inflammatory arthropathies seemed to fare better in terms of daily steps than the other categories. Patients of younger age reported a higher overall level of PA than elderly individuals for both the number of steps and MVPA. CONCLUSION Physical activity can be lower than the recommended threshold in patients with RMDs when objectively measured using WD. WDs could be a useful and affordable instrument for daily monitoring physical activity in RMDs and may support an increase in activity levels. PROSPERO TRIAL REGISTRATION CRD42021227681, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227681.
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Affiliation(s)
- Honoria Ocagli
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova
| | - Roberto Agarinis
- Division of Rheumatology, Department of Medicine, University of Udine, ASUFC, Udine
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova.,Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Alen Zabotti
- Division of Rheumatology, Department of Medicine, University of Udine, ASUFC, Udine
| | - Elena Treppo
- Division of Rheumatology, Department of Medicine, University of Udine, ASUFC, Udine
| | - Andrea Francavilla
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova
| | - Patrizia Bartolotta
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova
| | - Federica Todino
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova
| | - Marco Binutti
- Division of Rheumatology, Department of Medicine, University of Udine, ASUFC, Udine
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova
| | - Luca Quartuccio
- Division of Rheumatology, Department of Medicine, University of Udine, ASUFC, Udine
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9
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Fenton SAM, O’Brien CM, Kitas GD, Duda JL, Veldhuijzen van Zanten JJCS, Metsios GS. The behavioural epidemiology of sedentary behaviour in inflammatory arthritis: where are we, and where do we need to go? Rheumatol Adv Pract 2023; 7:rkac097. [PMID: 36699551 PMCID: PMC9870708 DOI: 10.1093/rap/rkac097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023] Open
Abstract
In the last decade, studies into sedentary behaviour in inflammatory arthritis have raised important questions regarding its role in this condition. Specifically, evidence is needed on whether sedentary behaviour might exacerbate adverse inflammatory arthritis outcomes, and whether reducing sedentary behaviour might offer an effective avenue for self-management in this population. Research exploring these important research questions is still very much in its infancy and lacks the direction and scientific rigour required to inform effective intervention design, delivery and evaluation. Behavioural epidemiology refers to research that aims explicitly to understand and influence health behaviour patterns to prevent disease and improve health. To this end, the Behavioural Epidemiology Framework specifies a focused approach to health behaviour research, which leads to the development of evidence-based interventions directed at specific populations. In this review, we introduce the Behavioural Epidemiology Framework in the context of research into sedentary behaviour in inflammatory arthritis and ask: where are we, and where do we need to go?
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Affiliation(s)
- Sally A M Fenton
- Correspondence to: Sally A. M. Fenton, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail:
| | - Ciara M O’Brien
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - George D Kitas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, UK,Department of Rheumatology, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Joan L Duda
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jet J C S Veldhuijzen van Zanten
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, UK,Department of Rheumatology, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - George S Metsios
- Department of Rheumatology, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, UK,Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, Volos, Greece
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10
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Bernaś M, Płaczek B, Lewandowski M. Ensemble of RNN Classifiers for Activity Detection Using a Smartphone and Supporting Nodes. SENSORS (BASEL, SWITZERLAND) 2022; 22:9451. [PMID: 36502154 PMCID: PMC9739648 DOI: 10.3390/s22239451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/27/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
Nowadays, sensor-equipped mobile devices allow us to detect basic daily activities accurately. However, the accuracy of the existing activity recognition methods decreases rapidly if the set of activities is extended and includes training routines, such as squats, jumps, or arm swings. Thus, this paper proposes a model of a personal area network with a smartphone (as a main node) and supporting sensor nodes that deliver additional data to increase activity-recognition accuracy. The introduced personal area sensor network takes advantage of the information from multiple sensor nodes attached to different parts of the human body. In this scheme, nodes process their sensor readings locally with the use of recurrent neural networks (RNNs) to categorize the activities. Then, the main node collects results from supporting sensor nodes and performs a final activity recognition run based on a weighted voting procedure. In order to save energy and extend the network's lifetime, sensor nodes report their local results only for specific types of recognized activity. The presented method was evaluated during experiments with sensor nodes attached to the waist, chest, leg, and arm. The results obtained for a set of eight activities show that the proposed approach achieves higher recognition accuracy when compared with the existing methods. Based on the experimental results, the optimal configuration of the sensor nodes was determined to maximize the activity-recognition accuracy and reduce the number of transmissions from supporting sensor nodes.
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Affiliation(s)
- Marcin Bernaś
- Department of Computer Science and Automatics, University of Bielsko-Biała, Willowa 2, 43-309 Bielsko-Biała, Poland
| | - Bartłomiej Płaczek
- Institute of Computer Science, University of Silesia, Będzińska 39, 41-200 Sosnowiec, Poland
| | - Marcin Lewandowski
- Institute of Computer Science, University of Silesia, Będzińska 39, 41-200 Sosnowiec, Poland
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11
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Yang Z, Chen S, Bao R, Li R, Bao K, Feng R, Zhong Z, Wang X. Public Health Concern on Sedentary Behavior and Cardiovascular Disease: A Bibliometric Analysis of Literature from 1990 to 2022. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121764. [PMID: 36556966 PMCID: PMC9780999 DOI: 10.3390/medicina58121764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 12/02/2022]
Abstract
Background and Objectives: Cardiovascular disease is a long-term threat to global public health security, while sedentary behavior is a modifiable behavior among cardiovascular risk factors. This study aimed to analyze the peer-reviewed literature published globally on sedentary behavior and cardiovascular disease (SB-CVD) and identify the hotspots and frontiers within this research area. Materials and Methods: Publications on SB-CVD from 1990 to 2022 were retrieved from the Web of Science Core Collection. CiteSpace and VOSviewer were applied to perform bibliometric and knowledge mapping visualization analyses. Results: A total of 2071 publications were retrieved, presenting a gradual growing trend. Authors from the USA topped the list with 748 (36.12%), followed by authors from England (373, 18.01%) and Australia (354, 17.09%). The University of Queensland, Australia, led with 95 (4.5%) publications. The top five active authors were all from Australia, while Dunstan D and Owen N published the most documents (56, 2.7%). A total of 71.27% of the publications received funding, and the United States Department of Health and Human Services provided 363 (17.53%) grants. Public Environmental Occupational Health (498, 24.05%), Sport Sciences (237, 11.44%), and Cardiac Cardiovascular Systems (212, 10.24%) were the three most popular disciplines, while PLOS One (96, 4.64%) and BMC Public Health (88, 4.25%) were the two most popular journals. Investigations within the SB-CVD research area addressed the entire lifespan, the most popular type of research was the epidemiological study, and the accelerometer was the primary instrument for measuring sedentary behavior. In terms of variables, physical activity and sedentary behavior were the dominant lifestyle behaviors, while obesity and hypertension were common health problems. Occupational physical activity and guidelines are at the frontier and are currently in the burst stage. Conclusions: The last three decades have witnessed the rapid development of the SB-CVD research area, and this study provided further research ideas for subsequent investigations.
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Affiliation(s)
- Zhen Yang
- Department of Movement Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Sitong Chen
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3011, Australia
| | - Ran Bao
- Priority Research Centre for Physical Activity and Nutrition, School of Education, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Ruizhe Li
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Kaiming Bao
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90033, USA
| | - Renzhi Feng
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Ziyi Zhong
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Xuebin Wang
- Department of Physical Education, Shanghai Jiao Tong University, Shanghai 200240, China
- Correspondence:
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12
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Hernández-Negrín H, Ricci M, Mancebo-Sevilla JJ, Sanz-Cánovas J, López-Sampalo A, Cobos-Palacios L, Romero-Gómez C, Pérez de Pedro I, Ayala-Gutiérrez MDM, Gómez-Huelgas R, Bernal-López MR. Obesity, Diabetes, and Cardiovascular Risk Burden in Systemic Lupus Erythematosus: Current Approaches and Knowledge Gaps-A Rapid Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14768. [PMID: 36429489 PMCID: PMC9690813 DOI: 10.3390/ijerph192214768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
Obesity, diabetes mellitus, and cardiovascular risk are real challenges in systemic lupus erythematosus (SLE) clinical practice and research. The evidence of the burden of these health problems in SLE patients is determined by the methods used to assess them. Therefore, the aim of this scoping review is to map current approaches in assessing obesity, diabetes mellitus, and cardiovascular risk burden in SLE patients and to identify existing knowledge gaps in this field. This rapid scoping review was conducted according to the Joanna Briggs Institute methodology and identified 274 articles, of which 73 were included. Most studies were conducted at European institutions and patients were recruited from specialist hospital clinics, the majority of whom were women. The burden of obesity and diabetes mellitus for SLE patients was assessed mainly in terms of prevalence, impact on disease activity, and cardiometabolic risk. The burden of cardiovascular risk was assessed using multiple approaches, mainly imaging and laboratory methods, and risk factor-based scores, although there is great heterogeneity and uncertainty between the methods used. This review highlights the importance of improving and standardizing the approach to obesity, diabetes, and cardiovascular risk in SLE patients through a holistic assessment that includes lifestyle, clinical, biological, and social aspects.
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Affiliation(s)
- Halbert Hernández-Negrín
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Michele Ricci
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Juan José Mancebo-Sevilla
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Jaime Sanz-Cánovas
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Almudena López-Sampalo
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Lidia Cobos-Palacios
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Carlos Romero-Gómez
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - Iván Pérez de Pedro
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - María del Mar Ayala-Gutiérrez
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - María Rosa Bernal-López
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
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13
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Mak A, Chan JKY. Endothelial function and endothelial progenitor cells in systemic lupus erythematosus. Nat Rev Rheumatol 2022; 18:286-300. [PMID: 35393604 DOI: 10.1038/s41584-022-00770-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 12/13/2022]
Abstract
The observations that traditional cardiovascular disease (CVD) risk factors fail to fully account for the excessive cardiovascular mortality in patients with systemic lupus erythematosus (SLE) compared with the general population have prompted in-depth investigations of non-traditional, SLE-related risk factors that contribute to cardiovascular complications in patients with SLE. Of the various perturbations of vascular physiology, endothelial dysfunction, which is believed to occur in the earliest step of atherosclerosis, has been extensively investigated for its contribution to CVD risk in SLE. Endothelial progenitor cells (EPCs), which play a crucial part in vascular repair, neovascularization and maintenance of endothelial function, are quantitatively and functionally reduced in patients with SLE. Yet, the lack of a unified definition of EPCs, standardization of the quantity and functional assessment of EPCs as well as endothelial function measurement pose challenges to the translation of endothelial function measurements and EPC levels into prognostic markers for CVD in patients with SLE. This Review discusses factors that contribute to CVD in SLE, with particular focus on how endothelial function and EPCs are evaluated currently, and how EPCs are quantitatively and functionally altered in patients with SLE. Potential strategies for the use of endothelial function measurements and EPC quantification as prognostic markers of CVD in patients with SLE, and the limitations of their prognostication potential, are also discussed.
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Affiliation(s)
- Anselm Mak
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore, Singapore.
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Academic Clinical Programme in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore, Singapore.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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14
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Huang S, Tian F, Yang X, Fang S, Fan Y, Bao J. Physical Activity and Systemic Lupus Erythematosus Among European Populations: A Two-Sample Mendelian Randomization Study. Front Genet 2022; 12:784922. [PMID: 35211151 PMCID: PMC8861300 DOI: 10.3389/fgene.2021.784922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The causal relationship between physical activity (PA) and systemic lupus erythematosus (SLE) remains uncertain. We aimed to assess the causal effect of PA on SLE by two-sample Mendelian randomization (MR) study. Methods: Summary statistics of SLE were obtained from a genome-wide association study (GWAS) meta-analysis of European descent, including 4,036 cases and 6,959 controls. Genetic instruments for PA, including MVPA, VPA, SSOE, and average acceleration, were identified from a large-scale GWAS meta-analysis among 377,234 individuals of European ancestry from United Kingdom biobank and Atherosclerosis Risk in Communities (ARIC) study, and another GWAS with 91,105 European participants was employed for sedentary behavior. The two-sample MR study was conducted to estimate causal relationship between PA and SLE, with the inverse-variance weighted (IVW) method, simple- and weighted-median method. Moreover, MR-Egger regression, MR-PRESSO and leave-one-out analysis were performed to evaluate the potential pleiotropy effect. Results: In the end, we totally selected 37 SNPs (15 SNPs for MVPA, 5 SNPs for VPA, 9 SNPs for SSOE, 5 SNPs for average acceleration and 3 SNPs for sedentary behavior). According to the IVW results, as the primary method, we found that genetically predicted PA was not causally associated with risk of SLE (MVPA: OR 0.44, 95% CI 0.09–2.10, p = 0.305; VPA: OR 0.20, 95% CI 0.00–18.97, p = 0.490; SSOE: OR 0.96, 95% CI 0.03–29.24, p = 0.983; average acceleration: OR 0.91, 95% CI 0.79–1.05, p = 0.190; sedentary behavior: OR 1.54, 95% CI 0.35–6.81, p = 0.572). MR-Egger, MR-PRESSO, and leave-one-out analysis did not indicate horizontal pleiotropy. Conclusions: Our MR study suggested that genetically predicted PA was not causally associated with SLE among the European populations.
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Affiliation(s)
- Shuo Huang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Fengyuan Tian
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoxuan Yang
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Sijia Fang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yongsheng Fan
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jie Bao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
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15
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Goessler KF, Gualano B, Nonino CB, Bonfá E, Nicoletti CF. Lifestyle Interventions and Weight Management in Systemic Lupus Erythematosus Patients: A Systematic Literature Review and Metanalysis. J Lifestyle Med 2022; 12:37-46. [PMID: 35300036 PMCID: PMC8918379 DOI: 10.15280/jlm.2022.12.1.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background We aimed to identify and describe different types of lifestyle interventions primarily or secondarily focused on weight loss in SLE patients. Methods A systematic search of controlled trials published until June 2021 that assigned adults patients after dietary or exercise intervention resulted in 248 studies initially screened. Results Six studies with seven interventions (3 dietary and 4 exercise training programs) fulfilled the eligibility criteria and were included in the meta-analysis with a median of age 35.8 (31.3 to 49.0 years); median of BMI 26.6 (25.2 to 33.6 kg/m2). After six to twelve weeks of diet or exercise program, no differences were observed in body weight [-1.539 (-4.482 to 1.405) kg (CI 95%), p = 0.306]. Also, a subgroup analysis also revelated no body weight difference following dietary intervention [-3.561 (-9.604 to 2.481) kg (CI 95%), p = 0.248] or exercise intervention [-0.910 (-4.279 to 2.460) kg (CI 95%), p = 0.597]. Conclusion The results showed that different protocols of exercise intervention or diets were not effective to reduce body weight in patients with SLE. However, only one of the selected trials had a specific study design and protocol focusing on weight loss management.
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Affiliation(s)
- Karla F. Goessler
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Faculdade de Medicina FMUSP, Sao Paulo, Brazil
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Faculdade de Medicina FMUSP, Sao Paulo, Brazil
- Rheumatology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Sao Paulo, Brazil
| | - Carla B. Nonino
- Department of Health Science, Ribeirão Preto School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Eloisa Bonfá
- Rheumatology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Sao Paulo, Brazil
| | - Carolina Ferreira Nicoletti
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Faculdade de Medicina FMUSP, Sao Paulo, Brazil
- Rheumatology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Sao Paulo, Brazil
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16
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Molina E, Petri M, Manno R, Williamson L, Williamson L, Timlin H. A prescription for exercise in systemic lupus erythematosus. Lupus 2021; 30:2183-2190. [PMID: 34903093 DOI: 10.1177/09612033211061060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with systemic lupus erythematosus (SLE) have increased cardiovascular risk, and fatigue is a major subjective complaint. Sedentary lifestyle has been shown to have negative health impacts in cardiovascular and rheumatic disease, though exercise has not traditionally been incorporated into routine therapy recommendations. Regular exercise in SLE may improve difficult to treat Type 2 symptoms, such as fatigue, depression, stress, and quality of life. Insufficient counseling on exercise by physicians is a notable barrier for SLE patients to engage in physical activity. Aerobic exercise regimens are more commonly studied, and have been shown to improve cardiovascular health in SLE. Exercise may improve some inflammatory markers, though does not definitively affect SLE clinical disease activity. Physical activity should be recommended to improve quality of life and cardiovascular health in patients with SLE. Developing clearer guidelines for exercise regimens in a patient-centered manner is warranted, especially given diverse phenotypes of SLE patients and varying degrees of physical limitations.
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Affiliation(s)
- Emily Molina
- Department of Internal Medicine, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Petri
- Department of Internal Medicine, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Manno
- Department of Rheumatology, 249252Comprehensive Orthopaedic Global, Saint Thomas, VI, USA
| | - Luke Williamson
- Department of Rheumatology, 8539Westmead Hospital, Westmead, NSW, USA
| | - Lyn Williamson
- Department of Rheumatology, 8539Great Western Hospital Wiltshire, Swindon, UK
| | - Homa Timlin
- Division of Rheumatology, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Straczkiewicz M, James P, Onnela JP. A systematic review of smartphone-based human activity recognition methods for health research. NPJ Digit Med 2021; 4:148. [PMID: 34663863 PMCID: PMC8523707 DOI: 10.1038/s41746-021-00514-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Smartphones are now nearly ubiquitous; their numerous built-in sensors enable continuous measurement of activities of daily living, making them especially well-suited for health research. Researchers have proposed various human activity recognition (HAR) systems aimed at translating measurements from smartphones into various types of physical activity. In this review, we summarized the existing approaches to smartphone-based HAR. For this purpose, we systematically searched Scopus, PubMed, and Web of Science for peer-reviewed articles published up to December 2020 on the use of smartphones for HAR. We extracted information on smartphone body location, sensors, and physical activity types studied and the data transformation techniques and classification schemes used for activity recognition. Consequently, we identified 108 articles and described the various approaches used for data acquisition, data preprocessing, feature extraction, and activity classification, identifying the most common practices, and their alternatives. We conclude that smartphones are well-suited for HAR research in the health sciences. For population-level impact, future studies should focus on improving the quality of collected data, address missing data, incorporate more diverse participants and activities, relax requirements about phone placement, provide more complete documentation on study participants, and share the source code of the implemented methods and algorithms.
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Affiliation(s)
- Marcin Straczkiewicz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
| | - Peter James
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
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18
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Pettersson H, Alexanderson H, Poole JL, Varga J, Regardt M, Russell AM, Salam Y, Jensen K, Mansour J, Frech T, Feghali-Bostwick C, Varjú C, Baldwin N, Heenan M, Fligelstone K, Holmner M, Lammi MR, Scholand MB, Shapiro L, Volkmann ER, Saketkoo LA. Exercise as a multi-modal disease-modifying medicine in systemic sclerosis: An introduction by The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis (G-FoRSS). Best Pract Res Clin Rheumatol 2021; 35:101695. [PMID: 34217607 PMCID: PMC8478716 DOI: 10.1016/j.berh.2021.101695] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Systemic sclerosis (SSc) is a heterogeneous multisystem autoimmune disease whereby its main pathological drivers of disability and damage are vascular injury, inflammatory cell infiltration, and fibrosis. These mechanisms result in diffuse and diverse impairments arising from ischemic circulatory dysfunction leading to painful skin ulceration and calcinosis, neurovascular aberrations hindering gastrointestinal (GI) motility, progressive painful, incapacitating or immobilizing effects of inflammatory and fibrotic effects on the lungs, skin, articular and periarticular structures, and muscle. SSc-related impairments impede routine activities of daily living (ADLs) and disrupt three critical life areas: work, family, social/leisure, and also impact on psychological well-being. Physical activity and exercise are globally recommended; however, for connective tissue diseases, this guidance carries greater impact on inflammatory disease manifestations, recovery, and cardiovascular health. Exercise, through myogenic and vascular phenomena, naturally targets key pathogenic drivers by downregulating multiple inflammatory and fibrotic pathways in serum and tissue, while increasing circulation and vascular repair. G-FoRSS, The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis recognizes the scientific basis of and advocates for education and research of exercise as a systemic and targeted SSc disease-modifying treatment. An overview of biophysiological mechanisms of physical activity and exercise are herein imparted for patients, clinicians, and researchers, and applied to SSc disease mechanisms, manifestations, and impairment. A preliminary guidance on exercise in SSc, a research agenda, and the current state of research and outcome measures are set forth.
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Affiliation(s)
- Henrik Pettersson
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Division of Rheumatology, Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helene Alexanderson
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Division of Rheumatology, Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Janet L Poole
- Occupational Therapy Graduate Program, University of New Mexico, Albuquerque, NM, USA
| | - Janos Varga
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Malin Regardt
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Occupational Therapy, Karolinska Institutet, Stockholm, Sweden
| | - Anne-Marie Russell
- University of Exeter, College of Medicine and Health, Exeter, UK; National Institute of Health Research, Senior Nurse Research Leader, London, UK
| | - Yasser Salam
- Department of Physical Therapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Kelly Jensen
- Oregon Health and Science University, Portland, OR, USA; New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA
| | - Jennifer Mansour
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA
| | - Tracy Frech
- Vanderbilt University, Division of Rheumatology, Nashville, TN, USA
| | | | - Cecília Varjú
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | | | - Matty Heenan
- Scleroderma Foundation/Pulmonary Hypertension Association, Tucson, AZ, USA
| | - Kim Fligelstone
- Scleroderma & Raynaud Society UK (SRUK), London, UK; Royal Free Hospital, London, UK
| | - Monica Holmner
- The Swedish Rheumatism Association National Association for Systemic Sclerosis, Sweden
| | - Matthew R Lammi
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA
| | - Mary Beth Scholand
- University of Utah, Division of Pulmonary Medicine, Pulmonary Fibrosis Center, Salt Lake City, UT, USA
| | - Lee Shapiro
- Division of Rheumatology, Albany Medical Center, Albany, NY, USA; Steffens Scleroderma Foundation, Albany, NY, USA
| | - Elizabeth R Volkmann
- University of California, David Geffen School of Medicine, UCLA Scleroderma Program and UCLA CTD-ILD Program, Division of Rheumatology, Department of Medicine, Los Angeles, CA, USA
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA.
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19
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Kao VP, Wen HJ, Pan YJ, Pai CS, Tsai ST, Su KY. Combined aerobic and resistance training improves physical and executive functions in women with systemic lupus erythematosus. Lupus 2021; 30:946-955. [PMID: 33657920 DOI: 10.1177/0961203321998749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Exercise is considered as an adjuvant therapeutic modality to alleviate symptoms of several rheumatic diseases. However, data regarding the benefits of exercise to patients with systemic lupus erythematosus (SLE) are relatively scant. METHODS This study aimed to assess the effects of regular, moderate-intensity, aerobic exercise combined with resistance training on women with SLE who had no regular exercise. Patients were recruited and allocated into either the exercise or control group by their willingness. Patients in the exercise group (n = 12) underwent 12 weeks of combined exercise (five days per week), whereas those in the control group (n = 11) maintained their usual lifestyle. RESULTS At baseline, there were no between-group differences in body composition, disease activity, two-kilometer walking test, and executive function test. After the combined exercise intervention for 12 weeks, significant improvements of both fitness index and reaction time to the stimuli in the go/no-go test were observed in the exercise group, but not in the control group. The disease activities in both study groups did not change significantly at the end of the study period. CONCLUSION Our results suggest that regular moderate-intensity aerobic exercise combined with resistance training improves the physical and executive functions of SLE patients without exacerbating disease activity.
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Affiliation(s)
- Victoria Py Kao
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Huei-Jhen Wen
- Center of Physical Education, Tzu Chi University, Hualien, Taiwan.,Sports Medicine Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yu-Jen Pan
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chia-Sheng Pai
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Shih-Tzu Tsai
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuei-Ying Su
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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20
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Legge A, Blanchard C, Hanly JG. Comment on: Physical activity, sedentary behaviour and their associations with cardiovascular risk in systemic lupus erythematosus: reply. Rheumatology (Oxford) 2021; 59:e153-e154. [PMID: 32940687 DOI: 10.1093/rheumatology/keaa486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - John G Hanly
- Department of Medicine, Division of Rheumatology.,Department of Pathology, Dalhousie University and Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
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21
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Gavilán-Carrera B, Vargas-Hitos JA, Soriano-Maldonado A. Comment on: Physical activity, sedentary behaviour and their associations with cardiovascular risk in systemic lupus erythematosus. Rheumatology (Oxford) 2020; 59:e151-e152. [DOI: 10.1093/rheumatology/keaa493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/03/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Blanca Gavilán-Carrera
- Physical Activity for Health Promotion Research Group (PA-HELP), Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada,
| | - José Antonio Vargas-Hitos
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, “Virgen de las Nieves” University Hospital, Granada
| | - Alberto Soriano-Maldonado
- Department of Education, Faculty of Education Sciences
- SPORT Research Group (CTS-1024), CERNEP Research Center, University of Almería, Almería, Spain
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22
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Using the Concept of Frailty to Understand Variability in Health Outcomes Among Individuals with Systemic Lupus Erythematosus. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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23
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Mak A. Physical exercise and systemic lupus erythematosus. Rheumatology (Oxford) 2020; 59:921-922. [PMID: 31691830 DOI: 10.1093/rheumatology/kez534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Anselm Mak
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore
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