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Wee J, Tan XR, Gunther SH, Ihsan M, Leow MKS, Tan DSY, Eriksson JG, Lee JKW. Effects of Medications on Heat Loss Capacity in Chronic Disease Patients: Health Implications Amidst Global Warming. Pharmacol Rev 2023; 75:1140-1166. [PMID: 37328294 DOI: 10.1124/pharmrev.122.000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/20/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
Pharmacological agents used to treat or manage diseases can modify the level of heat strain experienced by chronically ill and elderly patients via different mechanistic pathways. Human thermoregulation is a crucial homeostatic process that maintains body temperature within a narrow range during heat stress through dry (i.e., increasing skin blood flow) and evaporative (i.e., sweating) heat loss, as well as active inhibition of thermogenesis, which is crucial to avoid overheating. Medications can independently and synergistically interact with aging and chronic disease to alter homeostatic responses to rising body temperature during heat stress. This review focuses on the physiologic changes, with specific emphasis on thermolytic processes, associated with medication use during heat stress. The review begins by providing readers with a background of the global chronic disease burden. Human thermoregulation and aging effects are then summarized to give an understanding of the unique physiologic changes faced by older adults. The effects of common chronic diseases on temperature regulation are outlined in the main sections. Physiologic impacts of common medications used to treat these diseases are reviewed in detail, with emphasis on the mechanisms by which these medications alter thermolysis during heat stress. The review concludes by providing perspectives on the need to understand the effects of medication use in hot environments, as well as a summary table of all clinical considerations and research needs of the medications included in this review. SIGNIFICANCE STATEMENT: Long-term medications modulate thermoregulatory function, resulting in excess physiological strain and predisposing patients to adverse health outcomes during prolonged exposures to extreme heat during rest and physical work (e.g., exercise). Understanding the medication-specific mechanisms of altered thermoregulation has importance in both clinical and research settings, paving the way for work toward refining current medication prescription recommendations and formulating mitigation strategies for adverse drug effects in the heat in chronically ill patients.
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Affiliation(s)
- Jericho Wee
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Xiang Ren Tan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Samuel H Gunther
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Mohammed Ihsan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Melvin Khee Shing Leow
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Doreen Su-Yin Tan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Johan G Eriksson
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Jason Kai Wei Lee
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
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Bock JM, Hughes WE, Ueda K, Feider AJ, Hanada S, Casey DP. Glycemic management is inversely related to skeletal muscle microvascular endothelial function in patients with type 2 diabetes. Physiol Rep 2021; 9:e14764. [PMID: 33660935 PMCID: PMC7931618 DOI: 10.14814/phy2.14764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 11/24/2022] Open
Abstract
Microvascular endothelial dysfunction precipitates cardiovascular disease mortality in patients with type 2 diabetes mellitus (T2DM). However, the relationship between glycemic management and microvascular endothelial function of these patients remains ill defined. We investigated the association between skeletal muscle microvascular endothelial function with glycemic management (HbA1c) and responses to an oral glucose challenge (OGTT) in 30 patients with T2DM (59 ± 9 years, 31.2 ± 5.1 kg/m2 , HbA1c = 7.3 ± 1.3%). On study day 1, microvascular endothelial function was quantified as the increase (Δ from rest) in forearm vascular conductance (FVC, ml/min/100 mmHg) during intra-arterial acetylcholine infusion at 4.0 and 8.0 μg/dl forearm volume/min (ACh4 and ACh8, respectively). [Glucose] and [insulin] were measured in a fasted state as well as following a 75 g OGTT on a second day with an additional fasting blood sample collected to measure HbA1c. FVC increased (Δ) 221 ± 118 and 251 ± 144 ml/min/100 mm Hg during ACh4 and ACh8 trials, respectively (p < 0.05 between doses). [Glucose] and [insulin] increased at the 1-h time point, relative to fasting levels, and remained elevated 2 h post-consumption (p < 0.05 for both variables and time points). [Glucose] nor [insulin], fasting or during the OGTT, were associated with ΔFVC during ACh4 or ACh8, respectively (p = 0.11-0.86), although HbA1c was inversely related (r = -0.47 and -0.46, respectively, p < 0.01 for both). Patients whose HbA1c met the ADA's therapeutic target of ≤7.0% had greater ΔFVC to ACh4 (272 ± 147 vs. 182 ± 74 ml/100 mm Hg/min) and ACh8 (324 ± 171 vs. 196 ± 90 ml/100 mm Hg/min, p < 0.05 for both trials) compared to those with >7.0%, respectively. Our data show glycemic management is related to acetylcholine-mediated vasodilation (e.g., microvascular endothelial function) in skeletal muscle of patients with T2DM.
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Affiliation(s)
- Joshua M Bock
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - William E Hughes
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Kenichi Ueda
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Andrew J Feider
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Satoshi Hanada
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Darren P Casey
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Fraternal Order of Eagles Diabetes Research Center, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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6
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Strassheim D, Verin A, Batori R, Nijmeh H, Burns N, Kovacs-Kasa A, Umapathy NS, Kotamarthi J, Gokhale YS, Karoor V, Stenmark KR, Gerasimovskaya E. P2Y Purinergic Receptors, Endothelial Dysfunction, and Cardiovascular Diseases. Int J Mol Sci 2020; 21:ijms21186855. [PMID: 32962005 PMCID: PMC7555413 DOI: 10.3390/ijms21186855] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022] Open
Abstract
Purinergic G-protein-coupled receptors are ancient and the most abundant group of G-protein-coupled receptors (GPCRs). The wide distribution of purinergic receptors in the cardiovascular system, together with the expression of multiple receptor subtypes in endothelial cells (ECs) and other vascular cells demonstrates the physiological importance of the purinergic signaling system in the regulation of the cardiovascular system. This review discusses the contribution of purinergic P2Y receptors to endothelial dysfunction (ED) in numerous cardiovascular diseases (CVDs). Endothelial dysfunction can be defined as a shift from a “calm” or non-activated state, characterized by low permeability, anti-thrombotic, and anti-inflammatory properties, to a “activated” state, characterized by vasoconstriction and increased permeability, pro-thrombotic, and pro-inflammatory properties. This state of ED is observed in many diseases, including atherosclerosis, diabetes, hypertension, metabolic syndrome, sepsis, and pulmonary hypertension. Herein, we review the recent advances in P2Y receptor physiology and emphasize some of their unique signaling features in pulmonary endothelial cells.
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Affiliation(s)
- Derek Strassheim
- The Department of Medicine Cardiovascular and Pulmonary Research Laboratory, University of Colorado Denver, Aurora, CO 80045, USA; (D.S.); (N.B.); (V.K.); (K.R.S.)
| | - Alexander Verin
- Vascular Biology Center, Augusta University, Augusta, GA 30912, USA; (A.V.); (R.B.); (A.K.-K.)
| | - Robert Batori
- Vascular Biology Center, Augusta University, Augusta, GA 30912, USA; (A.V.); (R.B.); (A.K.-K.)
| | - Hala Nijmeh
- The Department of Pediatrics, Division of Critical Care Medicine, University of Colorado Denver, Aurora, CO 80045, USA;
| | - Nana Burns
- The Department of Medicine Cardiovascular and Pulmonary Research Laboratory, University of Colorado Denver, Aurora, CO 80045, USA; (D.S.); (N.B.); (V.K.); (K.R.S.)
| | - Anita Kovacs-Kasa
- Vascular Biology Center, Augusta University, Augusta, GA 30912, USA; (A.V.); (R.B.); (A.K.-K.)
| | | | - Janavi Kotamarthi
- The Department of BioMedical Engineering, University of Wisconsin, Madison, WI 53706, USA; (J.K.); (Y.S.G.)
| | - Yash S. Gokhale
- The Department of BioMedical Engineering, University of Wisconsin, Madison, WI 53706, USA; (J.K.); (Y.S.G.)
| | - Vijaya Karoor
- The Department of Medicine Cardiovascular and Pulmonary Research Laboratory, University of Colorado Denver, Aurora, CO 80045, USA; (D.S.); (N.B.); (V.K.); (K.R.S.)
| | - Kurt R. Stenmark
- The Department of Medicine Cardiovascular and Pulmonary Research Laboratory, University of Colorado Denver, Aurora, CO 80045, USA; (D.S.); (N.B.); (V.K.); (K.R.S.)
- The Department of Pediatrics, Division of Critical Care Medicine, University of Colorado Denver, Aurora, CO 80045, USA;
| | - Evgenia Gerasimovskaya
- The Department of Medicine Cardiovascular and Pulmonary Research Laboratory, University of Colorado Denver, Aurora, CO 80045, USA; (D.S.); (N.B.); (V.K.); (K.R.S.)
- The Department of Pediatrics, Division of Critical Care Medicine, University of Colorado Denver, Aurora, CO 80045, USA;
- Correspondence: ; Tel.: +1-303-724-5614
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Fujii N, Nishiyasu T, Sigal RJ, Boulay P, McGarr GW, Kenny GP. Aging attenuates adenosine triphosphate-induced, but not muscarinic and nicotinic, cutaneous vasodilation in men. Microcirculation 2018; 25:e12462. [PMID: 29846993 DOI: 10.1111/micc.12462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/13/2018] [Accepted: 05/28/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE We evaluated the hypothesis that aging attenuates muscarinic, nicotinic, and ATP-related cutaneous vasodilation. METHODS In 11 young (24 ± 4 years) and 11 older males (61 ± 8 years), CVC was assessed at 3 forearm skin sites that were infused with either: (i) methacholine (muscarinic receptor agonist, 5 doses: 0.0125, 0.25, 5, 100, 2000 mmol/L), (ii) nicotine (nicotinic receptor agonist, 5 doses: 1.2, 3.6, 11, 33, 100 mmol/L), or (iii) ATP (purinergic receptor agonist, 5 doses: 0.03, 0.3, 3, 30, 300 mmol/L). Each agonist was administered for 25 minutes per dose. RESULTS We showed that CVC at all doses of methacholine did not differ between groups. Similarly, no between-group differences in CVC were observed during nicotine administration at all doses administered. By contrast, while no differences in CVC were measured during the administration of ATP at low (0.03 and 0.3 mmol/L) or high (300 mmol/L) concentrations, CVC was reduced in the older relative to the young males at moderate concentrations of ATP (3 mmol/L: 23 ± 6 vs 40 ± 13%max, 30 mmol/L: 62 ± 11 vs 83 ± 8%max, both P ≤ .05). CONCLUSIONS We show that aging attenuates ATP-induced, but not muscarinic or nicotinic, cutaneous vasodilation in men.
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Affiliation(s)
- Naoto Fujii
- Human and Environmental Physiology Research Unit, University of Ottawa, Ottawa, ON, Canada.,Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan
| | - Takeshi Nishiyasu
- Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan
| | - Ronald J Sigal
- Human and Environmental Physiology Research Unit, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Pierre Boulay
- Faculty of Physical Activity Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Gregory W McGarr
- Human and Environmental Physiology Research Unit, University of Ottawa, Ottawa, ON, Canada
| | - Glen P Kenny
- Human and Environmental Physiology Research Unit, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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