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Wang L, Zhang X, Zhang H, Lu K, Li M, Li X, Ou Y, Zhao X, Wu X, Wu X, Liu J, Xing M, Liu H, Zhang Y, Tan Y, Li F, Deng X, Deng J, Zhang X, Li J, Zhao Y, Ding Q, Wang H, Wang X, Luo Y, Zhou B, Zhang H. Excessive apoptosis of Rip1-deficient T cells leads to premature aging. EMBO Rep 2023; 24:e57925. [PMID: 37965894 PMCID: PMC10702839 DOI: 10.15252/embr.202357925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/29/2023] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
In mammals, the most remarkable T cell variations with aging are the shrinking of the naïve T cell pool and the enlargement of the memory T cell pool, which are partially caused by thymic involution. However, the mechanism underlying the relationship between T-cell changes and aging remains unclear. In this study, we find that T-cell-specific Rip1 KO mice show similar age-related T cell changes and exhibit signs of accelerated aging-like phenotypes, including inflammation, multiple age-related diseases, and a shorter lifespan. Mechanistically, Rip1-deficient T cells undergo excessive apoptosis and promote chronic inflammation. Consistent with this, blocking apoptosis by co-deletion of Fadd in Rip1-deficient T cells significantly rescues lymphopenia, the imbalance between naïve and memory T cells, and aging-like phenotypes, and prolongs life span in T-cell-specific Rip1 KO mice. These results suggest that the reduction and hyperactivation of T cells can have a significant impact on organismal health and lifespan, underscoring the importance of maintaining T cell homeostasis for healthy aging and prevention or treatment of age-related diseases.
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Affiliation(s)
- Lingxia Wang
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xixi Zhang
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Haiwei Zhang
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Kaili Lu
- Department of NeurologyShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ming Li
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xiaoming Li
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Yangjing Ou
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xiaoming Zhao
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xiaoxia Wu
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xuanhui Wu
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Jianling Liu
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Mingyan Xing
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Han Liu
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Yue Zhang
- Department of Anesthesiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yongchang Tan
- Department of Anesthesiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Fang Li
- Department of Anesthesiology, Shanghai First People's HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Xiaoxue Deng
- CAS Key Laboratory of Molecular Virology and ImmunologyUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Jiangshan Deng
- Department of NeurologyShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaojie Zhang
- Department of NeurologyShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jinbao Li
- Department of Anesthesiology, Shanghai First People's HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Yuwu Zhao
- Department of NeurologyShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Qiurong Ding
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Haikun Wang
- CAS Key Laboratory of Molecular Virology and ImmunologyUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Xiuzhe Wang
- Department of NeurologyShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yan Luo
- Department of Anesthesiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ben Zhou
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Haibing Zhang
- CAS Key Laboratory of Nutrition, Metabolism and Food Safety, Shanghai Institute of Nutrition and HealthUniversity of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
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Domínguez-Horta MDC, Serrano-Díaz A, Hernández-Cedeño M, Martínez-Donato G, Guillén-Nieto G. A peptide derived from HSP60 reduces proinflammatory cytokines and soluble mediators: a therapeutic approach to inflammation. Front Immunol 2023; 14:1162739. [PMID: 37187739 PMCID: PMC10179499 DOI: 10.3389/fimmu.2023.1162739] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Cytokines are secretion proteins that mediate and regulate immunity and inflammation. They are crucial in the progress of acute inflammatory diseases and autoimmunity. In fact, the inhibition of proinflammatory cytokines has been widely tested in the treatment of rheumatoid arthritis (RA). Some of these inhibitors have been used in the treatment of COVID-19 patients to improve survival rates. However, controlling the extent of inflammation with cytokine inhibitors is still a challenge because these molecules are redundant and pleiotropic. Here we review a novel therapeutic approach based on the use of the HSP60-derived Altered Peptide Ligand (APL) designed for RA and repositioned for the treatment of COVID-19 patients with hyperinflammation. HSP60 is a molecular chaperone found in all cells. It is involved in a wide diversity of cellular events including protein folding and trafficking. HSP60 concentration increases during cellular stress, for example inflammation. This protein has a dual role in immunity. Some HSP60-derived soluble epitopes induce inflammation, while others are immunoregulatory. Our HSP60-derived APL decreases the concentration of cytokines and induces the increase of FOXP3+ regulatory T cells (Treg) in various experimental systems. Furthermore, it decreases several cytokines and soluble mediators that are raised in RA, as well as decreases the excessive inflammatory response induced by SARS-CoV-2. This approach can be extended to other inflammatory diseases.
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Affiliation(s)
- Maria del Carmen Domínguez-Horta
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Physiology Department, Latin American School of Medicine, Havana, Cuba
- *Correspondence: Maria del Carmen Domínguez-Horta,
| | - Anabel Serrano-Díaz
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Mabel Hernández-Cedeño
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gillian Martínez-Donato
- Biomedical Research Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gerardo Guillén-Nieto
- Physiology Department, Latin American School of Medicine, Havana, Cuba
- Biomedical Research Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
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3
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Luo OJ, Lei W, Zhu G, Ren Z, Xu Y, Xiao C, Zhang H, Cai J, Luo Z, Gao L, Su J, Tang L, Guo W, Su H, Zhang ZJ, Fang EF, Ruan Y, Leng SX, Ju Z, Lou H, Gao J, Peng N, Chen J, Bao Z, Liu F, Chen G. Multidimensional single-cell analysis of human peripheral blood reveals characteristic features of the immune system landscape in aging and frailty. NATURE AGING 2022; 2:348-364. [PMID: 37117750 DOI: 10.1038/s43587-022-00198-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022]
Abstract
Frailty is an intermediate status of the human aging process, associated with decompensated homeostasis and death. The immune phenotype of frailty and its underlying cellular and molecular processes remain poorly understood. We profiled 114,467 immune cells from cord blood, young adults and healthy and frail old adults using single-cell RNA and TCR sequencing. Here we show an age-dependent accumulation of transcriptome heterogeneity and variability in immune cells. Characteristic transcription factors were identified in given cell types of specific age groups. Trajectory analysis revealed cells from non-frail and frail old adults often fall into distinct paths. Numerous TCR clonotypes were shared among T-cell subtypes in old adults, indicating differential pluripotency and resilience capabilities of aged T cells. A frailty-specific monocyte subset was identified with exclusively high expression of long noncoding RNAs NEAT1 and MALAT1. Our study discovers human frailty-specific immune cell characteristics based on the comprehensive dimensions in the immune landscape of aging and frailty.
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Haga M, Okada M. Systems approaches to investigate the role of NF-κB signaling in aging. Biochem J 2022; 479:161-183. [PMID: 35098992 PMCID: PMC8883486 DOI: 10.1042/bcj20210547] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 12/14/2022]
Abstract
The nuclear factor-κB (NF-κB) signaling pathway is one of the most well-studied pathways related to inflammation, and its involvement in aging has attracted considerable attention. As aging is a complex phenomenon and is the result of a multi-step process, the involvement of the NF-κB pathway in aging remains unclear. To elucidate the role of NF-κB in the regulation of aging, different systems biology approaches have been employed. A multi-omics data-driven approach can be used to interpret and clarify unknown mechanisms but cannot generate mechanistic regulatory structures alone. In contrast, combining this approach with a mathematical modeling approach can identify the mechanistics of the phenomena of interest. The development of single-cell technologies has also helped clarify the heterogeneity of the NF-κB response and underlying mechanisms. Here, we review advances in the understanding of the regulation of aging by NF-κB by focusing on omics approaches, single-cell analysis, and mathematical modeling of the NF-κB network.
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Affiliation(s)
- Masatoshi Haga
- Laboratory for Cell Systems, Institute for Protein Research, Osaka University, Suita, Osaka 565-0871, Japan
- Basic Research Development Division, ROHTO Pharmaceutical Co., Ltd., Ikuno-ku, Osaka 544-8666, Japan
| | - Mariko Okada
- Laboratory for Cell Systems, Institute for Protein Research, Osaka University, Suita, Osaka 565-0871, Japan
- Center for Drug Design and Research, National Institutes of Biomedical Innovation, Health and Nutrition, Ibaraki, Osaka 567-0085, Japan
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Alsughayyir J, Alshaiddi W, Alsubki R, Alshammary A, Basudan AM, Alfhili MA. Geraniin inhibits whole blood IFN-γ and IL-6 and promotes IL-1β and IL-8, and stimulates calcium-dependent and sucrose-sensitive erythrocyte death. Toxicol Appl Pharmacol 2022; 436:115881. [PMID: 35026210 DOI: 10.1016/j.taap.2022.115881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 12/17/2022]
Abstract
Correlations between circulating cytokine levels and disease states are well established, and pharmacological modulation of the immune response is thus an important aspect of the assessment of investigational new drugs. Moreover, chemotherapy-related anemia is a major obstacle in cancer treatment. Geraniin (GRN), a tannin extracted from Geranium and other plants, possesses promising antitumor potential. However, the effect of GRN on whole blood (WB) cytokine response and RBC physiology remains unexplored. Heparinized blood from consented, healthy adults was challenged with 100 ng/mL of lipopolysaccharide (LPS) with and without pretreatment with 10 μM of GRN for 24 h at 37 °C, and tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-6, IL-8, and IL-10 were assayed by ELISA. Moreover, single-cell RBC suspensions were treated with 5-100 μM of GRN for 24 or 48 h at 37 °C and cytotoxicity and canonical eryptotic markers were examined by flow cytometry. It was revealed that GRN significantly attenuated LPS-induced IFN-γ levels, increased IL-1β, decreased IL-6 only in absence of LPS, and aggravated LPS-induced IL-8 while together with LPS significantly diminished IL-10. Furthermore, GRN induced dose-responsive, Ca2+-dependent, and sucrose-sensitive hemolysis, along with phosphatidylserine exposure and Ca2+ accumulation with no appreciable cell shrinkage or oxidative damage. GRN was also selectively toxic to platelets, significantly delayed reticulocyte maturation, and significantly disrupted leukocyte proportions. In conclusion, GRN regulates the WB cytokine response and promotes premature hemolysis and eryptosis. This study provides insights into the therapeutic utility of GRN in a highly relevant cellular model system.
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Affiliation(s)
- Jawaher Alsughayyir
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia
| | - Wafa Alshaiddi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia
| | - Roua Alsubki
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia
| | - Amal Alshammary
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia
| | - Ahmed M Basudan
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia
| | - Mohammad A Alfhili
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 12372, Saudi Arabia.
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6
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Luo T, Zheng F, Wang K, Xu Y, Xu H, Shen W, Zhu C, Zhang X, Sui W, Tang D, Yin L, Dai Y. A single-cell map for the transcriptomic signatures of peripheral blood mononuclear cells in end-stage renal disease. Nephrol Dial Transplant 2021; 36:599-608. [PMID: 31883338 DOI: 10.1093/ndt/gfz227] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immune aberrations in end-stage renal disease (ESRD) are characterized by systemic inflammation and immune deficiency. The mechanistic understanding of this phenomenon remains limited. METHODS We generated 12 981 and 9578 single-cell transcriptomes of peripheral blood mononuclear cells (PBMCs) that were pooled from 10 healthy volunteers and 10 patients with ESRD by single-cell RNA sequencing. Unsupervised clustering and annotation analyses were performed to cluster and identify cell types. The analysis of hallmark pathway and regulon activity was performed in the main cell types. RESULTS We identified 14 leukocytic clusters that corresponded to six known PBMC types. The comparison of cells from ESRD patients and healthy individuals revealed multiple changes in biological processes. We noticed an ESRD-related increase in inflammation response, complement cascade and cellular metabolism, as well as a strong decrease in activity related to cell cycle progression in relevant cell types in ESRD. Furthermore, a list of cell type-specific candidate transcription factors (TFs) driving the ESRD-associated transcriptome changes was identified. CONCLUSIONS We generated a distinctive, high-resolution map of ESRD-derived PBMCs. These results revealed cell type-specific ESRD-associated pathways and TFs. Notably, the pooled sample analysis limits the generalization of our results. The generation of larger single-cell datasets will complement the current map and drive advances in therapies that manipulate immune cell function in ESRD.
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Affiliation(s)
- Ting Luo
- Institute of Nephrology and Blood Purification, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Fengping Zheng
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Kang Wang
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Yong Xu
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Huixuan Xu
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Wenxi Shen
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Chengxin Zhu
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Xinzhou Zhang
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Weiguo Sui
- Department of Nephrology, Guangxi Key Laboratory of Metabolic Diseases Research, Guilin NO. 924 Hospital, Guilin, China
| | - Donge Tang
- The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
| | - Lianghong Yin
- Institute of Nephrology and Blood Purification, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Yong Dai
- Institute of Nephrology and Blood Purification, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China.,The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
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7
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Satake A, Kobayashi W, Tamura Y, Oyama T, Fukuta H, Inui A, Sawada K, Ihara K, Noguchi T, Murashita K, Nakaji S. Effects of oral environment on frailty: particular relevance of tongue pressure. Clin Interv Aging 2019; 14:1643-1648. [PMID: 31564844 PMCID: PMC6746308 DOI: 10.2147/cia.s212980] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/02/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose Oral frailty or the loss of oral functionality can be a symptomatic precursor of overall frailty. Previous studies have suggested that decreased tongue pressure causes a decline in ingesting and swallowing function and poor nutrition. This study investigated what factor(s) contribute to tongue pressure, thereby leading to frailty. Patients and methods For the purposes of the present study, 467 residents of Hirosaki city in northern Japan aged≥60 years who completed a questionnaire about frailty and underwent an intraoral assessment, which included number of teeth, presence or absence of periodontitis, tongue pressure, and oral diadochokinesis (ODK) were recruited. Results Of the 467 participants with complete data sets, frailty was identified in 13 (7.5%) of 173 males and in 34 (11.6%) of 294 females. Significantly fewer teeth, lower tongue pressure, and a reduced diadochokinetic syllable rate were more prevalent among frail than among healthy residents. Multivariable logistic regression analysis revealed that age, body mass index, number of teeth, and tongue pressure significantly contributed to frailty, whereas ODK did not. Multiple regression analysis showed that tongue pressure was positively associated with muscle index and number of teeth. Conclusion The results of the present study suggest that fewer teeth and lower tongue pressure, but not ODK function, are risk factors for developing overall frailty among older residents.
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Affiliation(s)
- Anna Satake
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Wataru Kobayashi
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshihiro Tamura
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Toshiaki Oyama
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Haruka Fukuta
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Akinari Inui
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kahori Sawada
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kazunari Ihara
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takao Noguchi
- Department of Oral and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Koichi Murashita
- COI Research Initiatives Organization, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shigeyuki Nakaji
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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