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Sadura-Sieklucka T, Szewczyk D, Liberacki P, Paśko S, Wojdasiewicz P, Targowski T. The 4DBODY system as a new tool for chest mobility assessment in patients with ankylosing spondylitis. Reumatologia 2023; 61:353-359. [PMID: 37970113 PMCID: PMC10634404 DOI: 10.5114/reum/173022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/22/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction Ankylosing spondylitis (AS) is a chronic inflammatory, progressive disease, which leads to deterioration of chest and spine mobility and decrease of physical capacity with abnormal chest movement patterns. We aimed to assess the usefulness of the 4DBODY technology for evaluation of the effectiveness of AS treatment. Material and methods The 4DBODY technology was assessed on single AS patient with axial involvement. The patient was examined twice, before and after 14 days of rehabilitation. Physiotherapeutic and plethysmographic examinations were used, as well as angular measurement of spine curvatures and measurement of chest mobility. Chest activity measured using the 4DBODY system and the quality of movement were visualized. Results There was observed an increase of chest mobility from 18 mm to 27.9 mm (up 55%) in the 4DBODY system measurement. The quality of the chest movement also improved, the required phases of inspiration were synchronized. The angular position of the spine has also changed. The chest expansion improved from 25 mm to 50 mm measured on the level of the fourth intercostal space and from 30 mm to 50 mm at the Th10 level. Inspiratory and expiratory muscle strength increased respectively from 80% to 93% and from 46% to 86% of the predicted values. Total airway resistance (Rtot) - increase from 59% to 67%, whereas functional residual capacity (FRC) and total lung capacity (TLC) did not change significantly. Conclusions The new 4DBODY technology was found to be an effective method of examination and assessment of the effectiveness of rehabilitation of patients with AS.
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Affiliation(s)
- Teresa Sadura-Sieklucka
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw, Poland
| | - Daniel Szewczyk
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw, Poland
| | - Paweł Liberacki
- Institute of Micromechanics and Photonics, Warsaw University of Technology, Poland
| | - Sławomir Paśko
- Institute of Micromechanics and Photonics, Warsaw University of Technology, Poland
| | | | - Tomasz Targowski
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw, Poland
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Ibrahim IMH, Alaqel AAH, Ghobashy NE, Azzam AI, Abd El-Mageed MR. Value of HRCT of the chest in evaluation of ankylosing spondylitis: correlation between pleuro-parenchymal abnormalities and disease activity. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00603-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Ankylosing spondylitis (AS) is a chronic inflammatory disorder primarily involving the sacroiliac joints and spine. It is associated with both articular and extra-articular clinical manifestations. Pulmonary involvement is a well-recognized comorbidity of AS, even among patients with early disease. The availability of high-resolution computed tomography (HRCT) has enabled better visualization of the entire lung parenchyma and earlier identification of lung pathologies, ranging from mild to more severe involvement, which were previously missed on X-rays. The aim of the study is to establish the role of HRCT in the detection of pleuro-parenchymal manifestations of AS and to look for correlations between these findings and AS activity.
Results
Lung CT scans were done for all our patients and 27 patients (90%) had positive HRCT thoracic findings, while the remaining 3 patients (10%) had a normal HRCT thoracic study. Lower lobe fibrotic changes were the most common finding seen in 20 patients (66.7%) followed by bronchial wall thickening in 13 patients (43.3%) and upper and lower fibrotic changes seen in 9 patients (30%). HRCT thoracic findings were more prominent in late AS (disease duration ≥ 10 years) (13 of 13 patients); while 14 of 17 patients with early AS (disease duration < 10 years) had mildly abnormal HRCT findings. The result of statistical analysis showed that there was negative correlation between thoracic findings and disease activity assessed by BASDAI and this correlation was insignificant (p value = 0.5).
Conclusion
HRCT offers an accurate and safe method of assessment of lung disease in patients with AS and without respiratory symptoms. Although there was no correlation between pulmonary findings and AS activity assessed by BASDAI, a positive correlation, albeit insignificant, between pulmonary involvement and disease duration had been found.
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Schwendner M, Seule M, Meyer B, Krieg SM. Management of spine fractures in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: a challenge. Neurosurg Focus 2021; 51:E2. [PMID: 34598125 DOI: 10.3171/2021.7.focus21330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ankylosing spinal disorders (ASDs) such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are complex diseases regarding diagnostics, treatment, and patient outcome, especially in trauma. Originating from rigid biomechanics and low bone quality in considerably comorbid patients, serious spinal injury requires thorough and immediate imaging and is frequently missed. The aim of this study was to evaluate patient characteristics as well as procedures in patients with ASD in order to identify the major particularities of treatment. METHODS A total of 60 patients aged 78.5 ± 8.9 years were retrospectively included. Preoperative imaging as well as surgical treatment procedures and postoperative patient outcome were analyzed, including 30-day readmissions. RESULTS CT imaging of the entire spine was performed within 24 hours after the initial trauma in 73.3% of patients. A delay in diagnostics (> 24 hours) occurred in 41.7% of patients transferred from primary care centers. At admission, 25.0% of patients had fracture-related neurological deficits (American Spinal Injury Association [ASIA] grades A and B in 4 patients, and ASIA grades C and D in 11 patients). A spinal epidural hematoma was found in 21.2% of patients and was symptomatic in 72.7% of those patients. Of the patients with fracture-related neurological deficits, 93.3% were operated on within 48 hours from symptom onset. One patient (1.7%) developed neurological deficits from diagnosis to surgery. Postoperatively, 18.3% of patients had surgical complications, and 76.7% of patients developed further medical issues, with pneumonia (38.3%), pulmonary decompensation (25.0%), and cardiac decompensation (20.0%) being the leading causes. The 30-day mortality rate was high at 10.0%. CONCLUSIONS Treatment of patients with ASDs is complex. While surgical outcome is usually good, the multimorbid nature of these patients results in a high rate of major medical complications. If an ankylosing disease is suspected, MRI of the entire spine is mandatory. Upon diagnosis, treatment should be performed in centers capable of managing all aspects of the regular complications these patients will develop.
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Affiliation(s)
- Maximilian Schwendner
- 1Department of Neurosurgery and.,2TUM Neuroimaging Center, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; and
| | - Martin Seule
- 3Department of Neurosurgery, Kantonsspital St. Gallen, Switzerland
| | | | - Sandro M Krieg
- 1Department of Neurosurgery and.,2TUM Neuroimaging Center, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; and
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Ahmed EA, Atar S, Atar Y, Sari H, Anarat MEA, Saltürk Z, Karaketir SG, Uyar Y, Kuru Ö. Evaluation of the Swallowing and Voice Functions in Ankylosing Spondylitis Patients. Dysphagia 2021; 37:455-462. [PMID: 34259915 DOI: 10.1007/s00455-021-10340-1] [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: 12/30/2020] [Accepted: 07/08/2021] [Indexed: 11/26/2022]
Abstract
This study aimed to evaluate the swallowing and voice functions in patients with ankylosing spondylitis. Thirty patients with ankylosing spondylitis (Group 1) and 30 healthy individuals (Group 2) were included in the study. Following the laryngoscopic evaluation of the patients, the fiberoptic endoscopic evaluation of swallowing was performed, and then, the penetration-aspiration score was determined. The participants were asked to fill the eating assessment tool form. Voice recordings obtained to evaluate sound disorders were measured acoustically and analyzed using the PRAAT program. In terms of swallowing, the penetration-aspiration score obtained as a result of the flexible endoscopic swallowing assessment and eating assessment tool score was found to be higher in Group 1 than in Group 2, and a statistically significant difference was noted (p ≤ 0.001). When analyzing the maximum phonation time (p < 0.001) and fundamental frequency (p = 0.408) values in phonation evaluation, a statistically significant difference was found between the two groups. Group 1 showed a deterioration in terms of jitter (p = 0.040) and shimmer (p = 0.007) compared to Group 2, and a statistically significant difference was noted. There was no statistically significant difference in the harmonic/noise ratio (mean ± standard deviation) between the two groups (p = 0.051). Swallowing and voice functions significantly affect quality of life. Therefore, approaches aimed to improve the associated symptoms have become increasingly important. In patients with ankylosing spondylitis, swallowing quality and phonation ability may be negatively affected. These patients should be monitored for hidden or overt food aspiration.Trial Registry: https://clinicaltrials.gov/ct2/show/NCT04437394.
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Affiliation(s)
| | - Sevgi Atar
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Darulaceze Cad. No: 25 Okmeydani-Sisli, Istanbul, Turkey.
| | - Yavuz Atar
- Department of Otorhinolaryngology, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Hüseyin Sari
- Department of Otorhinolaryngology, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Melis Ece Arkan Anarat
- Department of Otorhinolaryngology, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Ziya Saltürk
- Department of Otorhinolaryngology, Anadolu Medical Center, In Affiliation With Johns Hopkins Medicine, Istanbul, Turkey
| | | | - Yavuz Uyar
- Department of Otorhinolaryngology, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Ömer Kuru
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Darulaceze Cad. No: 25 Okmeydani-Sisli, Istanbul, Turkey
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Rapidly Progressive Pulmonary Apical Fibrosis and Parenchymal Destruction in a Patient with Ankylosing Spondylitis. Case Rep Rheumatol 2020; 2020:8852515. [PMID: 33014502 PMCID: PMC7512063 DOI: 10.1155/2020/8852515] [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: 04/29/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] Open
Abstract
Pulmonary apical fibrosis is a rare complication of ankylosing spondylitis (AS). The essential characteristics of this lesion are its very slow progression and frequently asymptomatic nature. Herein, we are presenting a patient with AS who rapidly developed pulmonary apical fibrosis in a 3-year period despite decreased musculoskeletal pains. The 60-year-old male applied with complaints of progressively increasing cough in the recent two years, dyspnea, and fatigue. He had no chronic disease except AS. He had no continuous medication except nonsteroid anti-inflammatory drugs for 2-3 days monthly since his musculoskeletal pains decreased in the recent years. His physical examination revealed reduced breath sounds in the upper zones of the right lung. Chest X-ray revealed increased diffuse opacity in the upper zones of the right lung. Thoracic high-resolution computed tomography showed a consolidation accompanied with traction bronchiectases compatible with chronic fibrosis in the upper lobe of the right lung. However, thoracic computed tomography of the patient performed 3 years ago did not reveal pulmonary apical fibrosis and parenchymal destruction. Biopsy revealed no finding of malignancy, granulomatous inflammation, or vasculitis. The results of cultures were negative. So, the patient was diagnosed as pulmonary involvement of AS, which developed in a 3-year period. This case has shown that extra-articular complications may continue to develop in patients with AS even if their musculoskeletal complaints have subsided. So, patients with AS should be followed up regularly with systemic examinations.
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Imaging of Cardiopulmonary Involvement in Systemic Immune-mediated Diseases: A Comprehensive Review. J Thorac Imaging 2020; 36:W35-W51. [PMID: 32205818 DOI: 10.1097/rti.0000000000000496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic immune-mediated diseases (SID) are a large group of disorders characterized by complex inflammatory and autoimmune damage to various organs and tissues. Among the possible manifestations, SIDs may potentially involve each structure of the cardiopulmonary system. Each disease is characterized by a specific clinical presentation. Coronary artery disease, myocarditis, pericarditis, valvular disease, pulmonary arterial hypertension, and interstitial lung disease represent characteristic findings of cardiopulmonary involvement in these disorders and their prompt recognition is crucial for the diagnosis of SIDs and the patient's prognosis. In this setting, chest high-resolution computed tomography and cardiac magnetic resonance are the most important noninvasive techniques for the assessment of these diseases and their complications. The knowledge of various cardiac and pulmonary radiologic patterns increases the likelihood of diagnosing these disorders and can lead to improved understanding of the underlying pathophysiology to personalize the treatment for each patient.
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Danve A. Thoracic Manifestations of Ankylosing Spondylitis, Inflammatory Bowel Disease, and Relapsing Polychondritis. Clin Chest Med 2019; 40:599-608. [PMID: 31376894 DOI: 10.1016/j.ccm.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ankylosing spondylitis, inflammatory bowel disease (IBD), and relapsing polychondritis are immune-mediated inflammatory diseases with variable involvement of lungs, heart and the chest wall. Ankylosing spondylitis is associated with anterior chest wall pain, restrictive lung disease, obstructive sleep apnea, apical fibrosis, spontaneous pneumothorax, abnormalities of cardiac valves and conduction system, and aortitis. Patients with IBD can develop necrobiotic lung nodules that can be misdiagnosed as malignancy or infection. Relapsing polychondritis involves large airways in at least half of the patients. Relapsing polychondritis can mimic asthma in some patients. Medications used to treat these inflammatory conditions can cause pulmonary complications such as infections, pneumonitis, and rarely serositis.
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Affiliation(s)
- Abhijeet Danve
- Section of Rheumatology, Department of Medicine, Yale School of Medicine, 300 Cedar Street, TACS-525, New Haven, CT 06520-8031, USA.
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Hill AT, Sullivan AL, Chalmers JD, De Soyza A, Elborn SJ, Floto AR, Grillo L, Gruffydd-Jones K, Harvey A, Haworth CS, Hiscocks E, Hurst JR, Johnson C, Kelleher PW, Bedi P, Payne K, Saleh H, Screaton NJ, Smith M, Tunney M, Whitters D, Wilson R, Loebinger MR. British Thoracic Society Guideline for bronchiectasis in adults. Thorax 2019; 74:1-69. [PMID: 30545985 DOI: 10.1136/thoraxjnl-2018-212463] [Citation(s) in RCA: 242] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Adam T Hill
- Respiratory Medicine, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Anita L Sullivan
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust (Queen Elizabeth Hospital), Birmingham, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Anthony De Soyza
- Institute of Cellular Medicine, NIHR Biomedical Research Centre for Aging and Freeman Hospital Adult Bronchiectasis service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Stuart J Elborn
- Royal Brompton Hospital and Imperial College London, and Queens University Belfast
| | - Andres R Floto
- Department of Medicine, University of Cambridge, Cambridge UK.,Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | | | - Alex Harvey
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Peter W Kelleher
- Centre for Immunology and Vaccinology, Chelsea &Westminster Hospital Campus, Department of Medicine, Imperial College London.,Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London.,Chest & Allergy Clinic St Mary's Hospital, Imperial College Healthcare NHS Trust
| | - Pallavi Bedi
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | | | | | | | - Maeve Smith
- University of Alberta, Edmonton, Alberta, Canada
| | - Michael Tunney
- School of Pharmacy, Queens University Belfast, Belfast, UK
| | | | - Robert Wilson
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
| | - Michael R Loebinger
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
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Kurucan E, Bernstein DN, Mesfin A. Surgical management of spinal fractures in ankylosing spondylitis. JOURNAL OF SPINE SURGERY 2018; 4:501-508. [PMID: 30547111 DOI: 10.21037/jss.2018.06.15] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Ankylosing spondylitis (AS) is a rheumatologic condition that affects the axial skeleton. Structural changes render the spine susceptible to fractures, which can be treated operatively or non-operatively. The preferred surgical approach is not well established. The objective of this study is to evaluate trends in the surgical treatment of AS patients with cervical and thoracolumbar spine fractures. Methods Using the nationwide inpatient sample (NIS) database, we identified 961 (4,683 weighted) AS patients from 2003 to 2014 who had fusion surgery for vertebral fractures. Our primary outcome was the national trend in use of posterior (PSF), anterior posterior (APSF), and anterior fusion (ASF) surgeries. In addition, we examined patient demographics, complications, institutional characteristics, and hospitalization lengths and costs. Results The number of fusions performed in AS patients with fractures increased significantly (P<0.01). The proportion of cervical fractures receiving fusions stayed consistent, whereas that of thoracolumbar fractures increased significantly (P<0.01). Patients undergoing APSF had higher hospitalization lengths in cervical and thoracolumbar fractures (P<0.01). There was significant association between pulmonary complications and cervical fusions (P<0.01). Conclusions Surgical treatment has been growing in popularity for thoracolumbar fractures but staying consistent for cervical fractures in AS patients. Surgical approach has shifted for cervical fractures with APSF transitioning from most to least popular approach from 2003 to 2014. For thoracolumbar fractures, PSF has remained the preferred approach. APSF had significantly higher pulmonary complication rates with cervical fractures. This finding can help surgeons in treating fractures in AS patients with underlying pulmonary disease.
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Affiliation(s)
- Etka Kurucan
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - David N Bernstein
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
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Shen TC, Lin CL, Wei CC, Chen CH, Tu CY, Hsia TC, Shih CM, Hsu WH, Sung FC. The risk of asthma in patients with ankylosing spondylitis: a population-based cohort study. PLoS One 2015; 10:e0116608. [PMID: 25658339 PMCID: PMC4320111 DOI: 10.1371/journal.pone.0116608] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/11/2014] [Indexed: 12/17/2022] Open
Abstract
Background The relationship between asthma and ankylosing spondylitis (AS) is controversial. We examined the risk of asthma among AS patients in a nationwide population. Methods We conducted a retrospective cohort study using data from the National Health Insurance (NHI) system of Taiwan. The cohort included 5,974 patients newly diagnosed with AS from 2000 to 2010. The date of diagnosis was defined as the index date. A 4-fold of general population without AS was randomly selected frequency matched by age, gender and the index year. The occurrence and hazard ratio (HR) of asthma were estimated by the end of 2011. Results The overall incidence of asthma was 1.74 folds greater in the AS cohort than in the non-AS cohort (8.26 versus 4.74 per 1000 person-years) with a multivariable Cox method measured adjusted HR of 1.54 (95% confidence interval (CI), 1.34–1.76). The adjusted HR of asthma associated with AS was higher in women (1.59; 95% CI, 1.33–1.90), those aged 50–64 years (1.66; 95% CI, 1.31–2.09), or those without comorbidities (1.82; 95% CI, 1.54–2.13). Conclusion Patients with AS are at a higher risk of developing asthma than the general population, regardless of gender and age. The pathophysiology needs further investigation.
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Affiliation(s)
- Te-Chun Shen
- Graduate Institute of Clinical Medicine Science, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chang-Ching Wei
- Division of Nephrology, Department of Pediatrics, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chia-Hung Chen
- Graduate Institute of Clinical Medicine Science, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
- * E-mail: (F-CS); (C-YT)
| | - Te-Chun Hsia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chuen-Ming Shih
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Fung-Chang Sung
- Graduate Institute of Clinical Medicine Science, College of Medicine, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, China Medical University, Taichung, Taiwan
- * E-mail: (F-CS); (C-YT)
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