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Fukatsu-Chikumoto A, Hirano T, Takahashi S, Ishida T, Yasuda K, Donishi T, Suga K, Doi K, Oishi K, Ohata S, Murata Y, Yamaji Y, Asami-Noyama M, Edakuni N, Kakugawa T, Matsunaga K. Correlation between frailty and reduction in cortical thickness in patients with chronic obstructive pulmonary disease. Sci Rep 2024; 14:6106. [PMID: 38480723 PMCID: PMC10937661 DOI: 10.1038/s41598-024-53933-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 02/06/2024] [Indexed: 03/17/2024] Open
Abstract
Physical inactivity and cognitive impairment in patients with chronic obstructive pulmonary disease (COPD) can lead to frailty and poor prognoses. However, little is known regarding the association between frailty and the human brain. We hypothesized that the brain structure could change according to frailty in patients with COPD and focused on cortical thickness. Cortical thickness measured by magnetic resonance imaging and frailty scores using the Kihon Checklist (KCL) were assessed in 40 patients with stable COPD and 20 healthy controls. Among the 34 regions assessed, multiple regions were thinner in patients with COPD than in healthy individuals (p < 0.05). We found significant negative correlations between the eight regions and the KCL scores only in patients with COPD. After adjusting for age and cognitive impairment, the association between the left and six right regions remained statistically significant. The correlation coefficient was the strongest in the bilateral superior frontal gyrus (left: ρ = - 0.5319, p = 0.0006) (right: ρ = - 0.5361, p = 0.0005). Interestingly, among the KCL scores, the daily activity domain showed the strongest correlation (sensitivity, 90%; specificity, 73%) with the bottom quartile of the reduction in the superior frontal gyrus. Frailty in patients with COPD is associated with a thickness reduction in the cortical regions, reflecting social vulnerability.
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Affiliation(s)
- Ayumi Fukatsu-Chikumoto
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan.
| | - Shun Takahashi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, 565-0871, Japan
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
- Graduate School of Rehabilitation Science, Osaka Metropolitan University, Habikino, 583-8555, Japan
- Clinical Research and Education Center, Asakayama General Hospital, Sakai, 590-0018, Japan
| | - Takuya Ishida
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Kasumi Yasuda
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Tomohiro Donishi
- Department of System Neurophysiology, Wakayama Medical University, Wakayama, 641-0012, Japan
| | - Kazuyoshi Suga
- Department of Radiology, St. Hill Hospital, Ube, 755-0155, Japan
| | - Keiko Doi
- Department of Pulmonology and Gerontology, Graduate School of Medicine, Yamaguchi University, Ube, 755-8505, Japan
| | - Keiji Oishi
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Shuichiro Ohata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Yoriyuki Murata
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
| | - Tomoyuki Kakugawa
- Department of Pulmonology and Gerontology, Graduate School of Medicine, Yamaguchi University, Ube, 755-8505, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
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Iwamoto H, Hirano T, Amano Y, Murakawa K, Fukatsu-Chikumoto A, Yamaji Y, Yamane M, Anabuki K, Otani T, Higaki N, Miyamoto S, Isobe T, Yokoyama A, Matsunaga K, Hattori N. Prospective Real-World Analysis of Asthma Patients With Preserved and Reduced Physical Activity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2792-2800.e2. [PMID: 37178763 DOI: 10.1016/j.jaip.2023.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Asthma is a highly heterogeneous airway disease, and the clinical characteristics of patients with asthma with preserved and reduced physical activity are poorly understood. OBJECTIVE We aimed to investigate the risk factors and clinical phenotypes associated with reduced physical activity in a wide range of patients with asthma. METHODS We conducted a prospective observational study of 138 patients with asthma, including patients with asthma without chronic obstructive pulmonary disease (COPD) (n = 104) and asthma-COPD overlap (n = 34), and 42 healthy controls. Physical activity levels were measured for 2 weeks using a triaxial accelerometer at baseline and 1 year later. RESULTS Higher eosinophils and body mass index (BMI) were associated with reduced physical activity in patients with asthma without COPD. Cluster analysis of asthma without COPD revealed 4 asthma phenotypes. We identified a cluster with preserved physical activity (n = 43) that was characterized by good symptom control and lung function and included a high proportion of biologics users (34.9%). Multivariate regression analysis revealed that patients with late-onset eosinophilic (n = 21), high-BMI noneosinophilic (n = 14), and symptom-predominant asthma phenotypes (n = 26) had lower levels of physical activity than controls. Patients with asthma-COPD overlap also had significantly lower physical activity levels than controls. Similar trends in physical activity levels were observed in each asthma group at 1-year follow-up. CONCLUSION This study showed the clinical features of patients with asthma with preserved and reduced physical activity. Reduced physical activity was observed in various asthma phenotypes and in asthma-COPD overlap.
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Affiliation(s)
- Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Yoshihiro Amano
- Department of Internal Medicine, Division of Medical Oncology & Respiratory Medicine, Shimane University Faculty of Medicine, Shimane, Japan
| | - Keita Murakawa
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Ayumi Fukatsu-Chikumoto
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Mayuka Yamane
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kazuki Anabuki
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Toshihito Otani
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoko Higaki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Isobe
- Department of Internal Medicine, Division of Medical Oncology & Respiratory Medicine, Shimane University Faculty of Medicine, Shimane, Japan
| | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Minakata Y, Azuma Y, Sasaki S, Murakami Y. Objective Measurement of Physical Activity and Sedentary Behavior in Patients with Chronic Obstructive Pulmonary Disease: Points to Keep in Mind during Evaluations. J Clin Med 2023; 12:jcm12093254. [PMID: 37176694 PMCID: PMC10179547 DOI: 10.3390/jcm12093254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Objective measurement methods using accelerometers have become the mainstream approach for evaluating physical activity (PA) and sedentary behavior (SB). However, several problems face the objective evaluation of PA and SB in patients with chronic obstructive pulmonary disease (COPD). For example, indicators of PA differ depending on whether the accelerometer detects the kind of activity on the one hand, or its intensity on the other. Measured data are also strongly influenced by environmental factors (weather, season, employment status, etc.) and methodological factors (days with uncommon activities, non-wearing time, minimum required wearing time per day, minimum number of valid days required, etc.). Therefore, adjusting for these factors is required when evaluating PA or SB, especially when evaluating the effects of intervention. The exclusion of sleeping time, unification of total measurement time, and minimization of the required wearing time per day might be more important for the evaluation of ST than for evaluating PA. The lying-down-time-to-sitting-time ratio was shown to be larger in COPD patients than in healthy subjects. In this review, we clarified the problems encountered during objective evaluations of PA and SB in patients with COPD and encouraged investigators to recognize the presence of these problems and the importance of adjusting for them.
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Affiliation(s)
- Yoshiaki Minakata
- National Hospital Organization Wakayama Hospital, 1138 Wada, Mihama-Cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Yuichiro Azuma
- National Hospital Organization Wakayama Hospital, 1138 Wada, Mihama-Cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Seigo Sasaki
- National Hospital Organization Wakayama Hospital, 1138 Wada, Mihama-Cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Yusuke Murakami
- National Hospital Organization Wakayama Hospital, 1138 Wada, Mihama-Cho, Hidaka-gun, Wakayama 644-0044, Japan
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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MUZ G, ERAT A, ŞAMDANLI Ş, YAVUZER N. Kronik obstrüktif akciğer hastalığı tanısı almış bireylerin integratif yöntemleri kullanma durumu ve umutsuzluk düzeyleri ile ilişkisi. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.742875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Minakata Y, Sasaki S. Data Reproducibility and Effectiveness of Bronchodilators for Improving Physical Activity in COPD Patients. J Clin Med 2020; 9:jcm9113497. [PMID: 33138116 PMCID: PMC7692282 DOI: 10.3390/jcm9113497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/24/2020] [Accepted: 10/27/2020] [Indexed: 11/16/2022] Open
Abstract
Increasing physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) is an important issue, however, the effect of bronchodilators on PA is still controversial. The indicators of PA, as measured by an accelerometer, can easily fluctuate based on several factors, which might cause inconsistent results. In this review, we listed the indicators of PA and the factors influencing the reproducibility of indicators of PA, and reviewed reports in which the effects of bronchodilators on PA were evaluated by an accelerometer. Then, we investigated the association between the processing of influencing factors and the effectiveness of bronchodilators for improving the PA of COPD patients. Fifteen reports were extracted using the PubMed database. In all seven reports in which adjustment was performed for at least two of four influencing factors (non-wear time, data from days with special behavior, environmental factors, and number of valid days required to obtain reproducible data), bronchodilators showed beneficial effects on PA. No adjustment was made for any of these factors in any of the four bronchodilator-ineffective reports. This suggests that the processing of influencing factors to secure reproducibility might affect the results regarding the effectiveness of bronchodilators for improving PA in COPD patients.
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Matsunaga K, Harada M, Suizu J, Oishi K, Asami-Noyama M, Hirano T. Comorbid Conditions in Chronic Obstructive Pulmonary Disease: Potential Therapeutic Targets for Unmet Needs. J Clin Med 2020; 9:E3078. [PMID: 32987778 PMCID: PMC7598716 DOI: 10.3390/jcm9103078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/18/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022] Open
Abstract
The management of chronic obstructive pulmonary disease (COPD) has improved significantly due to advances in therapeutic agents, but it has also become apparent that there are issues that remain difficult to solve with the current treatment algorithm. COPD patients face a number of unmet needs concerning symptoms, exacerbations, and physical inactivity. There are various risk factors and triggers for these unmet needs, which can be roughly divided into two categories. One is the usual clinical characteristics for COPD patients, and the other is specific clinical characteristics in patients with comorbid conditions, such as asthma, cardiovascular disease, and bronchiectasis. These comorbidities, which are also associated with the diversity of COPD, can cause unmet needs resistance to usual care. However, treatable conditions that are not recognized as therapeutic targets may be latent in patients with COPD. We again realized that treatable traits should be assessed and treated as early as possible. In this article, we categorize potential therapeutic targets from the viewpoint of pulmonary and systemic comorbid conditions, and address recent data concerning the pathophysiological link with COPD and the impact of intervention on comorbid conditions in order to obtain evidence that could enable us to provide personalized COPD management.
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Affiliation(s)
- Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Misa Harada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Junki Suizu
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan;
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube 755-8505, Japan; (M.H.); (J.S.); (M.A.-N.); (T.H.)
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Smith PJ, Frankel CW, Bacon DR, Bush E, Mentz RJ, Snyder LD. Depressive symptoms, physical activity, and clinical events: The ADAPT prospective pilot study. Clin Transplant 2019; 33:e13710. [DOI: 10.1111/ctr.13710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences Duke University Medical Center Durham NC
- Department of Medicine Duke University Medical Center Durham NC
- Duke Clinical Research Institute Durham NC
| | | | - Daniel R. Bacon
- Department of Medicine Duke University Medical Center Durham NC
| | - Erika Bush
- Department of Medicine Duke University Medical Center Durham NC
| | - Robert J. Mentz
- Department of Medicine Duke University Medical Center Durham NC
- Duke Clinical Research Institute Durham NC
| | - Laurie D. Snyder
- Department of Medicine Duke University Medical Center Durham NC
- Duke Clinical Research Institute Durham NC
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Nakanishi M, Minakata Y, Tanaka R, Sugiura H, Kuroda H, Yoshida M, Yamamoto N. Simple standard equation for daily step count in Japanese patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2019; 14:1967-1977. [PMID: 31564845 PMCID: PMC6724423 DOI: 10.2147/copd.s218705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/05/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose The improvement of physical activity in patients with COPD is an important issue. However, no standard for the recommended number of steps for patients with COPD has been determined. We conducted a retrospective observational study to create a simple standard equation for the daily step count, which makes it easier to determine whether each subject is attaining his/her predicted value or not. Patients and methods Stable outpatients diagnosed with COPD whose physical activities had been measured using a triaxial accelerometer for more than 2 weeks were recruited from 5 institutes in Japan. Factors associated with the step count were detected by multivariate regression analysis. After the data were transformed to a normalized distribution, a multivariate linear regression equation was created using stepwise regression. Results One hundred sixty-two patients aged 72.3 (7.2) years and of FEV1 %pred 59.2 (22.8) % were recruited. Among the parameters, age, mMRC dyspnea scale and inspiratory capacity (IC) were detected by the stepwise method. The created standard equation was “Step count = (−0.079×[age]−1.595×[mMRC]+2.078×[IC]+18.149)3”. The correlations between the calculated values and the measured values were observed, and fixed, and proportional biases between them were also observed. When patients with <6500 steps/day were selected, no systematic bias between them could be detected. Conclusion A simple standard equation for Japanese patients with COPD was created using age, mMRC and IC, and could provide an individual-predicted value, especially for patients with <6500 steps/day.
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Affiliation(s)
- Masanori Nakanishi
- Third Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiaki Minakata
- Department of Respiratory Medicine, National Hospital Organization Wakayama Hospital, Wakayama, Japan
| | - Rie Tanaka
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hikaru Kuroda
- Department of Respiratory Medicine, National Hospital Organization Asahikawa Medical Center, Asahikawa, Hokkaido, Japan
| | - Makoto Yoshida
- Department of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, Fukuoka, Japan
| | - Nobuyuki Yamamoto
- Third Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Minakata Y, Motegi T, Ueki J, Gon Y, Nakamura S, Anzai T, Hirata K, Ichinose M. Effect of tiotropium/olodaterol on sedentary and active time in patients with COPD: post hoc analysis of the VESUTO ® study. Int J Chron Obstruct Pulmon Dis 2019; 14:1789-1801. [PMID: 31496678 PMCID: PMC6689763 DOI: 10.2147/copd.s208081] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/10/2019] [Indexed: 12/31/2022] Open
Abstract
Background Patients with COPD are less physically active. This post hoc analysis of a randomized, double-blind, active-controlled, crossover trial assessed the efficacy of once-daily tiotropium/olodaterol combination therapy versus tiotropium monotherapy in Japanese patients with COPD. Patients and methods Patients were provided with a three-axis accelerometer to measure sedentary and active behavior defined as 1.0-1.5 metabolic equivalents (METs), ≥2.0 METs, and ≥3.0 METs, respectively. Of the 182 patients enrolled, 131 satisfied the conditions for the present analysis and were randomized to tiotropium monotherapy (n=62) or tiotropium/olodaterol combination therapy (n=69). Results Tiotropium/olodaterol combination therapy significantly reduced the duration of 1.0-1.5 MET activity by 8.64 mins (p=0.040) and significantly increased the duration of ≥2.0 MET and ≥3.0 MET activity by 6.51 mins (p=0.017) and 2.60 mins (p=0.008), respectively, compared with tiotropium alone. Subgroup analyses showed that better lung function, milder dyspnea, and higher levels of physical activity at baseline were associated with reduced sedentary time and increased duration of physical activity. Conclusion Tiotropium/olodaterol combination therapy significantly reduced sedentary time and improved physical activity compared with tiotropium monotherapy. This trial was registered in ClinicalTrials.gov (NCT02629965).
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Affiliation(s)
- Yoshiaki Minakata
- Department of Respiratory Medicine, National Hospital Organization Wakayama Hospital, Wakayama, Japan
| | - Takashi Motegi
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Jun Ueki
- Clinical Research Unit of Respiratory Pathophysiology, Juntendo University Graduate School of Health Care and Nursing, Chiba, Japan
| | - Yasuhiro Gon
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shuhei Nakamura
- Medical Division, Nippon Boehringer Ingelheim Co. Ltd., Tokyo, Japan
| | - Tatsuhiko Anzai
- Clinical Information Division Data Science Center, Statistics Analysis Department 1, EPS Corporation, Tokyo, Japan
| | - Kazuto Hirata
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Hirano T, Matsunaga K, Hamada K, Uehara S, Suetake R, Yamaji Y, Oishi K, Asami M, Edakuni N, Ogawa H, Ichinose M. Combination of assist use of short-acting beta-2 agonists inhalation and guidance based on patient-specific restrictions in daily behavior: Impact on physical activity of Japanese patients with chronic obstructive pulmonary disease. Respir Investig 2019; 57:133-139. [PMID: 30612948 DOI: 10.1016/j.resinv.2018.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/26/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Assist use of inhaled short-acting beta 2 agonists (SABAs) is reportedly effective for preventing shortness of breath on exertion in chronic obstructive pulmonary disease (COPD) patients. However, it is unclear what strategy would be useful for improving physical activity in such patients. The aim is to investigate the effects of assisted use of SABA (procaterol) on physical activity in Japanese COPD patients targeting patient-specific restrictions in daily behavior. METHODS Fourteen patients with stable COPD (age: 72.1±1.5, %FEV1: 55.6±4.5%) were asked to inhale 20 μg of procaterol 15 minutes before patient-specific daily physical activity that had been identified as limited by a questionnaire and document their usage in a diary. Physical activity was measured using a triaxial accelerometer and the results were collected every month for 2 months. In the first month, a clinician assessed whether inhalation of SABA was appropriate based on a usage diary and coached patients to conduct adequate assist use of SABA for limited physical activity. RESULTS The strategy significantly improved the physical activity level, assessed using the values of the metabolic equivalents (METs) multiplied by physical activity endurance, at ≥3.0 METs (p<0.05), and physical activity endurance at ≥2.5 and ≥3.0 METs, (p<0.05, p<0.05, respectively). The degree of improvement of physical activity level was significantly positively correlated with the baseline %FVC and %FEV1 (p<0.05, p<0.05, respectively). CONCLUSIONS Assist use of SABA targeting patient-specific restrictions, particularly when better lung function is still preserved, could be a useful approach for improving physical activity in patients with COPD.
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Affiliation(s)
- Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan.
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Kazuki Hamada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Sho Uehara
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Ryo Suetake
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Japan
| | - Maki Asami
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Hiromasa Ogawa
- Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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12
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Oishi K, Hirano T, Hamada K, Uehara S, Suetake R, Yamaji Y, Ito K, Asami-Noyama M, Edakuni N, Matsunaga K. Characteristics of 2017 GOLD COPD group A: a multicenter cross-sectional CAP study in Japan. Int J Chron Obstruct Pulmon Dis 2018; 13:3901-3907. [PMID: 30584291 PMCID: PMC6287652 DOI: 10.2147/copd.s181938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The 2017 GOLD ABCD classification shifts patients from groups C-D to A-B. Group A was the most widely distributed group in several studies. It would be useful to understand the characteristics for group A patients, but little has been reported concerning these issues. PATIENTS AND METHODS This was a multicenter cross-sectional study using the COPD Assessment in Practice study database from 15 primary or secondary care facilities in Japan. We investigated the clinical characteristics of group A by stratification according to a mMRC grade 0 or 1. RESULTS In 1,168 COPD patients, group A patients accounted for approximately half of the patients. Compared with the groups B-D, group A was younger and had a higher proportion of males, higher pulmonary function, and higher proportion of monotherapy with long-acting muscarinic antagonist or long-acting β-agonist. The prevalence of mMRC grade 1 patients was about two-thirds of group A. Compared with the mMRC 0 patients, mMRC 1 patients showed a tendency to have a higher proportion of exacerbations (P=0.054) and had a significantly lower pulmonary function. Regardless of the mMRC grade, 60% of group A patients were treated with monotherapy of long-acting muscarinic antagonist or long-acting β-agonist. CONCLUSION Group A patients accounted for approximately half of the patients, and they were younger, had higher pulmonary function, and had lower pharmacotherapy intensity compared with groups B-D. By stratifying according to the mMRC grade 0 or 1 in group A patients, there were differences in the exacerbation risk and airflow limitation.
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Affiliation(s)
- Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan,
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Kazuki Hamada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Sho Uehara
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Ryo Suetake
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Kosuke Ito
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
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13
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Shioya T, Sato S, Iwakura M, Takahashi H, Terui Y, Uemura S, Satake M. Improvement of physical activity in chronic obstructive pulmonary disease by pulmonary rehabilitation and pharmacological treatment. Respir Investig 2018; 56:292-306. [PMID: 29903607 DOI: 10.1016/j.resinv.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 04/24/2018] [Accepted: 05/02/2018] [Indexed: 10/14/2022]
Abstract
Physical activity (PA) is defined as bodily movement produced by skeletal muscles with energy expenditure beyond resting levels. PA is closely related to reduced morbidity and mortality in chronic obstructive pulmonary disease (COPD). Self-report questionnaires are often subject to recall bias, correlating poorly with objectively qualified PA, and do not provide an accurate estimate of free-living energy expenditure. PA may be objectively evaluated by newly developed tri-axial accelerometers by quantifying steps or body movements over a period of time. Low-intensity, home-based pulmonary rehabilitation (PR) using pedometer feedback improves PA. Improvement in physiological factors correlates with increased walking time in stable elderly COPD patients. This review focuses on the effects of PR and pharmacological treatment on PA in COPD patients. We selected 32 studies from our literature search evaluating the effects of PR and 11 studies examining the effects of pharmacological treatment on PA. Findings in both categories were inconsistent. Nineteen studies showed a positive effect with PR whereas 13 showed no effect. Eight studies showed a positive effect, while three revealed no effect from pharmacological intervention. As both interventions increase exercise capacity without a consistent effect on PA, counseling with behavioral changes may be necessary to achieve a significant and lasting increase in PA. Changing PA behavior in COPD patients requires an interdisciplinary approach involving specialists in respiratory medicine, rehabilitation, social, and behavioral sciences. Future research in this area is warranted to advance our knowledge in this area, specifically with regard to the interaction of pharmacological and non-pharmacological interventions.
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Affiliation(s)
- Takanobu Shioya
- Akita University Graduate School of Health Sciences, Department of Physical Therapy, Akita, Japan.
| | - Susumu Sato
- Kyoto University Hospital, Department of Rehabilitation & Pulmonary Medicine, Kyoto, Japan.
| | - Masahiro Iwakura
- Akita University Graduate School of Health Sciences, Department of Physical Therapy, Akita, Japan; Akita City General Hospital, Department of Rehabilitation, Akita, Japan.
| | - Hitomi Takahashi
- Akita City General Hospital, Department of Rehabilitation, Akita, Japan.
| | - Yoshino Terui
- Akita University Graduate School of Health Sciences, Department of Physical Therapy, Akita, Japan.
| | - Sachiko Uemura
- Akita University Graduate School of Health Sciences, Department of Physical Therapy, Akita, Japan.
| | - Masahiro Satake
- Akita University Graduate School of Health Sciences, Department of Physical Therapy, Akita, Japan.
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14
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Miyamoto S, Minakata Y, Azuma Y, Kawabe K, Ono H, Yanagimoto R, Suruda T. Verification of a Motion Sensor for Evaluating Physical Activity in COPD Patients. Can Respir J 2018; 2018:8343705. [PMID: 29849834 PMCID: PMC5937578 DOI: 10.1155/2018/8343705] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/06/2018] [Accepted: 03/20/2018] [Indexed: 11/17/2022] Open
Abstract
Background Objective evaluation of the physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) is important. We validated a triaxial accelerometer, Active Style Pro HJA-750C® (HJA), and evaluated the necessary conditions for obtaining reproducible data. Methods The PA measured by HJA was compared with that measured by two already validated accelerometers in 11 patients with COPD (age: 76.6 ± 6.9, FEV1% predicted: 57.6 ± 18.6). Then, the influence of weather and holidays on the PA and the required number of days to obtain repeatability were examined in 21 patients with COPD (age: 73.0 ± 8.0, FEV1% predicted: 58.7 ± 19.0). Results The PA values measured by HJA and those by DynaPort Move Monitor® (DMM) or Actimarker® (AM) were significantly correlated at all intensities (p=0.024 at ≥4.0 METs by DMM and p < 0.0001 at the rest) except at ≥4.0 METs by AM, though the values measured by HJA were higher than those by AM which was reported to underestimate PA. The durations of PA on rainy days were significantly shorter than those on nonrainy days, but those on holidays were not different from those on weekdays. The values of ICC for 3, 4, or 5 days were higher than 0.8 at all intensities. The PA measured by HJA was correlated with the dyspnea scale FVC and age and tended to correlate with FEV1. Conclusions The HJA was validated for evaluating the PA in patients with COPD. This trial is registered with UMIN000016363.
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Affiliation(s)
- Seiko Miyamoto
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Yoshiaki Minakata
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Yuichiro Azuma
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Kazumi Kawabe
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Hideya Ono
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Ryuta Yanagimoto
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
| | - Tadatoshi Suruda
- Department of Clinical Laboratory, National Hospital Organization Wakayama Hospital, 1138 Wada Mihama-cho, Hidaka-gun, Wakayama 644-0044, Japan
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15
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Yoshimura K, Sato S, Muro S, Yamada M, Hasegawa K, Kiyokawa H, Mishima M, Aoyama T. Interdependence of physical inactivity, loss of muscle mass and low dietary intake: Extrapulmonary manifestations in older chronic obstructive pulmonary disease patients. Geriatr Gerontol Int 2017; 18:88-94. [PMID: 28776926 DOI: 10.1111/ggi.13146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/19/2017] [Accepted: 06/27/2017] [Indexed: 11/26/2022]
Abstract
AIM Extrapulmonary manifestations, such as reductions in skeletal muscle and physical inactivity, are important clinical features of patients with chronic obstructive pulmonary disease (COPD), and might depend on the severity of COPD. As it is still unclear whether the relationship between muscle loss and physical inactivity is dominated by a disease-specific relationship or caused by patient factors, including physiological aging, we aimed to investigate the pulmonary or extrapulmonary factors associated with physical inactivity among older COPD patients. METHODS A total of 38 older male COPD patients (aged ≥65 years) were enrolled, and were evaluated cross-sectionally. Skeletal muscle mass was measured using bioelectrical impedance, and physical activity and energy intake were recorded for 2 weeks using a pedometer and diary. RESULTS Daily step counts were successfully evaluated in 28 participants (mean forced expiratory volume in 1 s [%predicted; %FEV1 ]; 49.5%), and ranged widely. The mean step counts was 5166 steps/day, and found to have a significant relationship with dyspnea (r = -0.46), diffusing capacity (r = 0.47), %FEV1 (r = 0.44), skeletal muscle index (r = 0.59) and total dietary intake (r = 0.47), but not with age (P = 0.14). A stepwise multivariate analysis showed that the skeletal muscle index (β = 0.50) and total dietary intake (β = 0.35) were significant determinants of the daily step count (R2 = 0.46, p < 0.01). CONCLUSIONS Although various pulmonary factors are associated with daily physical activity, skeletal muscle mass and dietary intake are more closely correlated with physical activity in COPD patients. Because physical inactivity might be the strongest predictor of prognosis, the present results suggest that a comprehensive treatment strategy must be considered for older COPD patients to improve their extrapulmonary manifestations and pulmonary dysfunction. Geriatr Gerontol Int 2018; 18: 88-94.
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Affiliation(s)
- Kazuya Yoshimura
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Sato
- Rehabilitation Unit, Kyoto University Hospital, Kyoto, Japan.,Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Minoru Yamada
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichi Hasegawa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hirofumi Kiyokawa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoki Aoyama
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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16
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Clarke CL, Witham MD. The Effects of Medication on Activity and Rehabilitation of Older People – Opportunities and Risks. Rehabil Process Outcome 2017. [DOI: 10.1177/1179572717711433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Multiple medication use, or polypharmacy, is common in people undergoing rehabilitation. Polypharmacy is also common in older people, where it has the potential to impact on habitual physical activity. Despite this, the interactions between medication, disease, activity, and rehabilitation outcomes are insufficiently researched. In this review, we consider common classes of medications that can affect physical activity levels and outcomes of rehabilitation. We consider medications that improve disease processes and improve limiting symptoms (eg, breathlessness in heart failure and lung disease, pain in arthritis), unwanted side effects of medications (eg, central slowing caused by opioids and hypnotics), and also medication classes that might have the ability to improve activity and rehabilitation outcomes via beneficial effects on neuromuscular function (eg, angiotensin-converting enzyme inhibitors). We conclude by giving practical advice on how to review and optimise medication use to support habitual physical activity and ensure the best results from rehabilitation.
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Affiliation(s)
- Clare L Clarke
- Section of Ageing and Health, University of Dundee, Dundee, UK
| | - Miles D Witham
- Section of Ageing and Health, University of Dundee, Dundee, UK
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17
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Hayata A, Minakata Y, Matsunaga K, Nakanishi M, Yamamoto N. Differences in physical activity according to mMRC grade in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:2203-2208. [PMID: 27695306 PMCID: PMC5028078 DOI: 10.2147/copd.s109694] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Physical activity (PA) is impaired from the early stages of COPD, is associated with a worsening of disease prognosis, and causes COPD patients to restrict their daily activities in order to avoid breathlessness. The development of a simple tool to estimate physical activity level (PAL) could be useful for the management of COPD. OBJECTIVES We investigated the differences in PA according to the modified Medical Research Council (mMRC) grade in patients with COPD. METHODS A cross-sectional study was performed on stable outpatients with COPD. PA was measured for 2 weeks using a triaxial accelerometer, and dyspnea grade was evaluated in all patients using the mMRC scale. RESULTS Ninety-eight patients were recruited. Significant differences in PA duration were observed at all intensities according to the mMRC grade. Despite treatment with controller medications, 59.2% of COPD patients had low PAL, which was <1.5 metabolic equivalents multiplied by hour per day. COPD patients with an mMRC grade ≥2, which was the most balanced cutoff point in the receiver operating characteristic curve, showed a higher reduction rate of PAL (80.0% at mMRC grade 2, 71.4% at mMRC grade 3, and 100% at mMRC grade 4). CONCLUSION PA differed according to the mMRC grade, and mMRC grade ≥2 could predict a low PAL. Therefore, assessment of breathlessness by the mMRC questionnaire would be useful to stratify the risks of reduced PA in COPD.
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Affiliation(s)
- Atsushi Hayata
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, Wakayama
| | - Yoshiaki Minakata
- Department of Respiratory Medicine, National Hospital Organization Wakayama Hospital, Wakayama
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Masanori Nakanishi
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, Wakayama
| | - Nobuyuki Yamamoto
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, Wakayama
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