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Mukai K, Ohmura H, Takahashi Y, Ebisuda Y, Yoneda K, Miyata H. Physiological and skeletal muscle responses to high-intensity interval exercise in Thoroughbred horses. Front Vet Sci 2023; 10:1241266. [PMID: 38026631 PMCID: PMC10679931 DOI: 10.3389/fvets.2023.1241266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The purpose of this study was to determine whether acute high-intensity interval exercise or sprint interval exercise induces greater physiological and skeletal muscle responses compared to moderate-intensity continuous exercise in horses. Methods In a randomized crossover design, eight trained Thoroughbred horses performed three treadmill exercise protocols consisting of moderate-intensity continuous exercise (6 min at 70% VO2max; MICT), high-intensity interval exercise (6 × 30 s at 100% VO2max; HIIT), and sprint interval exercise (6 × 15 s at 120% VO2max; SIT). Arterial blood samples were collected to measure blood gas variables and plasma lactate concentration. Biopsy samples were obtained from the gluteus medius muscle before, immediately after, 4 h, and 24 h after exercise for biochemical analysis, western blotting and real-time RT-PCR. Effects of time and exercise protocol were analyzed using mixed models (p < 0.05). Results Heart rate and plasma lactate concentration at the end of exercise were higher in HIIT and SIT than those in MICT (heart rate, HIIT vs. MICT, p = 0.0005; SIT vs. MICT, p = 0.0015; lactate, HIIT vs. MICT, p = 0.0014; SIT vs. MICT, p = 0.0003). Arterial O2 saturation and arterial pH in HIIT and SIT were lower compared with MICT (SaO2, HIIT vs. MICT, p = 0.0035; SIT vs. MICT, p = 0.0265; pH, HIIT vs. MICT, p = 0.0011; SIT vs. MICT, p = 0.0023). Muscle glycogen content decreased significantly in HIIT (p = 0.0004) and SIT (p = 0.0016) immediately after exercise, but not in MICT (p = 0.19). Phosphorylation of AMP-activated protein kinase (AMPK) in HIIT showed a significant increase immediately after exercise (p = 0.014), but the increase was not significant in MICT (p = 0.13) and SIT (p = 0.39). At 4 h after exercise, peroxisome proliferator-activated receptor γ co-activator-1α mRNA increased in HIIT (p = 0.0027) and SIT (p = 0.0019) and vascular endothelial growth factor mRNA increased in SIT (p = 0.0002). Discussion Despite an equal run distance, HIIT and SIT cause more severe arterial hypoxemia and lactic acidosis compared with MICT. In addition, HIIT activates the AMPK signaling cascade, and HIIT and SIT elevate mitochondrial biogenesis and angiogenesis, whereas MICT did not induce any significant changes to these signaling pathways.
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Affiliation(s)
- Kazutaka Mukai
- Sports Science Division, Equine Research Institute, Japan Racing Association, Shimotsuke, Japan
| | - Hajime Ohmura
- Sports Science Division, Equine Research Institute, Japan Racing Association, Shimotsuke, Japan
| | - Yuji Takahashi
- Sports Science Division, Equine Research Institute, Japan Racing Association, Shimotsuke, Japan
| | - Yusaku Ebisuda
- Sports Science Division, Equine Research Institute, Japan Racing Association, Shimotsuke, Japan
| | - Koki Yoneda
- Biological Sciences, Graduate School of Sciences and Technology for Innovation, Yamaguchi University, Yamaguchi, Japan
| | - Hirofumi Miyata
- Biological Sciences, Graduate School of Sciences and Technology for Innovation, Yamaguchi University, Yamaguchi, Japan
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Orsi JB, Araujo LS, Scariot PPM, Polisel EEC, Cardoso LO, Gobatto CA, Manchado-Gobatto FB. Critical Velocity, Maximal Lactate Steady State, and Muscle MCT1 and MCT4 after Exhaustive Running in Mice. Int J Mol Sci 2023; 24:15753. [PMID: 37958736 PMCID: PMC10648804 DOI: 10.3390/ijms242115753] [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: 08/22/2023] [Revised: 09/30/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023] Open
Abstract
Although the critical velocity (CV) protocol has been used to determine the aerobic capacity in rodents, there is a lack of studies that compare CV with maximal lactate steady state intensity (iMLSS) in mice. As a consequence, their physiological and molecular responses after exercise until exhaustion at CV intensity remain unclear. Thus, we aimed to compare and correlate CV with iMLSS in running mice, following different mathematical models for CV estimation. We also evaluated their physiological responses and muscle MCT1 and MCT4 after running until exhaustion at CV. Thirty C57BL/6J mice were divided into two groups (exercised-E and control-C). Group E was submitted to a CV protocol (4 days), using linear (lin1 and lin2) and hyperbolic (hyp) mathematical models to determine the distance, velocity, and time to exhaustion (tlim) of each predictive CV trial, followed by an MLSS protocol. After a running effort until exhaustion at CV intensity, the mice were immediately euthanized, while group C was euthanized at rest. No differences were observed between iMLSS (21.1 ± 1.1 m.min-1) and CV estimated by lin1 (21.0 ± 0.9 m.min-1, p = 0.415), lin2 (21.3 ± 0.9 m.min-1, p = 0.209), and hyp (20.6 ± 0.9 m.min-1, p = 0.914). According to the results, CV was significantly correlated with iMLSS. After running until exhaustion at CV (tlim = 28.4 ± 8,29 min), group E showed lower concentrations of hepatic and gluteal glycogen than group C, but no difference in the content of MCT1 (p = 0.933) and MCT4 (p = 0.123) in soleus muscle. Significant correlations were not found between MCT1 and MCT4 and tlim at CV intensity. Our results reinforce that CV is a valid and non-invasive protocol to estimate the maximal aerobic capacity in mice and that the content of MCT1 and MCT4 was not decisive in determining the tlim at CV, at least when measured immediately after the running effort.
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Affiliation(s)
- Juan B Orsi
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Lara S Araujo
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Pedro P M Scariot
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Emanuel E C Polisel
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Luisa O Cardoso
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Claudio A Gobatto
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
| | - Fúlvia B Manchado-Gobatto
- Laboratory of Applied Sport Physiology, School of Applied Sciences, University of Campinas, Pedro Zaccaria Street, 1.300, Jardim Santa Luíza, Limeira 13484-350, São Paulo, Brazil
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Denham J, McCluskey M, Denham MM, Sellami M, Davie AJ. Epigenetic control of exercise adaptations in the equine athlete: Current evidence and future directions. Equine Vet J 2020; 53:431-450. [PMID: 32671871 DOI: 10.1111/evj.13320] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 12/11/2022]
Abstract
Horses (Equus ferus caballus) have evolved over the past 300 years in response to man-made selection for particular athletic traits. Some of the selected traits were selected based on the size and horses' muscular power (eg Clydesdales), whereas other breeds were bred for peak running performance (eg Thoroughbred and Arabian). Although the physiological changes and some of the cellular adaptations responsible for athletic potential of horses have been identified, the molecular mechanisms are only just beginning to be comprehensively investigated. The purpose of this review was to outline and discuss the current understanding of the molecular mechanisms underpinning the athletic performance and cardiorespiratory fitness in athletic breeds of horses. A brief review of the biology of epigenetics is provided, including discussion on DNA methylation, histone modifications and small RNAs, followed by a summary and critical review of the current work on the exercise-induced epigenetic and transcriptional changes in horses. Important unanswered questions and currently unexplored areas that deserve attention are highlighted. Finally, a rationale for the analysis of epigenetic modifications in the context with exercise-related traits and ailments associated with athletic breeds of horses is outlined in order to help guide future research.
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Affiliation(s)
- Joshua Denham
- RMIT University, School of Health and Biomedical Sciences, Melbourne, VIC, Australia
| | | | | | - Maha Sellami
- Qatar University, College of Arts and Sciences (CAS), Sport Science Program (SSP), Doha, Qatar
| | - Allan J Davie
- Australian Equine Racing and Research Centre (AERR), Ballina, NSW, Australia
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Tougaard RS, Szocska Hansen ES, Laustsen C, Nørlinger TS, Mikkelsen E, Lindhardt J, Nielsen PM, Bertelsen LB, Schroeder M, Bøtker HE, Kim WY, Wiggers H, Stødkilde-Jørgensen H. Hyperpolarized [1- 13 C]pyruvate MRI can image the metabolic shift in cardiac metabolism between the fasted and fed state in a porcine model. Magn Reson Med 2018; 81:2655-2665. [PMID: 30387898 DOI: 10.1002/mrm.27560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/20/2018] [Accepted: 09/14/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE Owing to its noninvasive nature, hyperpolarized MRI may improve delineation of myocardial metabolic derangement in heart disease. However, consistency may depend on the changeable nature of cardiac metabolism in relation to whole-body metabolic state. This study investigates the impact of feeding status on cardiac hyperpolarized MRI in a large animal model resembling human physiology. METHODS Thirteen 30-kg pigs were subjected to an overnight fast, and 5 pigs were fed a carbohydrate-rich meal on the morning of the experiments. Vital parameters and blood samples were registered. All pigs were then scanned by hyperpolarized [1-13 C]pyruvate cardiac MRI, and results were compared between the 2 groups and correlated with circulating substrates and hormones. RESULTS The fed group had higher blood glucose concentration and mean arterial pressure than the fasted group. Plasma concentrations of free fatty acids (FFAs) were decreased in the fed group, whereas plasma insulin concentrations were similar between groups. Hyperpolarized MRI showed that fed animals had increased lactate/pyruvate, alanine/pyruvate, and bicarbonate/pyruvate ratios. Metabolic ratios correlated negatively with FFA levels. CONCLUSION Hyperpolarized MR can identify the effects of different metabolic states on cardiac metabolism in a large animal model. Unlike previous rodent studies, all metabolic derivatives of pyruvate increased in the myocardium of fed pigs. Carbohydrate-rich feeding seems to be a feasible model for standardized, large animal hyperpolarized MRI studies of myocardial carbohydrate metabolism.
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Affiliation(s)
- Rasmus Stilling Tougaard
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Esben Søvsø Szocska Hansen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | - Christoffer Laustsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Emmeli Mikkelsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jakob Lindhardt
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Per Mose Nielsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lotte Bonde Bertelsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marie Schroeder
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Won Yong Kim
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Rosenstein PG, Tennent-Brown BS, Hughes D. Clinical use of plasma lactate concentration. Part 1: Physiology, pathophysiology, and measurement. J Vet Emerg Crit Care (San Antonio) 2018. [PMID: 29533512 DOI: 10.1111/vec.12708] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the current literature with respect to the physiology, pathophysiology, and measurement of lactate. DATA SOURCES Data were sourced from veterinary and human clinical trials, retrospective studies, experimental studies, and review articles. Articles were retrieved without date restrictions and were sourced primarily via PubMed, Scopus, and CAB Abstracts as well as by manual selection. HUMAN AND VETERINARY DATA SYNTHESIS Lactate is an important energy storage molecule, the production of which preserves cellular energy production and mitigates the acidosis from ATP hydrolysis. Although the most common cause of hyperlactatemia is inadequate tissue oxygen delivery, hyperlactatemia can, and does occur in the face of apparently adequate oxygen supply. At a cellular level, the pathogenesis of hyperlactatemia varies widely depending on the underlying cause. Microcirculatory dysfunction, mitochondrial dysfunction, and epinephrine-mediated stimulation of Na+ -K+ -ATPase pumps are likely important contributors to hyperlactatemia in critically ill patients. Ultimately, hyperlactatemia is a marker of altered cellular bioenergetics. CONCLUSION The etiology of hyperlactatemia is complex and multifactorial. Understanding the relevant pathophysiology is helpful when characterizing hyperlactatemia in clinical patients.
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Affiliation(s)
- Patricia G Rosenstein
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Brett S Tennent-Brown
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Dez Hughes
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
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Gillespie Í, Rosenstein PG, Hughes D. Update: Clinical Use of Plasma Lactate. Vet Clin North Am Small Anim Pract 2016; 47:325-342. [PMID: 27914760 DOI: 10.1016/j.cvsm.2016.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Lactate is an essential, versatile metabolic fuel in cellular bioenergetics. In human emergency and critical care, lactate is used as a biomarker and therapeutic endpoint and evidence is growing in veterinary medicine supporting its clinical utility. Lactate production is a protective response providing ongoing cellular energy during tissue hypoperfusion or hypoxia and mitigating acidosis. Hence, hyperlactatemia is closely associated with disease severity but it is an epiphenomenon as the body attempts to protect itself. This article reviews lactate biochemistry, kinetics, pathophysiology, some practical aspects of measuring lactate, as well as its use in diagnosis, prognosis, and monitoring.
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Affiliation(s)
- Íde Gillespie
- Emergency and Critical Care Service, UVet Werribee Animal Hospital, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, 250 Princes Highway, Werribee, Melbourne, Victoria 3030, Australia
| | - Patricia G Rosenstein
- Emergency and Critical Care Service, UVet Werribee Animal Hospital, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, 250 Princes Highway, Werribee, Melbourne, Victoria 3030, Australia
| | - Dez Hughes
- Emergency and Critical Care Service, UVet Werribee Animal Hospital, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, 250 Princes Highway, Werribee, Melbourne, Victoria 3030, Australia.
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McGinley C, Bishop DJ. Distinct protein and mRNA kinetics of skeletal muscle proton transporters following exercise can influence interpretation of adaptations to training. Exp Physiol 2016; 101:1565-1580. [DOI: 10.1113/ep085921] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/27/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Cian McGinley
- College of Sport and Exercise Science; Victoria University; Melbourne Victoria Australia
| | - David J. Bishop
- College of Sport and Exercise Science; Victoria University; Melbourne Victoria Australia
- Institute of Sport; Exercise and Active Living (ISEAL); Victoria University; Melbourne Victoria Australia
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Regatieri IC, Almeida MLM, Teixeira Neto AR, Curi RA, Ferraz GC, Queiroz-Neto A. Quantification of MCT1 and CD147 in Red Blood Cells of Arabian and Quarter Horses. J Equine Vet Sci 2016. [DOI: 10.1016/j.jevs.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hiraga A, Sugano S. Studies on exercise physiology of the racehorse performed in Japan during the period from the 1930s to the 1970s: respiration and heart rate during exercise and the effect of exercise on blood characteristics. J Equine Sci 2016; 27:37-48. [PMID: 27330397 PMCID: PMC4914396 DOI: 10.1294/jes.27.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/24/2016] [Indexed: 11/09/2022] Open
Abstract
After publication of the epic report on equine exercise physiology by Matsuba and Shimamura in 1933, papers
on exercise physiology of the racehorse in Japan began appearing in scientific journals and increased in
number. In 1944, respiration during exercise at a walk, trot, and canter was measured by recording expiratory
sounds with a microphone attached near the nostril. Respiratory frequency during cantering was synchronized
with stride frequency, and expiratory sounds were found to occur during the stance phase of the trailing
forelimb. Development of a radiotelemetry system in 1964 for electrocardiogram recording enabled the first
recording of an equine electrocardiogram during field exercise that included fast galloping and calculation of
heart rate (HR) during exercise. During low intensity exercise including walking, trotting, cantering and
extended cantering, HR increased from 45 beat/min during pre-exercise to 150 beat/min at an extended canter.
HR increased to 200 beat/min or more in most horses during 100 m of high-intensity sprint galloping. When
blood lactate was measured after 3 days of draft work in 12 warhorses in 1934, no increase in blood lactate
was found. The erythrocyte sedimentation rate (ESR) was decreased by intense exercise and also decreased as
training increased. It was suggested that measuring changes in ESR and body weight in relation to training
might become useful as a screening index of training, condition, and fatigue. This evaluation method was named
the “ESR-body weight method.”
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Affiliation(s)
- Atsushi Hiraga
- Hidaka Training and Research Center of The Japan Racing Association, Hokkaido 057-0171, Japan
| | - Shigeru Sugano
- Professor Emeritus, The University of Tokyo, Tokyo 180-0004, Japan
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Rivero JLL, Hill EW. Skeletal muscle adaptations and muscle genomics of performance horses. Vet J 2015; 209:5-13. [PMID: 26831154 DOI: 10.1016/j.tvjl.2015.11.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/25/2015] [Accepted: 11/29/2015] [Indexed: 11/24/2022]
Abstract
Skeletal muscles in horses are characterised by specific adaptations, which are the result of the natural evolution of the horse as a grazing animal, centuries of selective breeding and the adaptability of this tissue in response to training. These adaptations include an increased muscle mass relative to body weight, a great locomotor efficiency based upon an admirable muscle-tendon architectural design and an adaptable fibre-type composition with intrinsic shortening velocities greater than would be predicted from an animal of comparable body size. Furthermore, equine skeletal muscles have a high mitochondrial volume that permits a higher whole animal aerobic capacity, as well as large intramuscular stores of energy substrates (glycogen in particular). Finally, high buffer and lactate transport capacities preserve muscles against fatigue during anaerobic exercise. Many of these adaptations can improve with training. The publication of the equine genome sequence in 2009 has provided a major advance towards an improved understanding of equine muscle physiology. Equine muscle genomics studies have revealed a number of genes associated with elite physical performance and have also identified changes in structural and metabolic genes following exercise and training. Genes involved in muscle growth, muscle contraction and specific metabolic pathways have been found to be functionally relevant for the early performance evaluation of elite athletic horses. The candidate genes discussed in this review are important for a healthy individual to improve performance. However, muscle performance limiting conditions are widespread in horses and many of these conditions are also genetically influenced.
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Affiliation(s)
- José-Luis L Rivero
- Laboratory of Muscular Biopathology, Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Sciences, University of Cordoba, Campus Universitario de Rabanales, 14014 Cordoba, Spain.
| | - Emmeline W Hill
- Animal Genomics Laboratory, School of Agriculture and Food Science, College of Agriculture, Food Science and Veterinary Medicine, University College Dublin, Belfield, Dublin, Ireland
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McKenzie E, Marlin D. Science-in-brief: The 9th Meeting of the International Conference on Equine Exercise Physiology 2014. Biochemistry, nutrition and cardiorespiratory function of athletic horses. Equine Vet J 2015; 47:254-6. [PMID: 25753804 DOI: 10.1111/evj.12381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E McKenzie
- Department of Clinical Sciences, Oregon State University, Corvallis, USA
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Kitaoka Y, Endo Y, Mukai K, Aida H, Hiraga A, Hatta H. Muscle glycogen breakdown and lactate metabolism during intensive exercise in Thoroughbred horses. THE JOURNAL OF PHYSICAL FITNESS AND SPORTS MEDICINE 2014. [DOI: 10.7600/jpfsm.3.451] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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