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Miyajima Y, Karashima S, Mizoguchi R, Kawakami M, Ogura K, Ogai K, Koshida A, Ikagawa Y, Ami Y, Zhu Q, Tsujiguchi H, Hara A, Kurihara S, Arakawa H, Nakamura H, Tamai I, Nambo H, Okamoto S. Prediction and causal inference of hyperuricemia using gut microbiota. Sci Rep 2024; 14:9901. [PMID: 38688923 PMCID: PMC11061287 DOI: 10.1038/s41598-024-60427-6] [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: 08/12/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
Hyperuricemia (HUA) is a symptom of high blood uric acid (UA) levels, which causes disorders such as gout and renal urinary calculus. Prolonged HUA is often associated with hypertension, atherosclerosis, diabetes mellitus, and chronic kidney disease. Studies have shown that gut microbiota (GM) affect these chronic diseases. This study aimed to determine the relationship between HUA and GM. The microbiome of 224 men and 254 women aged 40 years was analyzed through next-generation sequencing and machine learning. We obtained GM data through 16S rRNA-based sequencing of the fecal samples, finding that alpha-diversity by Shannon index was significantly low in the HUA group. Linear discriminant effect size analysis detected a high abundance of the genera Collinsella and Faecalibacterium in the HUA and non-HUA groups. Based on light gradient boosting machine learning, we propose that HUA can be predicted with high AUC using four clinical characteristics and the relative abundance of nine bacterial genera, including Collinsella and Dorea. In addition, analysis of causal relationships using a direct linear non-Gaussian acyclic model indicated a positive effect of the relative abundance of the genus Collinsella on blood UA levels. Our results suggest abundant Collinsella in the gut can increase blood UA levels.
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Affiliation(s)
- Yuna Miyajima
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kakuma, Kanazawa, Ishikawa, 920-1192, Japan.
| | - Ren Mizoguchi
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Masaki Kawakami
- School of Electrical Information Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Kohei Ogura
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Kazuhiro Ogai
- Department of Bio-Engineering Nursing, Graduate School of Nursing, Ishikawa Prefectural Nursing University, Kahoku, Ishikawa, Japan
| | - Aoi Koshida
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Yasuo Ikagawa
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Yuta Ami
- Faculty of Biology-Oriented Science and Technology, Kindai University, Kinokawa, Wakayama, Japan
| | - Qiunan Zhu
- Faculty of Pharmaceutical Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiromasa Tsujiguchi
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akinori Hara
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shin Kurihara
- Faculty of Biology-Oriented Science and Technology, Kindai University, Kinokawa, Wakayama, Japan
| | - Hiroshi Arakawa
- Faculty of Pharmaceutical Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Nakamura
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Ikumi Tamai
- Faculty of Pharmaceutical Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hidetaka Nambo
- School Introduction School of Entrepreneurial and Innovation Studies, College of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan
| | - Shigefumi Okamoto
- Laboratory of Medical Microbiology and Microbiome, Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Koshida A, Karashima S, Ogura K, Miyajima Y, Ogai K, Mizoguchi R, Ikagawa Y, Hara S, Mizushima I, Fujii H, Kawano M, Tsujiguchi H, Hara A, Nakamura H, Okamoto S. Impact of gut microbiome on serum IgG4 levels in the general population: Shika-machi super preventive health examination results. Front Cell Infect Microbiol 2023; 13:1272398. [PMID: 37908763 PMCID: PMC10613983 DOI: 10.3389/fcimb.2023.1272398] [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: 08/04/2023] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Introduction Immunoglobulin G4 (IgG4) is a member of the human immunoglobulin G (IgG) subclass, a protein involved in immunity to pathogens and the body's resistance system. IgG4-related diseases (IgG4-RD) are intractable diseases in which IgG4 levels in the blood are elevated, causing inflammation in organs such as the liver, pancreas, and salivary glands. IgG4-RD are known to be more prevalent in males than in females, but the etiology remains to be elucidated. This study was conducted to investigate the relationship between gut microbiota (GM) and serum IgG4 levels in the general population. Methods In this study, the relationship between IgG4 levels and GM evaluated in male and female groups of the general population using causal inference. The study included 191 men and 207 women aged 40 years or older from Shika-machi, Ishikawa. GM DNA was analyzed for the 16S rRNA gene sequence using next-generation sequencing. Participants were bifurcated into high and low IgG4 groups, depending on median serum IgG4 levels. Results ANCOVA, Tukey's HSD, linear discriminant analysis effect size, least absolute shrinkage and selection operator logistic regression model, and correlation analysis revealed that Anaerostipes, Lachnospiraceae, Megasphaera, and [Eubacterium] hallii group were associated with IgG4 levels in women, while Megasphaera, [Eubacterium] hallii group, Faecalibacterium, Ruminococcus.1, and Romboutsia were associated with IgG4 levels in men. Linear non-Gaussian acyclic model indicated three genera, Megasphaera, [Eubacterium] hallii group, and Anaerostipes, and showed a presumed causal association with IgG4 levels in women. Discussion This differential impact of the GM on IgG4 levels based on sex is a novel and intriguing finding.
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Affiliation(s)
- Aoi Koshida
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Kohei Ogura
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Yuna Miyajima
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuhiro Ogai
- Department of Bio-engineering Nursing, Graduate School of Nursing, Ishikawa Prefectural Nursing University, Kahoku, Japan
| | - Ren Mizoguchi
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Yasuo Ikagawa
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiromasa Tsujiguchi
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akinori Hara
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Nakamura
- Department of Hygiene and Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shigefumi Okamoto
- Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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Mizoguchi R, Karashima S, Miyajima Y, Ogura K, Kometani M, Aono D, Konishi S, Demura M, Tsujiguchi H, Hara A, Nakamura H, Yoneda T, Okamoto S, Satou K. Impact of gut microbiome on the renin-aldosterone system: Shika-machi Super Preventive Health Examination results. Hypertens Res 2023; 46:2280-2292. [PMID: 37280260 DOI: 10.1038/s41440-023-01334-7] [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: 02/27/2023] [Revised: 04/18/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is a regulatory mechanism of the endocrine system and is associated with various diseases, including hypertension and renal and cardiovascular diseases. The gut microbiota (GM) have been associated with various diseases, mainly in animal models. However, to our knowledge, no studies have examined the relationship between the RAAS and GM in humans. The present study aimed to assess the association between the systemic RAAS and GM genera and their causal relationships. The study participants were 377 members of the general population aged 40 years or older in Shika-machi, Japan. Plasma renin activity (PRA), plasma aldosterone concentration (PAC), aldosterone-renin ratio (ARR), and GM composition were analyzed using the 16S rRNA method. The participants were divided into high and low groups according to the PRA, PAC, and ARR values. U-tests, one-way analysis of covariance, and linear discriminant analysis of effect size were used to identify the important bacterial genera between the two groups, and binary classification modeling using Random Forest was used to calculate the importance of the features. The results showed that Blautia, Bacteroides, Akkermansia, and Bifidobacterium were associated with the RAAS parameters. Causal inference analysis using the linear non-Gaussian acyclic model revealed a causal effect of Blautia on PAC via SBP. These results strengthen the association between the systemic RAAS and GM in humans, and interventions targeting the GM may provide new preventive measures and treatments for hypertension and renal disease.
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Affiliation(s)
- Ren Mizoguchi
- School of Biological Science and Technology, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, Japan.
| | - Yuna Miyajima
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kohei Ogura
- Advanced Health Care Science Research Unit, Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kometani
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
| | - Daisuke Aono
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
| | - Seigo Konishi
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiromasa Tsujiguchi
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akinori Hara
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Nakamura
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
- Faculty of Transdisciplinary Sciences for Innovation, Institute of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan
| | - Shigefumi Okamoto
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
- Advanced Health Care Science Research Unit, Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Kenji Satou
- Faculty of Transdisciplinary Sciences for Innovation, Institute of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan.
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Vogt L, Marques FZ, Fujita T, Hoorn EJ, Danser AHJ. Novel mechanisms of salt-sensitive hypertension. Kidney Int 2023; 104:690-697. [PMID: 37454911 DOI: 10.1016/j.kint.2023.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
A high dietary sodium-consumption level is considered the most important lifestyle factor that can be modified to help prevent an increase in blood pressure and the development of hypertension. Despite numerous studies over the past decades, the pathophysiology explaining why some people show a salt-sensitive blood pressure response and others do not is incompletely understood. Here, a brief overview of the latest mechanistic insights is provided, focusing on the mononuclear phagocytic system and inflammation, the gut-kidney axis, and epigenetics. The article also discusses the effects of 3 types of novel drugs on salt-sensitive hypertension-sodium-glucose cotransporter 2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and aldosterone synthase inhibitors. The conclusion is that besides kidney-centered mechanisms, vasoconstrictor mechanisms are also relevant for both the understanding and treatment of this blood pressure phenotype.
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Affiliation(s)
- Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | - Francine Z Marques
- Hypertension Research Laboratory, School of Biological Sciences, and Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Toshiro Fujita
- Research Center for Advanced Science and Technology (RCAST), The University of Tokyo, Tokyo, Japan
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.
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Miyajima Y, Karashima S, Ogai K, Taniguchi K, Ogura K, Kawakami M, Nambo H, Kometani M, Aono D, Demura M, Yoneda T, Tsujiguchi H, Hara A, Nakamura H, Okamoto S. Impact of gut microbiome on dyslipidemia in japanese adults: Assessment of the Shika-machi super preventive health examination results for causal inference. Front Cell Infect Microbiol 2022; 12:908997. [PMID: 36118024 PMCID: PMC9479221 DOI: 10.3389/fcimb.2022.908997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Dyslipidemia (DL) is one of the most common lifestyle-related diseases. There are few reports showing the causal relationship between gut microbiota (GM) and DL. In the present study, we used a linear non-Gaussian acyclic model (LiNGAM) to evaluate the causal relationship between GM and DL. A total of 79 men and 82 women aged 40 years or older living in Shika-machi, Ishikawa Prefecture, Japan were included in the analysis, and their clinical information was investigated. DNA extracted from the GM was processed to sequence the 16S rRNA gene using next-generation sequencing. Participants were divided into four groups based on sex and lipid profile information. The results of one-way analysis of covariance, linear discriminant analysis effect size, and least absolute value reduction and selection operator logistic regression model indicated that several bacteria between men and women may be associated with DL. The LiNGAM showed a presumed causal relationship between different bacteria and lipid profiles in men and women. In men, Prevotella 9 and Bacteroides were shown to be potentially associated with changes in low- and high-density lipoprotein cholesterol levels. In women, the LiNGAM results showed two bacteria, Akkermansia and Escherichia/Shigella, had a presumptive causal relationship with lipid profiles. These results may provide a new sex-based strategy to reduce the risk of developing DL and to treat DL through the regulation of the intestinal environment using specific GM.
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Affiliation(s)
- Yuna Miyajima
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, Japan
- *Correspondence: Shigehiro Karashima, ; Shigefumi Okamoto,
| | - Kazuhiro Ogai
- AI Hospital/Macro Signal Dynamics Research and Development Center, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kouki Taniguchi
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kohei Ogura
- Advanced Health Care Science Research Unit, Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
| | - Masaki Kawakami
- School of Electrical, Information and Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Hidetaka Nambo
- School of Electrical, Information and Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kometani
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
| | - Daisuke Aono
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
- Faculty of Transdisciplinary Sciences, Institute of Transdisciplinary Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiromasa Tsujiguchi
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akinori Hara
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Nakamura
- Department of Public Health, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shigefumi Okamoto
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
- Advanced Health Care Science Research Unit, Institute for Frontier Science Initiative, Kanazawa University, Kanazawa, Japan
- *Correspondence: Shigehiro Karashima, ; Shigefumi Okamoto,
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Naqvi S, Asar TO, Kumar V, Al-Abbasi FA, Alhayyani S, Kamal MA, Anwar F. A cross-talk between gut microbiome, salt and hypertension. Biomed Pharmacother 2021; 134:111156. [PMID: 33401080 DOI: 10.1016/j.biopha.2020.111156] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
Cardiac disorders contribute to one of the major causes of fatality across the world. Hypertensive patients, even well maintained on drugs, possess a high risk to cardiovascular diseases. It is, therefore, highly important to identify different factors and pathways that lead to risk and progression of cardiovascular disorders. Several animals and human studies suggest that taxonomical alterations in the gut are involved in the cardiovascular physiology. In this article, with the help of various experimental evidences, we suggest that the host gut-microbiota plays an important in this pathway. Short chain fatty acids (SCFAs) and Trimethyl Amine -n-Oxide (TMAO) are the two major products of gut microbiome. SCFAs present a crucial role in regulating the blood pressure, while TMAO is involved in pathogenesis of atherosclerosis and other coronary artery diseases, including hypertension. We prove that there exists a triangular bridge connecting the gap between dietary salt, hypertension and gut microbiome. We also present some of the dietary interventions which can regulate and control microbiota that can prevent cardiovascular complications.We strongly believe that this article would improve the understanding the role of gut microbiota in hypertension, and will be helpful in the development of novel therapeutic strategies for prevention of hypertension through restoring gut microbiome homeostasis in the near future.
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Affiliation(s)
- Salma Naqvi
- Department of Biomedical Sciences, College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - Turky Omar Asar
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Biology, College of Science and Arts at Alkamil, University of Jeddah, Jeddah, Saudi Arabia
| | - Vikas Kumar
- Natural Product Discovery Laboratory, Department of Pharmaceutical Sciences, Shalom Institute of Health and Allied Sciences. Sam Higginbottom University of Agriculture, Technology and Sciences, Naini, Prayagraj, 211007, India.
| | - Fahad A Al-Abbasi
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sultan Alhayyani
- Department of Chemistry. College of Sciences & Arts, Rabigh King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad Amjad Kamal
- Novel Global Community Educational Foundation, Australia; King Fahd Medical Research Center, King Abdulaziz University, P. O. Box 80216, Jeddah, 21589, Saudi Arabia; Enzymoics, 7 Peterlee Place, Hebersham, NSW, 27707, Australia
| | - Firoz Anwar
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.
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