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Aaron SD, Montes de Oca M, Celli B, Bhatt SP, Bourbeau J, Criner GJ, DeMeo DL, Halpin DMG, Han MK, Hurst JR, Krishnan JK, Mannino D, van Boven JFM, Vogelmeier CF, Wedzicha JA, Yawn BP, Martinez FJ. Early Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease: The Costs and Benefits of Case Finding. Am J Respir Crit Care Med 2024; 209:928-937. [PMID: 38358788 DOI: 10.1164/rccm.202311-2120pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/14/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Shawn D Aaron
- The Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Maria Montes de Oca
- Universidad Central de Venezuela, Caracas, Venezuela
- Hospital Centro Médico de Caracas, Caracas, Venezuela
| | | | - Surya P Bhatt
- Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M G Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - MeiLan K Han
- Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Jamuna K Krishnan
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, New York
| | - David Mannino
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - Claus F Vogelmeier
- Philipps-Universität Marburg, German Center for Lung Research, Marburg, Germany
| | - Jadwiga A Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota; and
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Jankowski P, Mycroft K, Górska K, Korczyński P, Krenke R. How to Enhance the Diagnosis of Early Stages of Chronic Obstructive Pulmonary Disease (COPD)? The Role of Mobile Spirometry in COPD Screening and Diagnosis-A Systematic Review. Adv Respir Med 2024; 92:158-174. [PMID: 38666812 PMCID: PMC11047510 DOI: 10.3390/arm92020018] [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: 01/06/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/29/2024]
Abstract
COPD is the third leading cause of death worldwide. Its diagnosis can be made with spirometry, which is underused due to its limited accessibility. Portable spirometry holds promise for enhancing the efficacy of COPD diagnoses. The study aimed to estimate COPD prevalence diagnosed with a portable spirometer in high-risk patients and compare it with COPD prevalence based on data from conventional, on-site spirometry. We also evaluated the strategy of a proactive approach to identify COPD in high-risk individuals. We conducted a systematic review of original studies on COPD targeted screening and diagnosis with portable and conventional spirometers selected from 8496 publications initially found in three databases: Cochrane, PubMed, and Embase. The inclusion criteria were met by 28 studies. COPD prevalence evaluated with the use of portable spirometers reached 20.27% and was lower compared to that estimated with the use of conventional spirometers (24.67%). In 11 included studies, postbronchodilator tests were performed with portable spirometers, which enabled a bedside COPD diagnosis. Portable spirometers can be successfully used in COPD targeted screening and diagnosis and thus enhance the detection of COPD at early stages.
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Affiliation(s)
| | | | - Katarzyna Górska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097 Warsaw, Poland; (P.J.)
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Barteit S, Colmar D, Nellis S, Thu M, Watterson J, Gouwanda D, Bärnighausen T, Su TT. Developing Climate Change and Health Impact Monitoring with eHealth at the South East Asia Community Observatory and Health and Demographic Surveillance Site, Malaysia (CHIMES). Front Public Health 2023; 11:1153149. [PMID: 38125843 PMCID: PMC10732307 DOI: 10.3389/fpubh.2023.1153149] [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: 01/29/2023] [Accepted: 10/31/2023] [Indexed: 12/23/2023] Open
Abstract
Background Malaysia is projected to experience an increase in heat, rainfall, rainfall variability, dry spells, thunderstorms, and high winds due to climate change. This may lead to a rise in heat-related mortality, reduced nutritional security, and potential migration due to uninhabitable land. Currently, there is limited data regarding the health implications of climate change on the Malaysian populace, which hinders informed decision-making and interventions. Objective This study aims to assess the feasibility and reliability of using sensor-based devices to enhance climate change and health research within the SEACO health and demographic surveillance site (HDSS) in Malaysia. We will particularly focus on the effects of climate-sensitive diseases, emphasizing lung conditions like chronic obstructive pulmonary disease (COPD) and asthma. Methods In our mixed-methods approach, 120 participants (>18 years) from the SEACO HDSS in Segamat, Malaysia, will be engaged over three cycles, each lasting 3 weeks. Participants will use wearables to monitor heart rate, activity, and sleep. Indoor sensors will measure temperature in indoor living spaces, while 3D-printed weather stations will track indoor temperature and humidity. In each cycle, a minimum of 10 participants at high risk for COPD or asthma will be identified. Through interviews and questionnaires, we will evaluate the devices' reliability, the prevalence of climate-sensitive lung diseases, and their correlation with environmental factors, like heat and humidity. Results We anticipate that the sensor-based measurements will offer a comprehensive understanding of the interplay between climate-sensitive diseases and weather variables. The data is expected to reveal correlations between health impacts and weather exposures like heat. Participant feedback will offer perspectives on the usability and feasibility of these digital tools. Conclusion Our study within the SEACO HDSS in Malaysia will evaluate the potential of sensor-based digital technologies in monitoring the interplay between climate change and health, particularly for climate-sensitive diseases like COPD and asthma. The data generated will likely provide details on health profiles in relation to weather exposures. Feedback will indicate the acceptability of these tools for broader health surveillance. As climate change continues to impact global health, evaluating the potential of such digital technologies is crucial to understand its potential to inform policy and intervention strategies in vulnerable regions.
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Affiliation(s)
- Sandra Barteit
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - David Colmar
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Syahrul Nellis
- South East Asia Community Observatory (SEACO) and Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Min Thu
- South East Asia Community Observatory (SEACO) and Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Jessica Watterson
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Darwin Gouwanda
- School of Engineering (Mechanical), Monash University Malaysia, Bandar Sunway, Malaysia
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Cambridge, MA, United States
| | - Tin Tin Su
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- South East Asia Community Observatory (SEACO) and Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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Lin CH, Cheng SL, Chen CZ, Chen CH, Lin SH, Wang HC. Current Progress of COPD Early Detection: Key Points and Novel Strategies. Int J Chron Obstruct Pulmon Dis 2023; 18:1511-1524. [PMID: 37489241 PMCID: PMC10363346 DOI: 10.2147/copd.s413969] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, with approximately 70% to 80% of adults with COPD being undiagnosed. Patients with undiagnosed COPD are at increased risk of poor outcomes and a worsened quality of life, making early detection a crucial strategy to mitigate the impact of COPD and reduce the burden on healthcare systems. In the past decade, increased interest has been focused on the development of effective strategies and instrument for COPD early detection. However, identifying undiagnosed cases of COPD is still challenging. Both screening and case-finding approaches have been adopted to identify undiagnosed COPD, with case-finding being recommended by the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline and the updated United States Preventive Services Task Force (USPTF) recommendation. Nonetheless, the approaches, criteria, and instruments used for early detection of COPD are varied. However, advances in the taxonomy and risk factors of COPD are continuously being investigated. It is important to continuously assess the current state of knowledge on COPD early detection, given the challenges associated with identifying undiagnosed COPD. This review aims to highlight recent advances in early detection of COPD. To discuss the current challenge and opportunity in COPD early detection, providing an overview of existing literature on COPD case-finding strategies, including the approaches, criteria for subjects, and instruments. The review also summarizes the current progress in COPD case-findings and proposes a COPD case-finding flowchart as an efficient method for identifying at risk COPD patients.
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Affiliation(s)
- Ching-Hsiung Lin
- Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, 402, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Recreation and Holistic Wellness, MingDao University, Changhua, Taiwan
| | - Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, 220, Taiwan
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan, 320, Taiwan
| | - Chiung-Zuei Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, 404, Taiwan
| | - Sheng-Hao Lin
- Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
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Long H, Li S, Chen Y. Digital health in chronic obstructive pulmonary disease. Chronic Dis Transl Med 2023; 9:90-103. [PMID: 37305103 PMCID: PMC10249197 DOI: 10.1002/cdt3.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/11/2023] [Accepted: 04/03/2023] [Indexed: 06/13/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) can be prevented and treated through effective care, reducing exacerbations and hospitalizations. Early identification of individuals at high risk of COPD exacerbation is an opportunity for preventive measures. However, many patients struggle to follow their treatment plans because of a lack of knowledge about the disease, limited access to resources, and insufficient clinical support. The growth of digital health-which encompasses advancements in health information technology, artificial intelligence, telehealth, the Internet of Things, mobile health, wearable technology, and digital therapeutics-offers opportunities for improving the early diagnosis and management of COPD. This study reviewed the field of digital health in terms of COPD. The findings showed that despite significant advances in digital health, there are still obstacles impeding its effectiveness. Finally, we highlighted some of the major challenges and possibilities for developing and integrating digital health in COPD management.
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Affiliation(s)
- Huanyu Long
- Department of Pulmonary and Critical Care MedicinePeking University Third HospitalBeijingChina
| | - Shurun Li
- Peking University Health Science CenterBeijingChina
| | - Yahong Chen
- Department of Pulmonary and Critical Care MedicinePeking University Third HospitalBeijingChina
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Vogel EA, Rebuli ME, Wong M, Leventhal A, Monterosso J, Tackett AP. Feasibility and acceptability of remote procedures to study tobacco product use and respiratory health: an observational study. BMJ Open 2022; 12:e065962. [PMID: 36456013 PMCID: PMC9716794 DOI: 10.1136/bmjopen-2022-065962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Obtaining ecologically valid biological samples is critical for understanding respiratory effects of tobacco use, but can be burdensome. In two diverse samples, we examined feasibility and acceptability of studying pulmonary function and respiratory health entirely remotely. DESIGN Observational feasibility and acceptability study. SETTING AND PARTICIPANTS Adults age 18-25 (Biomedical Respiratory Effects Associated through Habitual Use of E-Cigarettes [BREATHE] Study) and 21-65 (Adult IQOS Respiratory [AIRS] Study) recruited from previous research studies and advertisements in Southern California, USA (BREATHE (AIRS): N=77 (N=31) completed baseline, n=64 (n=20) completed feasibility and acceptability measures). Shared inclusion criteria for the two studies were ownership of a smartphone, willingness to download applications and English fluency. In addition, BREATHE participants reported one of three tobacco use patterns. AIRS participants smoked daily and were willing to use a heated tobacco product. Exclusion criteria were medical contraindications. INTERVENTIONS A 4-week study consisted of five virtual study visits, twice daily ecological momentary assessment diaries and spirometry assessments, and weekly Nasal Epithelial Lining Fluid and saliva collection. All study visits were conducted via video conference; study materials and biospecimens were exchanged via mail. Participants reported feasibility and acceptability of daily diaries, breath tests, biospecimen collection and shipments. MEASURES Surveys assessed perceptions of timing and overall experience of daily diaries and breath tests, difficulty of and overall experience with biospecimen collection, and experience sending and receiving shipments. RESULTS Most participants evaluated daily diaries and breath tests as manageable (62.5%-95.0%) and likeable (54.7%-70.0%). Breath tests were frequently described as 'interesting' (55.0%-57.8%) and 'easy' (25.0%-48.4%). Most participants reported that biospecimen collection was easy (50.0%-85.0%), and that shipments were easy to send (87.5%-95.0%), receive (95.3%-95.0%) and schedule (56.3%-60.0%). No participants received shipments in poor condition. CONCLUSIONS Remote research procedures may be feasible and acceptable to facilitate tobacco research studies, potentially resulting in more diverse samples of participants and more generalisable research results.
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Affiliation(s)
- Erin A Vogel
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Meghan E Rebuli
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melissa Wong
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Adam Leventhal
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - John Monterosso
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
- Department of Psychology, University of Southern California, Los Angeles, California, USA
| | - Alayna P Tackett
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
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Accuracy of portable spirometers in the diagnosis of chronic obstructive pulmonary disease A meta-analysis. NPJ Prim Care Respir Med 2022; 32:15. [PMID: 35440665 PMCID: PMC9019105 DOI: 10.1038/s41533-022-00275-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/11/2022] [Indexed: 12/03/2022] Open
Abstract
Portable spirometers has been approved for diagnosing chronic obstructive pulmonary disease (COPD). However, their diagnostic accuracy has not been reviewed. Therefore, the purpose of this study was to systematically evaluate the diagnostic value of portable spirometers in detecting COPD. A comprehensive literature search for relevant studies was conducted in PubMed, Embase, CNKI, Wan Fang, and Web of Science databases. Pooled sensitivity, specificity, summary receiver operating characteristic (SROC), area under the curve (AUC), and other related indices were calculated using the bivariate mixed-effect model. Subgroup analysis was performed to explore the source of heterogeneity. Thirty one studies were included in the meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic ratio (DOR), SROC, and AUC of the SROC of portable spirometers were 0.85 (0.81–0.88), 0.85 (0.81–0.88), 5.6 (4.4–7.3), 0.18 (0.15–0.22), 31 (21–46) and 0.91 (0.89–0.94), respectively. Among the three commonly used types of portable spirometers, the accuracy of PIKO-6 was higher (0.95) than that of COPD-6 (0.91) and PEF (0.82). Subgroup analysis indicated that the accuracy of a multi-indices portable spirometer was higher than that of a single-index one (P < 0.05). In addition, portable spirometry performed by professional technicians in tertiary hospitals was more accurate than for those conducted by trained technicians in primary care facilities and communities (P < 0.05). Moreover, the accuracy of studies conducted in developing country was superior to developed country (P < 0.05). Portable spirometers have high accuracy in the diagnosis of COPD. Multi-index COPD-6 and PIKO-6 displayed higher accuracy than others. Standardized training of instrument operators should be considered to achieve reliable results.
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Chen CZ, Sheu CC, Cheng SL, Wang HC, Lin MC, Hsu WH, Lee KY, Perng DW, Lin HI, Lin MS, Lin SH, Tsai JR, Wang CC, Wang CY, Yang TM, Liu CL, Wang TY, Lin CH. Performance and Clinical Utility of Various Chronic Obstructive Pulmonary Disease Case-Finding Tools. Int J Chron Obstruct Pulmon Dis 2021; 16:3405-3415. [PMID: 34955636 PMCID: PMC8694402 DOI: 10.2147/copd.s339340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Chronic obstructive pulmonary disease (COPD) is frequently underdiagnosed because of the unavailability of spirometers, especially in resource-limited outpatient settings. This study provides real-world evidence to identify optimal approaches for COPD case finding in outpatient settings. METHODS This retrospective study enrolled individuals who were at risk of COPD (age ≥40 years, ≥10 pack-years, and ≥1 respiratory symptom). Eligible participants were examined using various COPD case-finding tools, namely the COPD Population Screener (COPD-PS) questionnaire, a COPD prediction (PCOPD) model, and a microspirometer, Spirobank Smart; subsequently, the participants underwent confirmatory spirometry. The definition and confirmation of COPD were based on conventional spirometry. Receiver operating characteristic curve (ROC), area under the curve (AUC), and decision curve analyses were conducted, and a clinical impact curve was constructed. RESULTS In total, 385 participants took part in the study [284 without COPD (73.77%) and 101 with COPD (26.23%)]. The microspirometer exhibited a higher AUC value than did the COPD-PS questionnaire and the PCOPD model. The AUC for microspirometry was 0.908 (95% confidence interval [CI] = 0.87-0.95), that for the PCOPD model was 0.788 (95% CI = 0.74-0.84), and that for the COPD-PS questionnaire was 0.726 (95% CI = 0.67-0.78). Decision and clinical impact curve analyses revealed that a microspirometry-derived FEV1/FVC ratio of <74% had superior clinical utility to the other measurement tools. CONCLUSION The PCOPD model and COPD-PS questionnaire were useful for identifying symptomatic patients likely to have COPD, but microspirometry was more accurate and had higher clinical utility. This study provides real-world evidence to identify optimal practices for COPD case finding; such practices ensure that physicians have convenient access to up-to-date evidence when they encounter a symptomatic patient likely to have COPD.
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Affiliation(s)
- Chiung-Zuei Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, 807, Taiwan
| | - Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, 220, Taiwan
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli, Taoyuan, 320, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, 404, Taiwan
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, 833, Taiwan
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 110, Taiwan
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan
| | - Hen-I Lin
- Department of Internal Medicine, Cardinal Tien Hospital, Fu-Jen Catholic University, Taipei, 242, Taiwan
| | - Ming-Shian Lin
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, 600, Taiwan
| | - Sheng-Hao Lin
- Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Jong-Rung Tsai
- Division of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, 404, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital, Fu-Jen Catholic University, Taipei, 242, Taiwan
| | - Tsung-Ming Yang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Ching-Lung Liu
- Division of Chest Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, 104, Taiwan
| | - Tsai-Yu Wang
- Pulmonary Disease Research Centre, Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, 402, Taiwan
- Department of Recreation and Holistic Wellness, MingDao University, Changhua, 523, Taiwan
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