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Hirotsu Y, Nagakubo Y, Maejima M, Shibusawa M, Hosaka K, Sueki H, Mochizuki H, Omata M. Changes in Viral Dynamics Following the Legal Relaxation of COVID-19 Mitigation Measures in Japan From Children to Adults: A Single Center Study, 2020-2023. Influenza Other Respir Viruses 2024; 18:e13278. [PMID: 38513611 PMCID: PMC10957242 DOI: 10.1111/irv.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Respiratory infections are an ongoing global health challenge. The COVID-19 pandemic triggered global nonpharmacological measures that reshaped public health. In Japan, the shift from legal to individual discretion in pandemic management started on May 8, 2023. However, it still unknown how the relaxation of measures affects respiratory pathogens across age groups. METHODS We collected 16,946 samples from 13,526 patients between February 2020 and September 2023, analyzing the circulating respiratory pathogen dynamics using FilmArray respiratory panel. RESULTS Our analysis revealed significant increases in the positivity rates of respiratory pathogens across multiple age groups after relaxation. The pathogens including adenovirus, Bordetella pertussis, parainfluenza 2 and parainfluenza 4 showed increased positivity predominantly in children aged under 10 years. Conversely, some pathogens including human metapneumovirus, rhinovirus/enterovirus, and respiratory virus (RSV) increased in broad range of age groups. SARS-CoV-2 positivity rates decreased in children under 10 years but increased in those aged over 60 years. DISCUSSION Age-stratified analysis reveals a dynamic pattern of circulating pathogen in each age group after relaxation measures. This study provides essential epidemiologic data that can guide strategies to protect different age groups and effectively respond to respiratory infections in post-COVID-19 era.
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Affiliation(s)
- Yosuke Hirotsu
- Genome Analysis CenterYamanashi Central HospitalKofuYamanashiJapan
| | - Yuki Nagakubo
- Genome Analysis CenterYamanashi Central HospitalKofuYamanashiJapan
- Division of Microbiology in Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
- Division of Genetics and Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
| | - Makoto Maejima
- Division of Microbiology in Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
| | - Masahiro Shibusawa
- Division of Microbiology in Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
| | - Kazuhiro Hosaka
- Division of Microbiology in Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
| | - Hitomi Sueki
- Division of Microbiology in Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
| | - Hitoshi Mochizuki
- Genome Analysis CenterYamanashi Central HospitalKofuYamanashiJapan
- Central Clinical LaboratoryYamanashi Central HospitalKofuYamanashiJapan
- Department of GastroenterologyYamanashi Central HospitalKofuYamanashiJapan
| | - Masao Omata
- Department of GastroenterologyYamanashi Central HospitalKofuYamanashiJapan
- The University of TokyoTokyoJapan
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Horie M, Takagane K, Itoh G, Kuriyama S, Yanagihara K, Yashiro M, Umakoshi M, Goto A, Arita J, Tanaka M. Exosomes secreted by ST3GAL5 high cancer cells promote peritoneal dissemination by establishing a premetastatic microenvironment. Mol Oncol 2024; 18:21-43. [PMID: 37716915 PMCID: PMC10766203 DOI: 10.1002/1878-0261.13524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/29/2023] [Accepted: 09/15/2023] [Indexed: 09/18/2023] Open
Abstract
Peritoneal dissemination of cancer affects patient survival. The behavior of peritoneal mesothelial cells (PMCs) and immune cells influences the establishment of a microenvironment that promotes cancer cell metastasis in the peritoneum. Here, we investigated the roles of lactosylceramide alpha-2,3-sialyltransferase (ST3G5; also known as ST3GAL5 and GM3 synthase) in the exosome-mediated premetastatic niche in peritoneal milky spots (MSs). Exosomes secreted from ST3G5high cancer cells (ST3G5high -cExos) were found to contain high levels of hypoxia-inducible factor 1-alpha (HIF1α) and accumulated in MSs via uptake in macrophages (MΦs) owing to increased expression of sialic acid-binding Ig-like lectin 1 (CD169; also known as SIGLEC1). ST3G5high -cExos induced pro-inflammatory cytokines and glucose metabolic changes in MΦs, and the interaction of these MΦs with PMCs promoted mesothelial-mesenchymal transition (MMT) in PMCs, thereby generating αSMA+ myofibroblasts. ST3G5high -cExos also increased the expression of immune checkpoint molecules and T-cell exhaustion in MSs, which accelerated metastasis to the omentum. These events were prevented following ST3G5 depletion in cancer cells. Mechanistically, ST3G5high -cExos upregulated chemokines, including CC-chemokine ligand 5 (CCL5), in recipient MΦs and dendritic cells (DCs), which induced MMT and immunosuppression via activation of signal transducer and activator of transcription 3 (STAT3). Maraviroc, a C-C chemokine receptor type 5 (CCR5) antagonist, prevented ST3G5high -cExo-mediated MMT, T-cell suppression, and metastasis in MSs. Our results suggest ST3G5 as a suitable therapeutic target for preventing cExo-mediated peritoneal dissemination.
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Affiliation(s)
- Misato Horie
- Department of Molecular Medicine and BiochemistryAkita University Graduate School of MedicineJapan
- Department of Gastroenterological SurgeryAkita University Graduate School of MedicineJapan
| | - Kurara Takagane
- Department of Molecular Medicine and BiochemistryAkita University Graduate School of MedicineJapan
| | - Go Itoh
- Department of Molecular Medicine and BiochemistryAkita University Graduate School of MedicineJapan
| | - Sei Kuriyama
- Department of Molecular Medicine and BiochemistryAkita University Graduate School of MedicineJapan
| | - Kazuyoshi Yanagihara
- Division of Rare Cancer ResearchNational Cancer Center Research InstituteTokyoJapan
| | - Masakazu Yashiro
- Department of Molecular Oncology and TherapeuticsOsaka Metropolitan University Graduate School of MedicineJapan
| | - Michinobu Umakoshi
- Department of Cellular and Organ PathologyAkita University Graduate School of MedicineJapan
| | - Akiteru Goto
- Department of Cellular and Organ PathologyAkita University Graduate School of MedicineJapan
| | - Junichi Arita
- Department of Gastroenterological SurgeryAkita University Graduate School of MedicineJapan
| | - Masamitsu Tanaka
- Department of Molecular Medicine and BiochemistryAkita University Graduate School of MedicineJapan
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Frey T, Murakami T, Maki K, Kawaue T, Tani N, Sugai A, Nakazawa N, Ishiguro K, Adachi T, Kengaku M, Ohki K, Gotoh Y, Kishi Y. Age-associated reduction of nuclear shape dynamics in excitatory neurons of the visual cortex. Aging Cell 2023; 22:e13925. [PMID: 37476844 PMCID: PMC10497821 DOI: 10.1111/acel.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/22/2023] Open
Abstract
Neurons decline in their functionality over time, and age-related neuronal alterations are associated with phenotypes of neurodegenerative diseases. In nonneural tissues, an infolded nuclear shape has been proposed as a hallmark of aged cells and neurons with infolded nuclei have also been reported to be associated with neuronal activity. Here, we performed time-lapse imaging in the visual cortex of Nex-Cre;SUN1-GFP mice. Nuclear infolding was observed within 10 min of stimulation in young nuclei, while the aged nuclei were already infolded pre-stimulation and showed reduced dynamics of the morphology. In young nuclei, the depletion of the stimuli restored the nucleus to a spherical shape and reduced the dynamic behavior, suggesting that nuclear infolding is a reversible process. We also found the aged nucleus to be stiffer than the young one, further relating to the age-associated loss of nuclear shape dynamics. We reveal temporal changes in the nuclear shape upon external stimulation and observe that these morphological dynamics decrease with age.
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Affiliation(s)
- Tanita Frey
- Graduate School of Pharmaceutical SciencesThe University of TokyoTokyoJapan
- New York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Tomonari Murakami
- Graduate School of MedicineThe University of TokyoTokyoJapan
- Institute for AI and Beyond, The University of TokyoTokyoJapan
| | - Koichiro Maki
- Institute for Life and Medical Sciences, Kyoto UniversityKyotoJapan
| | - Takumi Kawaue
- Institute for Integrated Cell‐Material Sciences, Institute for Advanced Study, Kyoto UniversityKyotoJapan
| | - Naoki Tani
- Liaison Laboratory Research Promotion CenterIMEG, Kumamoto UniversityKumamotoJapan
| | - Ayaka Sugai
- Graduate School of Pharmaceutical SciencesThe University of TokyoTokyoJapan
- Institute for Quantitative Biosciences, The University of TokyoTokyoJapan
| | - Naotaka Nakazawa
- Institute for Integrated Cell‐Material Sciences, Institute for Advanced Study, Kyoto UniversityKyotoJapan
- Department of Energy and Materials, Faculty of Science and EngineeringKindai UniversityOsakaJapan
| | - Kei‐ichiro Ishiguro
- Department of Chromosome BiologyInstitute of Molecular Embryology and Genetics (IMEG), Kumamoto UniversityKumamotoJapan
| | - Taiji Adachi
- Institute for Life and Medical Sciences, Kyoto UniversityKyotoJapan
| | - Mineko Kengaku
- Institute for Integrated Cell‐Material Sciences, Institute for Advanced Study, Kyoto UniversityKyotoJapan
| | - Kenichi Ohki
- Graduate School of MedicineThe University of TokyoTokyoJapan
- Institute for AI and Beyond, The University of TokyoTokyoJapan
- International Research Center for Neurointelligence (WPI‐IRCN), The University of TokyoTokyoJapan
| | - Yukiko Gotoh
- Graduate School of Pharmaceutical SciencesThe University of TokyoTokyoJapan
- International Research Center for Neurointelligence (WPI‐IRCN), The University of TokyoTokyoJapan
| | - Yusuke Kishi
- Graduate School of Pharmaceutical SciencesThe University of TokyoTokyoJapan
- Institute for Quantitative Biosciences, The University of TokyoTokyoJapan
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Kohzaki M. Mammalian Resilience Revealed by a Comparison of Human Diseases and Mouse Models Associated With DNA Helicase Deficiencies. Front Mol Biosci 2022; 9:934042. [PMID: 36032672 PMCID: PMC9403131 DOI: 10.3389/fmolb.2022.934042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/23/2022] [Indexed: 12/01/2022] Open
Abstract
Maintaining genomic integrity is critical for sustaining individual animals and passing on the genome to subsequent generations. Several enzymes, such as DNA helicases and DNA polymerases, are involved in maintaining genomic integrity by unwinding and synthesizing the genome, respectively. Indeed, several human diseases that arise caused by deficiencies in these enzymes have long been known. In this review, the author presents the DNA helicases associated with human diseases discovered to date using recent analyses, including exome sequences. Since several mouse models that reflect these human diseases have been developed and reported, this study also summarizes the current knowledge regarding the outcomes of DNA helicase deficiencies in humans and mice and discusses possible mechanisms by which DNA helicases maintain genomic integrity in mammals. It also highlights specific diseases that demonstrate mammalian resilience, in which, despite the presence of genomic instability, patients and mouse models have lifespans comparable to those of the general population if they do not develop cancers; finally, this study discusses future directions for therapeutic applications in humans that can be explored using these mouse models.
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Miyake K, Ito J, Karasuyama H. Role of Basophils in a Broad Spectrum of Disorders. Front Immunol 2022; 13:902494. [PMID: 35693800 PMCID: PMC9186123 DOI: 10.3389/fimmu.2022.902494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
Basophils are the rarest granulocytes and have long been overlooked in immunological research due to their rarity and similarities with tissue-resident mast cells. In the last two decades, non-redundant functions of basophils have been clarified or implicated in a broad spectrum of immune responses, particularly by virtue of the development of novel analytical tools for basophils. Basophils infiltrate inflamed tissues of patients with various disorders, even though they circulate in the bloodstream under homeostatic conditions. Depletion of basophils results in the amelioration or exaggeration of inflammation, depending on models of disease, indicating basophils can play either beneficial or deleterious roles in a context-dependent manner. In this review, we summarize the recent findings of basophil pathophysiology under various conditions in mice and humans, including allergy, autoimmunity, tumors, tissue repair, fibrosis, and COVID-19. Further mechanistic studies on basophil biology could lead to the identification of novel biomarkers or therapeutic targets in a broad range of diseases.
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Yamawaki Y, Kimura H, Nagata S, Ozawa K, Hosoi T. Peripheral Immune Activation in Mice Elicits Unfolded Protein Responses Independent on MyD88 Pathway in the Liver but not the Hypothalamus and Hippocampus. Front Physiol 2022; 13:854538. [PMID: 35574480 PMCID: PMC9096091 DOI: 10.3389/fphys.2022.854538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Neuroimmune interactions between the immune system and CNS as well as peripheral organs such as the liver play a key role in the pathophysiological state of diseases. Unfolded protein responses (UPRs), which are activated by cells in response to endoplasmic reticulum stress, have been linked to the occurrence of inflammation diseases, neurodegenerative diseases, and metabolic disorders such as type 2 diabetes. Peripheral injection of lipopolysaccharide (LPS) is known to induce a systemic inflammatory response, along with fever, anorexia, and depressive behaviors. LPS also elicits UPRs, although the underlying physiological mechanism remains unclear. In the present study, we investigated whether peripheral activation of the immune system can elicit UPRs in the CNS and liver. Peripheral injection of LPS is known to elevate pro-inflammatory cytokines in the liver, hypothalamus and hippocampus. We report that LPS-induced systemic inflammation elicits UPRs in the liver, but not the hypothalamus. Injection of LPS upregulated the expression levels of glucose-regulated protein 78 and pro-apoptotic transcription factor C/EBP homologous protein, along with increased splicing of X-box binding protein one mRNA in the liver, but not in the hypothalamus and hippocampus. Myeloid differentiation primary response 88 (MyD88), an adaptor protein, is known to play a key role in the signal transduction of LPS mediated by Toll-like receptor 4. Using MyD88 deficient mice, we found that LPS-induced UPRs occurred independently of MyD88 expression. In summary, peripheral activation of the immune system elicits UPRs in the liver, but not the hypothalamus and hippocampus, which may have implications for the pathophysiology of diseases.
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Affiliation(s)
- Yosuke Yamawaki
- Laboratory of Advanced Pharmacology, Daiichi University of Pharmacy, Fukuoka, Japan
- Department of Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitomi Kimura
- Department of Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Susumu Nagata
- Laboratory of Advanced Pharmacology, Daiichi University of Pharmacy, Fukuoka, Japan
| | - Koichiro Ozawa
- Department of Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Hosoi
- Department of Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Clinical Pharmacology, Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University, Yamaguchi, Japan
- *Correspondence: Toru Hosoi,
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Bando H, Urai S, Kanie K, Sasaki Y, Yamamoto M, Fukuoka H, Iguchi G, Camper SA. Novel genes and variants associated with congenital pituitary hormone deficiency in the era of next-generation sequencing. Front Endocrinol (Lausanne) 2022; 13:1008306. [PMID: 36237189 PMCID: PMC9551393 DOI: 10.3389/fendo.2022.1008306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/09/2022] [Indexed: 01/07/2023] Open
Abstract
Combined pituitary hormone deficiency (CPHD) is not a rare disorder, with a frequency of approximately 1 case per 4,000 live births. However, in most cases, a genetic diagnosis is not available. Furthermore, the diagnosis is challenging because no clear correlation exists between the pituitary hormones affected and the gene(s) responsible for the disorder. Next-generation sequencing (NGS) has recently been widely used to identify novel genes that cause (or putatively cause) CPHD. This review outlines causative genes for CPHD that have been newly reported in recent years. Moreover, novel variants of known CPHD-related genes (POU1F1 and GH1 genes) that contribute to CPHD through unique mechanisms are also discussed in this review. From a clinical perspective, variants in some of the recently identified causative genes result in extra-pituitary phenotypes. Clinical research on the related symptoms and basic research on pituitary formation may help in inferring the causative gene(s) of CPHD. Future NGS analysis of a large number of CPHD cases may reveal new genes related to pituitary development. Clarifying the causative genes of CPHD may help to understand the process of pituitary development. We hope that future innovations will lead to the identification of genes responsible for CPHD and pituitary development.
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Affiliation(s)
- Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- *Correspondence: Hironori Bando,
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Yuriko Sasaki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Division of Biosignal Pathophysiology, Kobe University Graduate School of Medicine, Kobe, Japan
- Medical Center for Student Health, Kobe University, Kobe, Japan
| | - Sally A. Camper
- Department of Human Genetics, University of Michigan, Ann Arbor, MI, United States
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Kawada T, Yamamoto H, Miyamoto T, Hayama Y, Li M, Zheng C, Uemura K, Sugimachi M, Saku K. Ivabradine increases the high frequency gain ratio in the vagal heart rate transfer function via an interaction with muscarinic potassium channels. Physiol Rep 2021; 9:e15134. [PMID: 34889074 PMCID: PMC8661101 DOI: 10.14814/phy2.15134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
Muscarinic potassium channels (IK,ACh ) are thought to contribute to the high frequency (HF) dynamic heart rate (HR) response to vagal nerve stimulation (VNS) because they act faster than the pathway mediated by hyperpolarization-activated cyclic nucleotide-gated (HCN) channels. However, the interactions between the two pathways have not yet been fully elucidated. We previously demonstrated that HCN channel blockade by ivabradine (IVA) increased the HF gain ratio of the transfer function from VNS to HR. To test the hypothesis that IVA increases the HF gain ratio via an interaction with IK,ACh , we examined the dynamic HR response to VNS under conditions of control (CNT), IK,ACh blockade by tertiapin-Q (TQ, 50 nM/kg), and TQ plus IVA (2 mg/kg) (TQ + IVA) in anesthetized rats (n = 8). In each condition, the right vagal nerve was stimulated for 10 min with binary white noise signals between 0-10, 0-20, and 0-40 Hz. On multiple regression analysis, the HF gain ratio positively correlated with the VNS rate with a coefficient of 1.691 ± 0.151 (×0.01) (p < 0.001). TQ had a negative effect on the HF gain ratio with a coefficient of -1.170 ± 0.214 (×0.01) (p < 0.001). IVA did not significantly increase the HF gain ratio in the presence of TQ. The HF gain ratio remained low under the TQ + IVA condition compared to controls. These results affirm that the IVA-induced increase in the HF gain ratio is dependent on the untethering of the hyperpolarizing effect of IK,ACh .
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Affiliation(s)
- Toru Kawada
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Hiromi Yamamoto
- Department of CardiologyKurashiki Central HospitalOhara HealthCare FoundationOkayamaJapan
- Division of Clinical ResearchKurashiki Clinical Research InstituteOhara HealthCare FoundationOkayamaJapan
| | - Tadayoshi Miyamoto
- Department of Sport and Health SciencesFaculty of Sport and Health ScienceOsaka Sangyo UniversityOsakaJapan
| | - Yohsuke Hayama
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Meihua Li
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Can Zheng
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Kazunori Uemura
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Masaru Sugimachi
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Keita Saku
- Department of Cardiovascular DynamicsNational Cerebral and Cardiovascular CenterOsakaJapan
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