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南部 静紀医学部附属病院 小児科助教
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■ 論文- (公社)日本小児科学会, 2026年02月, 日本小児科学会雑誌, 130(2) (2), 332 - 332, 日本語横紋筋融解症を主徴とした肢帯型筋ジストロフィーR19例
- Background/Objectives: Duchenne muscular dystrophy (DMD) is an X-linked inherited muscle disease. Patients with DMD demonstrate improved prognosis with angiotensin-converting enzyme inhibitors and beta-blockers at the time of cardiac dysfunction. However, most deaths due to DMD are due to cardiac dysfunction. Fragmented QRS (fQRS) is an abnormal finding that forms a notch in the QRS wave on electrocardiography (ECG) and is associated with fibrosis and scarring of the myocardium. Methods: Patients with DMD were examined for the number of leads of fQRS, their sites of appearance, changes in cardiac dysfunction, and age using the chest leads of a synthesized 18-ECG. A retrospective analysis of 184 patients under 20 years of age with DMD and known genetic mutations was performed; they were divided into three age groups: 3-10, 11-15, and 16-20 years. The chest leads of the ECG were defined as follows: V1-3, anterior leads; V4-6, lateral leads; V7-9, posterior leads; and V3R-V5R, right-sided chest leads. Cardiac dysfunction was defined as a left ventricular (LV) ejection fraction <53% on the same day, and echocardiography was performed. LV dilation was defined as dilation beyond the normal range, considering the body surface area. Results: In 167 of 184 patients (91%), fQRS was present in one or more chest leads. The number of fQRS leads in the anterior and lateral walls was significantly higher in 16-20-year-olds than in 3-10-year-olds. The total number of chest leads with fQRS was 4.9 ± 3.1 in the cardiac dysfunction group and 3.5 ± 2.5 in the preserved group. The cardiac dysfunction group had a significantly greater number of fQRS leads than did the preserved group (p = 0.003). The group with LV dilation had a significantly greater number of fQRS leads than did the non-dilation group (p = 0.009). Conclusions: The fQRS site is associated with age, cardiac dysfunction, and LV dilation. Multivariate regression analysis revealed that the number of anterior leads of the fQRS correlated with age and that of lateral leads of the fQRS with cardiac dysfunction and LV dilation. The number of fQRS leads on the lateral wall marks cardiac dysfunction and LV dilation.2025年03月, Biomedicines, 13(4) (4), 英語, 国際誌研究論文（学術雑誌）
- Background/Objectives: Nusinersen is a disease-modifying drug for spinal muscular atrophy (SMA) that improves motor function. However, its effects on the skeletal muscles remain unclear. This study aimed to assess the intramuscular fat fraction in patients with SMA types II and III using muscle magnetic resonance imaging (MRI) and to explore the relationship between muscle tissue, lipid metabolism, and motor function during nusinersen treatment. Methods: This study included seven pediatric patients with SMA types II and III who received nusinersen treatment. Muscle MRIs were performed at three time points. Images of the central thigh were used to measure the cross-sectional area (CSA) and muscle fat area, and the intramuscular fat fraction (IMFF) was calculated. The thigh muscles were categorized into three groups: quadriceps, adductor, and hamstrings. Results: The median (range) of total IMFF for SMA type II and III at T-0, T-2, and T-4 were 18.5 (12.6-48.4), 24.4 (10.1-61.4), and 39.0 (30.0-68.6) % and increased over time. In five patients whose motor function was evaluated, a moderate negative correlation was observed between the changes in the Hammersmith Functional Motor Score Expanded (HSFME) and IMFF (r = -0.51). No significant changes in serum triglyceride or total cholesterol levels were observed during treatment. Conclusions: An increase in IMFF was associated with a decline in motor function. The baseline IMFF score was related to improvements in motor function scores, suggesting that the IMFF of the thigh muscle may serve as a novel, objective, and quantitative skeletal muscle-related biomarker for predicting the effects of nusinersen on muscle tissue.2025年03月, Diagnostics (Basel, Switzerland), 15(6) (6), 英語, 国際誌研究論文（学術雑誌）
- INTRODUCTION: A 20 kDa fragment at the N-terminus of titin is highly excreted in the urine of patients with Duchenne muscular dystrophy (DMD), making urine titin a prominent biomarker for muscle breakdown. This N-terminal fragment is presumed to be a product of degradation by a protein-degrading enzyme, calpain 3; however, whether calpain 3 is required remains unclear. We aimed to determine whether urine titin elevation occurs in the absence of calpain 3. METHODS: We measured urine titin by ELISA in two genetically confirmed limb-girdle muscular dystrophy type R1(LGMDR1) patients, 11 other LGMD patients, and five healthy controls. Five Capn3-/- and nine wild-type mice were also examined. RESULTS: Urine titin in LGMDR1 patients was ~100-fold higher than in controls (median 112.3 vs. 1.3 pmol/mg Cr, p < 0.0001), with no difference between LGMDR1 and other LGMD subtypes. Similarly, urine titin levels in Capn3-/- mice were more than four times higher than normal (p < 0.01). DISCUSSION: These results suggest the involvement of other protein-degrading enzymes leading to the production of the N-terminal fragment.2025年03月, Muscle & nerve, 71(3) (3), 442 - 445, 英語, 国際誌研究論文（学術雑誌）
- The coronavirus disease 2019 (COVID-19) pandemic has affected people worldwide, and pediatric patients with underlying diseases are at high risk of developing severe COVID-19. However, there are limited reports on the clinical impact of COVID-19, especially in patients with underlying neuromuscular diseases (NMD) and inborn errors of metabolism (IEM). This study aimed to investigate the incidence and clinical presentation of COVID-19 in patients with NMD and IEM. This was a single-center, cross-sectional study of patients with NMD and IEM in Japan for 2 years, from April 1, 2020 to March 31, 2022. Among 255 participants with a median age of 14 (range: 0-50) years, 192 (75%) and 63 (25%) had NMD and IEM, respectively. Among 255 patients, 8 (5 NMD and 3 IEM) were positive for the anti-severe acute respiratory syndrome coronavirus 2 nucleocapsid antibody, and the incidence was considered 3%. All positive patients had mild or asymptomatic COVID-19. None of the patients exhibited moderate or severe symptoms. In conclusion, this study revealed that the incidence of COVID-19 was low, and mild or subclinical infection was common even in patients with NMD and IEM, who may be at a higher risk of severe COVID-19.2025年02月, The Kobe journal of medical sciences, 70(4) (4), E106-E112, 英語, 国内誌研究論文（学術雑誌）
- BACKGROUND: Becker muscular dystrophy (BMD) is a dystrophinopathy caused by a pathological variant of the DMD gene. Urinary titin, a degradation product of the giant protein titin present in muscle sarcomeres, has been used as a biomarker to reflect muscle degradation in Duchenne muscular dystrophy, a more severe dystrophinopathy. However, the clinical significance of urinary titin levels in BMD remains unclear. This study aimed to investigate the relationship between urinary titin levels and the clinical data in patients with BMD. METHODS: Urine samples were collected from 123 patients with BMD, and urinary titin levels were measured. The association of urinary titin with clinical data, including age, physical measurements, physical activity, blood tests, and cardiopulmonary test results, was examined. RESULTS: A total of 257 urine samples were obtained from patients of 5-79 years of age. The median urinary titin level was 72.6 pmol/mg Cr (range 0.2-4325.0 pmol/mg Cr). No strong correlation was found between urinary titin levels and age, physical measurements, physical function, blood test results, or cardiopulmonary function. However, on comparing clinical data between the age-matched high urinary titin (N = 94) and normal (N = 29) groups, the high urinary titin group had a significantly greater number of non-ambulatory cases (23.9 % vs. 3.6 %), weaker grip strength (16.3 vs. 32.0 kg), and higher serum creatine kinase (1072 vs. 398 U/L) and cardiac troponin I (10.6 vs. 2.5 pg/mL) levels. CONCLUSION: Urinary titin was identified as a biomarker reflecting walking ability, muscle strength, and skeletal and cardiac damage in patients with BMD.2025年01月, Clinica chimica acta; international journal of clinical chemistry, 566, 120053 - 120053, 英語, 国際誌研究論文（学術雑誌）
- INTRODUCTION: Duchenne/Becker muscular dystrophies (DMD/BMD) are inherited muscle diseases, collectively referred to as dystrophinopathy, which are characterized by progressive degeneration or loss. Although serum creatine kinase (CK) is a classical biomarker of DMD and BMD, it alone cannot clearly differentiate between severe DMD and milder BMD. Among potential biomarkers, the levels of the fragmented products of titin, a structural muscle protein, may directly reflect the degree of muscle loss in DMD and BMD. Therefore, this study measured the serum titin/creatinine (Cr) ratio and evaluated its discriminatory ability in patients with DMD and BMD. METHODS: The patients with dystrophinopathy and healthy controls were included in this study. Patients were classified by the reading frame rule (out-of-frame, DMD; in-frame, BMD). Exceptional cases in which in-frame variants presented with severe symptoms or out-of-frame variants presented with mild symptoms were considered clinically DMD or clinically BMD, respectively. Serum titin levels were measured using enzyme-linked immunosorbent assay. Serum Cr levels measured on the same day were used to calculate serum titin/Cr ratios. RESULTS: The DMD, BMD, and control groups included 89 patients (85 DMD and four clinically DMD; aged 3-32 years), 21 patients (16 BMD and five clinically BMD; aged 6-33 years), and five participants (aged 7-12 years), respectively. Although serum CK levels did not differ significantly between DMD and BMD, the serum titin/Cr ratio in DMD was approximately 10 times higher than that in BMD group (p < 0.0001). Receiver operating characteristic curve analysis revealed that the ability of serum titin/Cr to distinguish DMD from BMD was superior to that of serum CK. Serum titin/Cr ratios in patients with DMD were higher than those with BMD across all age groups (3-10, 11-15, 16-20, and 21-33), but serum CK levels in patients with DMD were significantly higher than those with BMD only in the 11-15 and 21-33-year age groups. CONCLUSION: Unlike serum CK, the serum titin/Cr ratio in patients with DMD was consistently higher than that in patients with BMD, regardless of age. Serum titin/Cr was shown to be a biomarker to discriminate clinical severity in patients with dystrophinopathy.Frontiers Media SA, 2025年, Frontiers in neurology, 16, 1591748 - 1591748, 英語, 国際誌研究論文（学術雑誌）
- (一社)日本小児神経学会, 2024年05月, 脳と発達, 56(Suppl.) (Suppl.), S236 - S236, 日本語
- INTRODUCTION/AIMS: Duchenne muscular dystrophy (DMD) presents with skeletal muscle weakness, followed by cardiorespiratory involvement. The need for longitudinal data regarding DMD that could serve as a control for determining treatment efficacy in clinical trials has increased notably. The present study examined the longitudinal data of Japanese DMD patients collectively and assessed individual patients with pathogenic variants eligible for exon-skipping therapy. METHODS: Patients with DMD who visited Kobe University Hospital between March 1991 and March 2019 were enrolled. Data between the patients' first visit until age 20 years were examined. RESULTS: Three hundred thirty-seven patients were included. Serum creatine kinase levels showed extremely high values until the age of 6 years and a rapid decline from ages 7-12 years. Both the median 10-m run/walk velocity and rise-from-floor velocity peaked at the age of 4 years and declined with age. The values for respiratory function declined from the age of 11 years. The median left ventricular ejection fraction was >60% until the age of 12 years and rapidly declined from ages 13-15 years. Examination of the relationship between pathogenic variants eligible for exon-skipping therapy and longitudinal data revealed no characteristic findings. DISCUSSION: We found that creatine kinase levels and motor, respiratory, and cardiac functions each exhibited various changes over time. These findings provide useful information about the longitudinal data of several outcome measures for patients with DMD not receiving corticosteroids. These data may serve as historical controls in comparing the natural history of DMD patients not on regular steroid use in appropriate clinical trials.2024年05月, Muscle & nerve, 69(5) (5), 604 - 612, 英語, 国際誌研究論文（学術雑誌）
- Becker muscular dystrophy is caused by DMD mutations and is characterized by progressive muscle atrophy. The wide variations observed in muscle atrophy progression in Becker muscular dystrophy are considered multifactorial, including differences in mutations and environmental factors. In this case, two brothers, aged 2 and 3 years, had the identical DMD mutation, confirming their Becker muscular dystrophy diagnosis. They began using handrails when ascending and descending stairs at the age of 16 due to progressive muscular weakness. Over an 18-year follow-up, the older brother consistently had high serum creatine kinase levels, significantly over median levels. Muscle computed tomography finings revealed that the older brother's gluteus maximus and vastus femoris cross-sectional areas were only half and one-third of the younger brother's, respectively. The mean computed tomography values of gluteus maximus and vastus femoris were significantly lower in the older brother. Our report suggests that muscle atrophy in Becker muscular dystrophy cannot be solely explained by dystrophin mutation or environmental factors.2024年, SAGE open medical case reports, 12, 2050313X231221436, 英語, 国際誌研究論文（学術雑誌）
- Newborn screening (NBS) for spinal muscular atrophy (SMA) is necessary, as favorable outcomes can be achieved by treatment with disease-modifying drugs in early infancy. Although SMA-NBS has been initiated in Japan, its clinical results have not been fully reported. We report the findings of the initial 2.5 years of a pilot SMA-NBS of approximately 16,000 infants conducted from February 2021 in Hyogo Prefecture, Japan. Clinical data of 17 infants who tested positive were retrospectively obtained from the NBS follow-up centers participating in this multicenter cohort observational study. Genetic testing revealed 14 false positives, and three infants were diagnosed with SMA. Case 1 had two copies of survival motor neuron (SMN) 2 and showed SMA-related symptoms at diagnosis. Case 2 was asymptomatic, with two copies of SMN2. Asymptomatic case 3 had four copies of SMN2 exon 7, including the SMN1/2 hybrid gene. Cases 1 and 2 were treated within 1 month and case 3 at 8 months. All the patients showed improved motor function scores and did not require respiratory support. The identification of infants with SMA via NBS and early treatment improved their motor and respiratory outcomes. Thus, implementation of SMA-NBS at a nationwide scale should be considered.2023年12月, Genes, 14(12) (12), 英語, 国際誌研究論文（学術雑誌）
- PURPOSE: Duchenne muscular dystrophy (DMD) is an inherited muscular disease characterized by progressive and fatal muscle weakness. Electrocardiographic (ECG) abnormalities, including abnormal R wave amplitudes are frequently observed in DMD. However, clinical implications of abnormal R wave amplitudes remain unclear. Hence, DMD patients were examined for changes in R wave amplitude over time using synthesized 18-lead ECG and the relationship between R wave amplitude and cardiac function. METHODS: The results of 969 ECG examinations of 193 patients with DMD who underwent electrocardiography and echocardiography on the same day were retrospectively reviewed. RESULTS: A negative correlation was observed between R wave amplitude and age. Positive correlations between R wave amplitude and left ventricular ejection fraction were observed in leads V4, V5, V6, syn-V7, syn-V8, and syn-V9, with V6 showing the strongest correlation (r = 0.52). Mean R wave amplitude during cardiac dysfunction was lower than that observed with preserved cardiac function in leads V6 to syn-V9. Patients had preserved R wave amplitude up to three years before the onset of cardiac dysfunction, with a sharp decrease two years before cardiac dysfunction in leads V6 to syn-V9. CONCLUSIONS: In DMD patients, the R wave amplitude decreases with age. The sharp decline in R amplitude two years before cardiac dysfunction indicates that electrophysiological damage to the myocardium of the left ventricle lateral to the posterior wall precedes the finding of cardiac dysfunction. The R amplitude in V6 of the standard 12-lead ECG is a convenient predictive marker of cardiac dysfunction, similar to that of the 18-lead ECG.2023年11月, Journal of cardiology, 82(5) (5), 363 - 370, 英語, 国際誌研究論文（学術雑誌）
- Rotavirus (RV) is the leading cause of acute gastroenteritis (AGE), particularly in infants. In 2006, the high efficacy of oral RV vaccines (RVVs, RotarixTM and RotaTeqTM) was demonstrated. Voluntary RVV started in Japan in 2011, and in October 2020 were launched as universal oral RVVs in Japan. However, the impact of changes from voluntary to universal RVVs has not been studied in a primary emergency medical center in Japan. We investigated changes in the number of pediatric patients with AGE after introducing universal RVVs in our center. A clinical database of consecutive patients aged <16 who presented to Kobe Children’s Primary Emergency Medical Center between 1 April 2016 and 30 June 2022 was reviewed. After implementing universal RVVs, fewer children presented with RV-associated AGE (the reduction of proportion of the patients in 2022 was −61.7% (all ages), −57.9% (<1 years), −67.8% (1−<3 years), and −61.4% (3−<5 years) compared to 2019). A similar decrease in those of age who were not covered by the universal RVV was observed. There was a significant decline in the number of patients with AGE during the RV season who presented to the emergency department after implementing universal RVVs.2022年10月, Vaccines, 10(11) (11), 英語, 国際誌研究論文（学術雑誌）
- INTRODUCTION/AIMS: Serum cardiac troponin I (cTnI), its relation to cardiomyopathy, and the contribution of the ACTN3 genotype to serum levels of cTnI in Duchenne and Becker muscular dystrophy (DMD and BMD, respectively) remain unknown. In this study we aimed to reveal the characteristics of cTnI, assess whether cTnI is a biomarker for cardiomyopathy in these dystrophinopathies, and evaluate the contribution of the ACTN3 genotype to the serum levels of cTnI in DMD patients. METHODS: Serum cTnI values obtained from 127 DMD and 47 BMD patients were analyzed retrospectively. The relationship between cTnI and echocardiography data or the ACTN3 XX genotype was assessed. RESULTS: The cTnI levels and proportion of patients with abnormal cTnI levels were significantly higher among DMD patients than BMD, especially in the second decade of life. In DMD, the cTnI level reached a maximum at 13 years, and left ventricular ejection fraction (LVEF) became abnormal approximately 1 year subsequently. In BMD, the cTnI level peaked at the age of 14 years, and LVEF became abnormal 3 years later. Decreased LVEF was observed after cTnI elevation in both populations. cTnI levels by age in DMD patients with the ACTN3 XX genotype tended to increase significantly and early. DISCUSSION: Myocardial injury indicated by cTnI elevation was more common and severe in DMD patients. cTnI elevation preceding cardiac dysfunction may represent an early phase of cardiomyopathy progression and may be a biomarker for early detection of cardiomyopathy in these dystrophinopathies. The ACTN3 XX genotype may be a risk factor for early myocardial injury.2022年05月, Muscle & nerve, 65(5) (5), 521 - 530, 英語, 国際誌研究論文（学術雑誌）
- The mdx mouse is a model of Duchenne muscular dystrophy (DMD), a fatal progressive muscle wasting disease caused by dystrophin deficiency, and is used most widely in preclinical studies. Mice with dystrophin deficiency, however, show milder muscle strength phenotypes than humans. In human, the introduction of a sandwich enzyme-linked immunosorbent assay (ELISA) kit revealed a more than 700-fold increase in titin N-terminal fragment levels in the urine of pediatric patients with DMD. Notably, the urinary titin level declines with aging, reflecting progression of muscle wasting. In mouse, development of a highly sensitive ELISA kit has been awaited. Here, a sandwich ELISA kit to measure titin N-terminal fragment levels in mouse urine was developed. The developed kit showed good linearity, recovery, and repeatability in measuring recombinant or natural mouse titin N-terminal fragment levels. The titin N-terminal fragment concentration in the urine of mdx mice was more than 500-fold higher than that of normal mice. Urinary titin was further analyzed by extending the collection of urine samples to both young (3-11 weeks old) and aged (56-58 weeks old) mdx mice. The concentration in the young group was significantly higher than that in the aged group. It was concluded that muscle protein breakdown is active and persistent in mdx mice even though the muscle phenotype is mild. Our results provide an opportunity to develop DMD treatments that aim to alleviate muscle protein breakdown by monitoring urinary titin levels.2022年02月, Animal models and experimental medicine, 5(1) (1), 48 - 55, 英語, 国際誌研究論文（学術雑誌）
- Rapidly growing nontuberculous mycobacteria should be considered if GPRs gram-positive rods are detected in blood cultures 2-3 days after the blood sample collection.2021年02月, Clinical case reports, 9(2) (2), 835 - 840, 英語, 国際誌研究論文（学術雑誌）
- In myasthenia gravis (MG), damage to neuromuscular junctions may induce endoplasmic reticulum (ER) stress in skeletal muscles. In the current study, skeletal muscles obtained from patients with MG exhibited upregulation of glucose-regulated protein 78 (GRP78) mRNA that was activated by ER stress. Furthermore, GRP78 mRNA expression was higher in patients with MG and myositis than in patients with non-myopathy. We also observed a significant positive correlation between GRP78 mRNA expression and GRP78 protein levels and between GRP78 mRNA expression and age of MG onset. Our findings suggest that muscle weakness in MG might be caused by both neuromuscular junction disruption and ER stress.2014年08月, Journal of neuroimmunology, 273(1-2) (1-2), 72 - 6, 英語, 国際誌研究論文（学術雑誌）
- 2025年, 日本小児科学会雑誌, 129(6) (6)便中のフィルムアレイ検査が診療方針決定に有用であったエルシニア腸炎の2例
- 2025年, 日本小児科学会雑誌, 129(6) (6)摂食障害患者の体重の回復と骨密度の検討
- 2025年, 近畿小児科学会プログラム・抄録集, 38th血清アシルカルニチン分析で異常を認めない横紋筋融解症に対して網羅的遺伝子解析が有用であった3例
- 2025年, 近畿小児科学会プログラム・抄録集, 38thMCAD欠損症8名のsick day時の臨床データおよび注意点
- 2024年, 日本小児科学会雑誌, 128(2) (2)当院における新生児拡大マススクリーニング(NBS)検査費用の変更に伴う検査数や同意率取得率への影響
- 2024年, 兵庫県小児科医会報, (82) (82)古典型フェニルケトン尿症に対しペグバリアーゼを導入することによりフェニルアラニン血中濃度を低下することができた一例
- 2024年, 日本マススクリーニング学会誌, 34(2) (2)新生児マススクリーニング(NBS)を契機に発見された先天性乳糖不耐症(CLD)の新生児例
- 2024年, 日本マススクリーニング学会誌, 34(2) (2)兵庫県/神戸市の拡大新生児マススクリーニングにおけるポンペ病精密検査例の遺伝学的背景と酵素活性の検討
- 2024年, 日本先天代謝異常学会雑誌, 40 (CD-ROM)乳酸/ピルビン酸比の上昇を伴う高乳酸血症を呈したフルクトース1,6ビスホスファターゼ欠損症の新生児例
- 2024年, 日本小児科学会雑誌, 128(4) (4)兵庫県拡大新生児スクリーニングで発見された脊髄性筋萎縮症の3例
- (公社)日本小児科学会, 2023年04月, 日本小児科学会雑誌, 127(4) (4), 627 - 627, 日本語COVID-19感染症を契機に急性増悪した全身型重症筋無力症の女児例
- 2023年, 日本先天代謝異常学会雑誌, 39神戸こども初期急病センターを受診した低血糖患者における“血清グルコース値×Δanion gap”の分布
- 2023年, 日本小児遺伝学会学術集会プログラム・抄録集, 46th遺伝学的検査が死後の原因検索に有用であったグルタル酸血症2型の症例
- 2023年, 日本マススクリーニング学会誌, 33(2) (2)拡大新生児マススクリーニングで診断されたSMN2遺伝子4コピーのSMAに対して発症前治療を行った1例
- (一社)日本先天代謝異常学会, 2022年10月, 日本先天代謝異常学会雑誌, 38, 193 - 193, 日本語死亡時のアシルカルニチン分析結果を契機に確定診断したグルタル酸血症2型の一例
- (一社)日本先天代謝異常学会, 2022年10月, 日本先天代謝異常学会雑誌, 38, 215 - 215, 日本語糖原病9a型の3家系6人における食事療法開始後の身長の推移
- (一社)日本小児神経学会, 2022年05月, 脳と発達, 54(Suppl.) (Suppl.), S210 - S210, 日本語
- (公社)日本小児科学会, 2022年03月, 日本小児科学会雑誌, 126(3) (3), 551 - 551, 日本語過去5年間の小児摂食障害に対する家族療法の経験
- (一社)日本先天代謝異常学会, 2021年09月, 日本先天代謝異常学会雑誌, 37, 131 - 131, 日本語極低出生体重児におけるビオチンおよびビオチン関連代謝産物の推移
- (一社)日本先天代謝異常学会, 2021年09月, 日本先天代謝異常学会雑誌, 37, 158 - 158, 日本語著しい高アンモニア血症がない急性肝障害から診断したOTC欠損症の一例
- (一社)日本先天代謝異常学会, 2021年09月, 日本先天代謝異常学会雑誌, 37, 131 - 131, 日本語極低出生体重児におけるビオチンおよびビオチン関連代謝産物の推移
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