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Li D, Yu Q, Wu R, Tuo Z, Zhu W, Wang J, Shao F, Ye L, Ye X, Yoo KH, Ke M, Yang Y, Wei W, Feng D. Chronobiology of the Tumor Microenvironment: Implications for Therapeutic Strategies and Circadian-Based Interventions. Aging Dis 2024:AD.2024.0327. [PMID: 38607733 DOI: 10.14336/ad.2024.0327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Numerous research works have emphasized the critical role that circadian rhythm plays in the tumor microenvironment (TME). The goal of clarifying chrono-pharmacological strategies for improving cancer treatment in clinical settings is a continuous endeavor. Consequently, to enhance the use of time-based pharmaceutical therapies in oncology, combining existing knowledge on circadian rhythms' roles within the TME is essential. This perspective elucidates the functions of circadian rhythms in the TME across various stages of cancer development, progression, and metastasis. Specifically, aging, angiogenesis, and inflammation are implicated in modulating circadian rhythm within the TME. Furthermore, circadian rhythm exerts a profound influence on current cancer treatments and thereby generates chronotheray to manage tumors. From a TME perspective, circadian rhythm offers promising opportunities for cancer prevention and treatment; nevertheless, further study is needed to address unanswered scientific problems.
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Affiliation(s)
- Dengxiong Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Qingxin Yu
- Department of pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, Zhejiang, China
| | - Ruicheng Wu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhouting Tuo
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Weizhen Zhu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Fanglin Shao
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Luxia Ye
- Department of Public Research Platform, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Xing Ye
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Koo Han Yoo
- Department of Urology, Kyung Hee University, Korea
| | - Mang Ke
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yubo Yang
- Department of Urology, Three Gorges Hospital, Chongqing University, Wanzhou, Chongqing, China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
- Division of Surgery & Interventional Science, University College London, London W1W 7TS, UK
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Chavanne A, Jacobi D. Precision medicine in endocrinology: Unraveling metabolic health through time-restricted eating. Ann Endocrinol (Paris) 2024; 85:63-69. [PMID: 38101564 DOI: 10.1016/j.ando.2023.12.001] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023]
Abstract
As a promising avenue in nutrition, intermittent fasting, particularly time-restricted eating like the 8/16 protocol, requires careful individualization. This approach involves voluntary food restriction interspersed with normal eating, aiming to align with inner circadian rhythms for potential benefits in metabolism and weight management. Endocrinologists, responding to patient interest and backed by evidence-based medicine, can now delve into the intricacies of time-restricted eating. They consider each patient's unique medical history and expectations, integrating this approach into tailored treatment plans in a personalized medicine approach. Ongoing research is essential to deepen our comprehension of how time-restricted eating influences metabolic health, enabling the development of precise recommendations suitable for diverse populations and various clinical conditions. While time-restricted eating is a relevant metabolic approach, endocrinologists should exercise caution to prevent the promotion of eating disorders due to its restrictive nature.
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Affiliation(s)
- Albane Chavanne
- CHU de Nantes, Nantes Université, CNRS, INSERM, l'Institut du thorax, Nantes, France
| | - David Jacobi
- Institut de recherche en santé de Nantes Université, 8, quai Moncousu, 44000 Nantes, France.
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Lin X, Wang S, Huang J. The effects of time-restricted eating for patients with nonalcoholic fatty liver disease: a systematic review. Front Nutr 2024; 10:1307736. [PMID: 38239843 PMCID: PMC10794638 DOI: 10.3389/fnut.2023.1307736] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) represents a significant global health concern. Numerous investigations have explored the implications of time-restricted eating (TRE) in the management of NAFLD. Therefore, the objective of our study was to conduct a systematic review to summarize and analyze all randomized controlled trials (RCTs) of TRE for patients with NAFLD. A thorough literature search was executed across Embase, Cochrane Library, and PubMed databases, covering all records from their inception until 1 September 2023. All clinical studies of TRE for NAFLD were summarized and analyzed. Our systematic review included four RCTs, encompassing a total of 443 NAFLD patients. These studies varied in sample size from 32 to 271 participants. The TRE intervention was consistently applied in an 8-h window, over durations ranging from 4 weeks to 12 months. The findings suggest that TRE could offer several health benefits for NAFLD patients, such as improved liver health indicators like liver stiffness and intrahepatic triglyceride (IHTG) levels. Consequently, TRE appears to be a promising dietary intervention for NAFLD patients. However, it is premature to recommend TRE for patients with NAFLD. The existing body of research on the effects of TRE in NAFLD contexts is limited, underscoring the need for further high-quality studies to expand our understanding of TRE's benefits in treating NAFLD. Ongoing clinical trials may provide more insights into the effects of TRE in NAFLD.
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Affiliation(s)
| | - Shuai Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jinyu Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Talebi S, Shab-Bidar S, Mohammadi H, Moini A, Djafarian K. The effects of intermittent fasting diet alone or in combination with probiotic supplementation in comparison with calorie-restricted diet on metabolic and hormonal profile in patients with polycystic ovary syndrome: study protocol for a randomized clinical trial. Trials 2023; 24:690. [PMID: 37880791 PMCID: PMC10601288 DOI: 10.1186/s13063-023-07691-5] [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: 05/03/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in females characterized by ovulatory dysfunction, hyperandrogenism, and other metabolic disorders. Both intermittent fasting and specific probiotics have been suggested to help improve patients with PCOS through changes in gut microbial composition, circadian clock, and metabolic regulation. Therefore, the present study aims to investigate the effects of intermittent fasting alone or in combination with probiotic supplementation compared to the calorie-restricted (CR) diet on anthropometric measures, metabolic status, inflammation, and oxidative stress in women with PCOS. METHODS We will carry out a randomized clinical trial for 8 weeks. Participants will be randomly assigned (1:1:1) to one of the three groups: (1) a 14:10 early time-restricted feeding (TRF) diet with probiotic supplementation (n = 30); (2) a 14:10 early TRF diet with placebo supplementation (n = 30); (3) a CR diet (energy-restricted 25% of required calories) with placebo supplementation as a control group (n = 30). The primary outcomes will be changes in body weight and insulin resistance. However, glycemic control, lipid profile, metabolic parameters, sex hormone-binding globulin, dehydroepiandrosterone, anti-Mullerian hormone, free androgen index, hirsutism, acne, antioxidant and oxidant status, inflammation, anthropometric measures, mental health, sleep quality, appetite, eating behavior, food craving, and blood pressure are secondary outcomes. All outcomes of this study will be evaluated in pre- and post-intervention. DISCUSSION We hypothesized that 10-h TRE administered alone or in combination with probiotic supplementation to overweight and obese PCOS subjects would lead to weight loss and improved metabolic, hormonal, inflammatory, and antioxidant markers compared to control subjects following a standard 3-meal-per-day CR diet. ETHICAL ASPECTS The current trial received approval from the Medical Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.MEDICNE.REC.1401.425). TRIAL REGISTRATION Iranian Registry of Clinical Trials IRCT20121110011421N5. Registered on 3 October 2022.
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Affiliation(s)
- Sepide Talebi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Moini
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Kurosh Djafarian
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.
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BaHammam AS, Pirzada A. Timing Matters: The Interplay between Early Mealtime, Circadian Rhythms, Gene Expression, Circadian Hormones, and Metabolism-A Narrative Review. Clocks Sleep 2023; 5:507-535. [PMID: 37754352 PMCID: PMC10528427 DOI: 10.3390/clockssleep5030034] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/28/2023] Open
Abstract
Achieving synchronization between the central and peripheral body clocks is essential for ensuring optimal metabolic function. Meal timing is an emerging field of research that investigates the influence of eating patterns on our circadian rhythm, metabolism, and overall health. This narrative review examines the relationship between meal timing, circadian rhythm, clock genes, circadian hormones, and metabolic function. It analyzes the existing literature and experimental data to explore the connection between mealtime, circadian rhythms, and metabolic processes. The available evidence highlights the importance of aligning mealtime with the body's natural rhythms to promote metabolic health and prevent metabolic disorders. Specifically, studies show that consuming meals later in the day is associated with an elevated prevalence of metabolic disorders, while early time-restricted eating, such as having an early breakfast and an earlier dinner, improves levels of glucose in the blood and substrate oxidation. Circadian hormones, including cortisol and melatonin, interact with mealtimes and play vital roles in regulating metabolic processes. Cortisol, aligned with dawn in diurnal mammals, activates energy reserves, stimulates appetite, influences clock gene expression, and synchronizes peripheral clocks. Consuming meals during periods of elevated melatonin levels, specifically during the circadian night, has been correlated with potential implications for glucose tolerance. Understanding the mechanisms of central and peripheral clock synchronization, including genetics, interactions with chronotype, sleep duration, and hormonal changes, provides valuable insights for optimizing dietary strategies and timing. This knowledge contributes to improved overall health and well-being by aligning mealtime with the body's natural circadian rhythm.
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Affiliation(s)
- Ahmed S. BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh 11324, Saudi Arabia
| | - Abdulrouf Pirzada
- North Cumbria Integrated Care (NCIC), National Health Service (NHS), Carlisle CA2 7HY, UK;
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Guan L, Liu R. The Role of Diet and Gut Microbiota Interactions in Metabolic Homeostasis. Adv Biol (Weinh) 2023; 7:e2300100. [PMID: 37142556 DOI: 10.1002/adbi.202300100] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/10/2023] [Indexed: 05/06/2023]
Abstract
Diet is a pivotal determinant in shaping the structure and function of resident microorganisms in the gut through different food components, nutritive proportion, and calories. The effects of diet on host metabolism and physiology can be mediated through the gut microbiota. Gut microbiota-derived metabolites have been shown to regulate glucose and lipid metabolism, energy consumption, and the immune system. On the other hand, emerging evidence indicates that baseline gut microbiota could predict the efficacy of diet intervention, highlighting gut microbiota can be harnessed as a biomarker in personalized nutrition. In this review, the alterations of gut microbiota in different dietary components and dietary patterns, and the potential mechanisms in the diet-microbiota crosstalk are summarized to understand the interactions of diet and gut microbiota on the impact of metabolic homeostasis.
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Affiliation(s)
- Lizhi Guan
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the P. R. China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Ruixin Liu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the P. R. China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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7
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Saglam D, Colak GA, Sahin E, Ekren BY, Sezerman U, Bas M. Effects of Ramadan intermittent fasting on gut microbiome: is the diet key? Front Microbiol 2023; 14:1203205. [PMID: 37705730 PMCID: PMC10495574 DOI: 10.3389/fmicb.2023.1203205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/07/2023] [Indexed: 09/15/2023] Open
Abstract
Much research has been conducted regarding the impact of diet on the gut microbiota. However, the effects of dietary habits such as intermittent fasting are unclear. This study aimed to investigate the effect of intermittent fasting during Ramadan on the gut microbiota. The study was conducted on 12 healthy adult individuals who practiced fasting 17 h per day for 29 consecutive days during the month of Ramadan. To determine the dietary intake of individuals, a 3-day dietary record was kept at the beginning and end of the study. Reads that passed quality filtering were clustered, and custom-prepared 16S rRNA gene regions of bacteria associated with the human microbiome were used as a reference. Consensus sequences were created, and genus-level taxonomic annotations were determined using a sequence identity threshold of 95%. The correlations between the dietary intake measurements of the participants and the respective relative abundance of bacterial genera were investigated. The results showed that Firmicutes were higher in abundance in the gut microbiota before fasting among participants, while they were significantly lower in abundance at the end of Ramadan fasting (p < 0.05). Proteobacteria were significantly higher in abundance at the end of the month of Ramadan (p < 0.05). Fasting was associated with a significant decrease in levels of seven genera: Blautia, Coprococcus, Dorea, Faecalicatena, Fusicatenibacter, Lachnoclostridium, and Mediterraneibacter. Conversely, the abundances of two bacterial genera were enhanced at the end of the fasting month: Escherichia and Shigella. The results of the dietary intake analysis showed that a negative correlation was detected for three comparisons: Ihubacter and protein (rho = -0.54, p = 0.0068), Fusicatenibacter and vegetables (rho = -0.54, p = 0.0042), and Intestinibacter and nuts (rho = -0.54, p-value = 0.0065). The results suggest that even when the fasting period during Ramadan is consistent, the types of food consumed by individuals can affect the gut microbiota.
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Affiliation(s)
- Duygu Saglam
- Department of Nutrition and Dietetics, Health Sciences Faculty, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Gozde Aritici Colak
- Department of Nutrition and Dietetics, Health Sciences Faculty, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Eray Sahin
- Department of Biostatistics and Bioinformatics, Institute of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Berkay Yekta Ekren
- Department of Biostatistics and Bioinformatics, Institute of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Ugur Sezerman
- Department of Medical Statistics and Bioinformatics, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Murat Bas
- Department of Nutrition and Dietetics, Health Sciences Faculty, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
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Dyńka D, Paziewska A, Kowalcze K. Keto Menu-Effect of Ketogenic Menu and Intermittent Fasting on the Biochemical Markers and Body Composition in a Physically Active Man-A Controlled Case Study. Foods 2023; 12:3219. [PMID: 37685152 PMCID: PMC10486763 DOI: 10.3390/foods12173219] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
The combination of ketogenic diet (KD) with intermittent fasting (IF) has, for years, aroused a great interest in the scientific world and among healthy lifestyle enthusiasts. Its importance is even greater when the study subjects are physically active individuals. The aim of the study was a determination of the effect of strict calculated ketogenic menu combined with IF and with caloric deficit on the selected biochemical markers and body composition in a 23-year-old man performing strength training. At the same time, we decided to conduct the first so-deeply investigated and controlled case study in this respect. The study protocol included a 13-week-long ketogenic diet with intermittent fasting (of delayed time-restricted eating 16:8 type) and caloric deficit. A detailed menu was designed and was used by the man throughout the whole study duration. A number of blood tests were performed before and after the implemented dietary intervention. Additionally, body composition was determined weekly and the concentrations of glucose and ketone bodies, as well as pulse rate and arterial pressure, were measured daily. The most important changes noted included a significant increase in testosterone and vitamin D concentrations and significant reduction in the HOMA-IR index and concentrations of hepatic enzymes, insulin, glucose, iron, urea, and free triiodothyronine (FT3). Moreover, a significant improvement of body composition occurred (the ratio of total body mass to the adipose and muscular tissue and water mass improved). Favourable changes were also noted in heart rate and arterial pressure values. In view of that, the KD with IF and caloric deficit exerted favourable effects on most biochemical parameters and on body composition and caused an almost twofold increase in serum testosterone concentration.
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Affiliation(s)
| | | | - Katarzyna Kowalcze
- Institute of Health Sciences, Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, 08-110 Siedlce, Poland; (D.D.); (A.P.)
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Mahmoud A, Begg M, Tarhuni M, N Fotso M, Gonzalez NA, Sanivarapu RR, Osman U, Latha Kumar A, Sadagopan A, Alfonso M. Inflammatory Bowel Sugar Disease: A Pause From New Pharmacological Agents and an Embrace of Natural Therapy. Cureus 2023; 15:e42786. [PMID: 37664383 PMCID: PMC10469711 DOI: 10.7759/cureus.42786] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are immune-mediated chronic inflammatory diseases that target the gastrointestinal tract and other distant organs. The incidence of IBDs has been rising and is more prevailing in Western communities. The etiology has been vague, but different theories include environmental factors that elicit an uncontrolled immune response, which damages internal organs. Treatment of either Crohn's disease or ulcerative colitis has witnessed significant advances; however, pharmacological drugs' side effects limit their use. Research about microbiota and its influence on IBDs has gained fame, and multiple studies correlate microbiota diversity positively with IBD treatment. Many factors contribute to the microbiota's health, including different diets, antibiotics, prebiotics, probiotics, synbiotics, and postbiotics. Specific immune responses lie behind the pathogenesis of IBDs and microbiota dysbiosis, and different studies have postulated new ways to control this abnormal response. Physical activity, sun exposure, efficient sleep, intermittent fasting, and supplementation of probiotics and vitamins are natural ways that help modulate this immune response, do not cost money as IBD pharmacological drugs, and do not come with deleterious side effects that are sometimes more harmful than IBDs. Our article proposes a comprehensive natural approach that can benefit IBD patients enormously. This approach does not replace the medications currently used in treating IBDs. The suggested approach can be used in combination with medications and might aid in reducing the doses of those medications.
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Affiliation(s)
- Anas Mahmoud
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maha Begg
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mawada Tarhuni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Monique N Fotso
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Natalie A Gonzalez
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Raghavendra R Sanivarapu
- Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Odessa, USA
- Pulmonary and Critical Care Medicine, Nassau University Medical Center, East Meadow, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Usama Osman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA
| | - Abishek Latha Kumar
- Internal Medicine, Spartan Health Sciences University, Vieux Fort, LCA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aishwarya Sadagopan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Michael Alfonso
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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