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King SD, Veliginti S, Brouwers MCGJ, Ren Z, Zheng W, Setiawan VW, Wilkens LR, Shu XO, Arslan AA, Freeman LEB, Bracci PM, Canzian F, Du M, Gallinger SJ, Giles GG, Goodman PJ, Haiman CA, Kogevinas M, Kooperberg C, LeMarchand L, Neale RE, Visvanathan K, White E, Albanes D, Andreotti G, Babic A, Berndt SI, Brais LK, Brennan P, Buring JE, Rabe KG, Bamlet WR, Chanock SJ, Fuchs CS, Gaziano JM, Giovannucci EL, Hackert T, Hassan MM, Katzke V, Kurtz RC, Lee IM, Malats N, Murphy N, Oberg AL, Orlow I, Porta M, Real FX, Rothman N, Sesso HD, Silverman DT, Thompson IM, Wactawski-Wende J, Wang X, Wentzensen N, Yu H, Zeleniuch-Jacquotte A, Yu K, Wolpin BM, Duell EJ, Li D, Hung RJ, Perdomo S, McCullough ML, Freedman ND, Patel AV, Peters U, Riboli E, Sund M, Tjønneland A, Zhong J, Van Den Eeden SK, Kraft P, Risch HA, Amundadottir LT, Klein AP, Stolzenberg-Solomon RZ, Antwi SO. Genetic Susceptibility to Nonalcoholic Fatty Liver Disease and Risk for Pancreatic Cancer: Mendelian Randomization. Cancer Epidemiol Biomarkers Prev 2023; 32:1265-1269. [PMID: 37351909 PMCID: PMC10529823 DOI: 10.1158/1055-9965.epi-23-0453] [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: 04/25/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND There are conflicting data on whether nonalcoholic fatty liver disease (NAFLD) is associated with susceptibility to pancreatic cancer. Using Mendelian randomization (MR), we investigated the relationship between genetic predisposition to NAFLD and risk for pancreatic cancer. METHODS Data from genome-wide association studies (GWAS) within the Pancreatic Cancer Cohort Consortium (PanScan; cases n = 5,090, controls n = 8,733) and the Pancreatic Cancer Case Control Consortium (PanC4; cases n = 4,163, controls n = 3,792) were analyzed. We used data on 68 genetic variants with four different MR methods [inverse variance weighting (IVW), MR-Egger, simple median, and penalized weighted median] separately to predict genetic heritability of NAFLD. We then assessed the relationship between each of the four MR methods and pancreatic cancer risk, using logistic regression to calculate ORs and 95% confidence intervals (CI), adjusting for PC risk factors, including obesity and diabetes. RESULTS No association was found between genetically predicted NAFLD and pancreatic cancer risk in the PanScan or PanC4 samples [e.g., PanScan, IVW OR, 1.04; 95% confidence interval (CI), 0.88-1.22; MR-Egger OR, 0.89; 95% CI, 0.65-1.21; PanC4, IVW OR, 1.07; 95% CI, 0.90-1.27; MR-Egger OR, 0.93; 95% CI, 0.67-1.28]. None of the four MR methods indicated an association between genetically predicted NAFLD and pancreatic cancer risk in either sample. CONCLUSIONS Genetic predisposition to NAFLD is not associated with pancreatic cancer risk. IMPACT Given the close relationship between NAFLD and metabolic conditions, it is plausible that any association between NAFLD and pancreatic cancer might reflect host metabolic perturbations (e.g., obesity, diabetes, or metabolic syndrome) and does not necessarily reflect a causal relationship between NAFLD and pancreatic cancer.
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Affiliation(s)
- Sontoria D. King
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Swathi Veliginti
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Martijn C. G. J. Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Zhewen Ren
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Wei Zheng
- Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Veronica W. Setiawan
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lynne R. Wilkens
- Cancer Epidemiology Division, Population Sciences in the Pacific Program, University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Xiao-Ou Shu
- Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alan A. Arslan
- Departments of Obstetrics and Gynecology, Population Health and Environmental Medicine, NYU Perlmutter Comprehensive Cancer Center, New York, New York, USA
| | - Laura E. Beane Freeman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Paige M. Bracci
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Federico Canzian
- Genomic Epidemiology Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mengmeng Du
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Steven J. Gallinger
- Hepatobiliary/Pancreatic Surgical Oncology Program, University Health Network, Toronto, ON, Canada
- The Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Graham G. Giles
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Phyllis J. Goodman
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Christopher A. Haiman
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Manolis Kogevinas
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Loic LeMarchand
- Cancer Epidemiology Division, Population Sciences in the Pacific Program, University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
- Cancer Epidemiology Division, Population Sciences in the Pacific Program, University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Rachel E. Neale
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Kala Visvanathan
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Emily White
- Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Demetrius Albanes
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gabriella Andreotti
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ana Babic
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sonja I. Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lauren K. Brais
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul Brennan
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Julie E. Buring
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kari G. Rabe
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - William R. Bamlet
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Stephen J. Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Charles S. Fuchs
- Yale Cancer Center, New Haven, Connecticut, USA
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Smilow Cancer Hospital, New Haven, Connecticut, USA
| | - J. Michael Gaziano
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Boston Veteran Affairs Healthcare System, Boston, Massachusetts, USA
| | - Edward L. Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Manal M. Hassan
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Verena Katzke
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Robert C. Kurtz
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - I-Min Lee
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Núria Malats
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Center (CNIO), Madrid, Spain
| | - Neil Murphy
- Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
| | - Ann L. Oberg
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Irene Orlow
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miquel Porta
- Hospital del Mar Institute of Medical Research (IMIM), Universitat Autònoma de Barcelona, Spain
| | - Francisco X. Real
- Epithelial Carcinogenesis Group, Spanish National Cancer Research Centre-CNIO, Madrid, Spain
| | - Nathaniel Rothman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Howard D. Sesso
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Debra T. Silverman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ian M. Thompson
- CHRISTUS Santa Rosa Hospital – Medical Center, San Antonio, Texas, USA
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, University of Buffalo, Buffalo, New York, USA
| | - Xiaoliang Wang
- Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Herbert Yu
- Cancer Epidemiology Division, Population Sciences in the Pacific Program, University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Anne Zeleniuch-Jacquotte
- Departments of Population Health and Environmental Medicine, NYU Perlmutter Comprehensive Cancer Center, New York, New York, USA
| | - Kai Yu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brian M. Wolpin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eric J. Duell
- Unit of Nutrition and Cancer, Cancer Epidemiology Research Program, Bellvitge Biomedical Research Institute (IDIBELL), Catalan Institute of Oncology (ICO), Barcelona, Spain
| | - Donghui Li
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rayjean J. Hung
- Lunenfeld-Tanenbaum Research Institute of Sinai Health System, University of Toronto, Toronto, Canada
| | - Sandra Perdomo
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | | | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alpa V. Patel
- Department of Population Science, American Cancer Society, Atlanta, GA, USA
| | - Ulrike Peters
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elio Riboli
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Malin Sund
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | | | - Jun Zhong
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Stephen K. Van Den Eeden
- Division of Research, Kaiser Permanente, Northern California, Oakland, CA, USA
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Peter Kraft
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Harvey A. Risch
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Laufey T. Amundadottir
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alison P. Klein
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Rachael Z. Stolzenberg-Solomon
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Samuel O. Antwi
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Antwi SO, Heckman M, White L, Yan I, Sarangi V, Lauer KP, Reddy J, Ahmed F, Veliginti S, Mejías Febres ED, Hatia RI, Chang P, Izquierdo-Sanchez L, Boix L, Rojas A, Banales JM, Reig M, Stål P, Gómez MR, Singal AG, Li D, Hassan MM, Roberts LR, Patel T. Metabolic liver cancer: associations of rare and common germline variants in one-carbon metabolism and DNA methylation genes. Hum Mol Genet 2023; 32:2646-2655. [PMID: 37369012 PMCID: PMC10407694 DOI: 10.1093/hmg/ddad099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Animal studies implicate one-carbon metabolism and DNA methylation genes in hepatocellular carcinoma (HCC) development in the setting of metabolic perturbations. Using human samples, we investigated the associations between common and rare variants in these closely related biochemical pathways and risk for metabolic HCC development in a multicenter international study. We performed targeted exome sequencing of 64 genes among 556 metabolic HCC cases and 643 cancer-free controls with metabolic conditions. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for multiple comparisons. Gene-burden tests were used for rare variant associations. Analyses were performed in the overall sample and among non-Hispanic whites. The results show that among non-Hispanic whites, presence of rare functional variants in ABCC2 was associated with 7-fold higher risk of metabolic HCC (OR = 6.92, 95% CI: 2.38-20.15, P = 0.0004), and this association remained significant when analyses were restricted to functional rare variants observed in ≥2 participants (cases 3.2% versus controls 0.0%, P = 1.02 × 10-5). In the overall multiethnic sample, presence of rare functional variants in ABCC2 was nominally associated with metabolic HCC (OR = 3.60, 95% CI: 1.52-8.58, P = 0.004), with similar nominal association when analyses were restricted to functional rare variants observed in ≥2 participants (cases 2.9% versus controls 0.2%, P = 0.006). A common variant in PNPLA3 (rs738409[G]) was associated with higher HCC risk in the overall sample (P = 6.36 × 10-6) and in non-Hispanic whites (P = 0.0002). Our findings indicate that rare functional variants in ABCC2 are associated with susceptibility to metabolic HCC in non-Hispanic whites. PNPLA3-rs738409 is also associated with metabolic HCC risk.
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Affiliation(s)
- Samuel O Antwi
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Heckman
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Launia White
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Irene Yan
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | - Vivekananda Sarangi
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Kimberly P Lauer
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Joseph Reddy
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Fowsiyo Ahmed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Swathi Veliginti
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | | | - Rikita I Hatia
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Chang
- Department of Gastrointestinal Medical Oncology, The MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Izquierdo-Sanchez
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute—Donostia University Hospital, University of the Basque Country (UPV/EHU), CIBERehd, San Sebastian, Spain
| | - Loreto Boix
- BCLC Group, Liver Unit, ICMDM, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Angela Rojas
- SeLiver Group, UCM Digestive Diseases, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
- Hepatic and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Madrid, Spain
| | - Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute—Donostia University Hospital, University of the Basque Country (UPV/EHU), CIBERehd, San Sebastian, Spain
- Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Maria Reig
- BCLC Group, Liver Unit, ICMDM, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Per Stål
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Manuel Romero Gómez
- SeLiver Group, UCM Digestive Diseases, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
- Hepatic and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Madrid, Spain
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donghui Li
- Department of Gastrointestinal Medical Oncology, The MD Anderson Cancer Center, Houston, TX, USA
| | - Manal M Hassan
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tushar Patel
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
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3
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Bangolo A, Fwelo P, Iyer KM, Klinger S, Tavares L, Dey S, Chacko AA, Hein M, Gudena S, Lawal G, Sivasubramanian BP, Rimba Z, Hirpara K, Merajunnissa M, Veliginti S, Arana G, Sathyarajan DT, Singh S, Shetty T, Bhardwaj K, Hashemy S, Duran RL, Kim SH, Hipolito CM, Yoon K, Patel V, Alshimari A, Inban P, Yasmeen S, Devanaboyina K, Kumar G, Preet S, Akhtar M, Abdi A, Nalajala N, Rizvi SFM, Gupta B, Weissman S. Primary Cardiac Sarcoma: Clinical Characteristics and Prognostic Factors over the Past 2 Decades. Diseases 2023; 11:diseases11020074. [PMID: 37218887 DOI: 10.3390/diseases11020074] [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: 04/20/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Primary cardiac sarcomas (PCS) are extremely rare malignant tumors involving the heart. Only isolated case reports have been described in the literature over different periods of time. This pathology has been associated with a dismal prognosis and given its rarity; treatment options are very limited. Furthermore, there are contrasting data about the effectiveness of current treatment modalities in improving the survival of patients with PCS, including surgical resection which is the mainstay of therapy. There is a paucity of data on the epidemiological characteristics of PCS. This study has the objective of investigating the epidemiologic characteristics, survival outcomes, and independent prognostic factors of PCS. METHODS A total of 362 patients were ultimately registered in our study from the Surveillance, Epidemiology, and End Results (SEER) database. The study period was from 2000 to 2017. Demographics such as clinical characteristics, overall mortality (OM), and PCS-specific mortality (CSM) were taken into account. A p value of <0.1 in the univariate analysis leads to the incorporation of the variable into multivariate analysis adjusting for covariates. Adverse prognostic factors were represented by a Hazard Ratio (HR) greater than one. The five-year survival analysis was carried out using the Kaplan-Meier method and the log-rank test was used to compare survival curves. RESULTS Crude analysis revealed a high OM in age 80+ (HR = 5.958, 95% CI 3.357-10.575, p < 0.001), followed by age 60-79 (HR = 1.429, 95% CI 1.028-1.986, p = 0.033); and PCS with distant metastases (HR = 1.888, 95% CI 1.389-2.566, p < 0.001). Patients that underwent surgical resection of the primary tumor and patients with malignant fibrous histiocytomas (HR = 0.657, 95% CI 0.455-0.95, p = 0.025) had a better OM (HR = 0.606, 95% CI 0.465-0.791, p < 0.001). The highest cancer-specific mortality was observed in age 80+ (HR = 5.037, 95% CI 2.606-9.736, p < 0.001) and patients with distant metastases (HR = 1.953, 95% CI 1.396-2.733, p < 0.001). Patients with malignant fibrous histiocytomas (HR = 0.572, 95% CI 0.378-0.865, p = 0.008) and those who underwent surgery (HR = 0.581, 95% CI 0.436-0.774, p < 0.001) had a lower CSM. Patients in the age range 80+ (HR = 13.261, 95% CI 5.839-30.119, p < 0.001) and advanced disease with distant metastases (HR = 2.013, 95% CI 1.355-2.99, p = 0.001) were found to have a higher OM in the multivariate analyses adjusting for covariates). Lower OM was found in patients with rhabdomyosarcoma (HR = 0.364, 95% CI 0.154-0.86, p = 0.021) and widowed patients (HR = 0.506, 95% CI 0.263-0.977, p = 0.042). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups, and lower mortality in patients with Rhabdomyosarcoma. CONCLUSION In this United States population-based retrospective cohort study using the SEER database, we found that cardiac rhabdomyosarcoma was associated with the lowest CSM and OM. Furthermore, as expected, age and advanced disease at diagnosis were independent factors predicting poor prognosis. Surgical resection of the primary tumor showed lower CSM and OM in the crude analysis but when adjusted for covariates in the multivariate analysis, it did not significantly impact the overall mortality or the cancer-specific mortality. These findings allow for treating clinicians to recognize patients that should be referred to palliative/hospice care at the time of diagnosis and avoid any surgical interventions as they did not show any differences in mortality. Surgical resection, adjuvant chemotherapy, and/or radiation in patients with poor prognoses should be reserved as palliative measures rather than an attempt to cure the disease.
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Affiliation(s)
- Ayrton Bangolo
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Pierre Fwelo
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX 77030, USA
| | - Kritika M Iyer
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Sarah Klinger
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Lorena Tavares
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Shraboni Dey
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Angel Ann Chacko
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Myat Hein
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Samyukta Gudena
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Gbenga Lawal
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Barath P Sivasubramanian
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Zekordavar Rimba
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Kinjal Hirpara
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Merajunnissa Merajunnissa
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Swathi Veliginti
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Georgemar Arana
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Dily T Sathyarajan
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Sachin Singh
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Tanvi Shetty
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Kshitij Bhardwaj
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Sayed Hashemy
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Roberto L Duran
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Sung H Kim
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Candice M Hipolito
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Kibo Yoon
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Vrusha Patel
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Aseel Alshimari
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Pugazhendi Inban
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Saaniya Yasmeen
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Krushika Devanaboyina
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Gulshan Kumar
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Saran Preet
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Mishgan Akhtar
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Ayanleh Abdi
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Navya Nalajala
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Syed F M Rizvi
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Bhavna Gupta
- Department of Hematology and Oncology, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
| | - Simcha Weissman
- Department of Medicine, Hackensack Meridian Health/Palisades Medical Center, North Bergen, NJ 07047, USA
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4
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Bangolo A, Sagireddy S, Mahamadeen S, Hasta F, Reddy SA, Naz A, Ranganatha R, Ricketts C, Muppalla P, Veliginti S, Arana G, Sathyarajan DT, Singh S, Shetty T, Bhardwaj K, Hashemy S, Duran RL, Kim SH, Hipolito CM, Yoon K, Patel V, Alshimari A, Inban P, Yasmeen S, Weissman S. A Rare Case of Refractory Catastrophic Antiphospholipid Syndrome Successfully Treated With Rituximab and Plasma Exchange. J Community Hosp Intern Med Perspect 2023; 13:79-82. [PMID: 37877050 PMCID: PMC10593160 DOI: 10.55729/2000-9666.1175] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 10/26/2023] Open
Abstract
A small subset of patients with antiphospholipid syndrome (APS) may develop widespread thrombotic disease with organ damage, referred to as catastrophic APS (CAPS) that is associated with a high mortality. Medical therapy typically involves a combination of anticoagulation, systemic glucocorticoids, plasmapheresis, and intravenous immune globulin (IVIG). There is currently no consensus for the management of refractory cases of CAPS. However, monoclonal antibodies such as rituximab and eculizumab have shown some benefits. Herein, we present a 29-year-old female with previous pulmonary embolism who presented with necrotic left toes and was eventually diagnosed with refractory CAPS, successfully treated with Plasmapheresis and Rituximab. With this case report, we hope to encourage the usage of Rituximab in the management of CAPS.
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Affiliation(s)
- Ayrton Bangolo
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sowmya Sagireddy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sarah Mahamadeen
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Felicia Hasta
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sadhu A. Reddy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Afshan Naz
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Ravishankar Ranganatha
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Cleveland Ricketts
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Padmavathi Muppalla
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Swathi Veliginti
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Georgemar Arana
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Dily T. Sathyarajan
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sachin Singh
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Tanvi Shetty
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Kshitij Bhardwaj
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sayed Hashemy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Roberto L. Duran
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sung H. Kim
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Candice M. Hipolito
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Kibo Yoon
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Vrusha Patel
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Aseel Alshimari
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Pugazhendi Inban
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Saaniya Yasmeen
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
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5
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Mohan A, Godugu S, Joshi SS, Shah KB, Vanka SC, Shakil H, P D, Veliginti S, Sure PS, Goranti J. Gut-brain axis: altered microbiome and depression - review. Ann Med Surg (Lond) 2023; 85:1784-1789. [PMID: 37228982 PMCID: PMC10205384 DOI: 10.1097/ms9.0000000000000573] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/22/2023] [Indexed: 05/27/2023] Open
Abstract
The concept of a 'gut-brain axis' was recently developed when the complex communications between the brain and the gut became evident. The interaction may affect emotions, motivation, mood, and higher cognitive functions as well as gut homeostasis. Human microbe symbiosis's merits are now acknowledged to transcend human mental health. Research has recently indicated that the gut-brain axis plays a vital role in brain health maintenance. The term 'gut-brain axis' can only partially capture the intricacy of these interactions. Dysbiosis of the gut commensals has been seen in patients with psychiatric diseases, such as depression. Major depressive disorder is caused by complicated interactions between the individual gene and the environment. In a forced swimming test, P. Zheng et al. discovered that germ-free mice with no gut microbiota had a shorter immobility duration than healthy mice. More radical effects were expressed on the use of probiotics rather than prebiotics and postbiotics in reducing the symptoms of depression in patients with major depressive disorder. One of prime importance can be given to exploring more microbiota to investigate the better therapeutic effects of probiotics, prebiotics, and postbiotics.
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Affiliation(s)
- Anmol Mohan
- Department of Medicine, Karachi Medical & Dental College, Karachi, Pakistan
| | - Swathi Godugu
- Department of Medicine, Zaporozhye State Medical University, Zaporozhye, Ukraine
| | - Saumya S. Joshi
- Department of Medicine, Gujarat Medical Education and Research Society, Sola, Ahmedabad
| | - Kenisha B. Shah
- Department of Medicine, Gujarat Medical Education and Research Society, Sola, Ahmedabad
| | - Srija C. Vanka
- Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinna Avutapalli, Andhra Pradesh
| | - Hania Shakil
- Hamdard College of Medicine and Dentistry, Hamdard University, Pakistan Medical Commission, Karachi, Pakistan
| | - Dhanush P
- Department of Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka
| | - Swathi Veliginti
- Department of Internal Medicine, Hackensack Meridian Health-Palisades Medical Center, New Jersey, USA
| | | | - Jyothsna Goranti
- Hamdard College of Medicine and Dentistry, Hamdard University, Pakistan Medical Commission, Karachi, Pakistan
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6
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Lungba RM, Khan SZA, Ajibawo-Aganbi U, Perez Bastidas MV, Veliginti S, Saleem S, Cancarevic I. The Role of the Gut Microbiota and the Immune System in the Development of Autism. Cureus 2020; 12:e11226. [PMID: 33269154 PMCID: PMC7707059 DOI: 10.7759/cureus.11226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 12/28/2022] Open
Abstract
Autism spectrum disorders (ASDs) are neurodevelopmental disorders that present with social skills and communication challenges, restricted interest, and repetitive behavior. The specific cause of autism is not well understood yet. However, numerous studies indicated that environmental and genetic factors, dysregulated immune response, and alterations to the balance and content of the gut microbiota are implemented in the development of autism. Many non-pharmacological interventions are nominated to manage autism, including family support services and psychoeducational methods. Moreover, different pharmacological therapy modalities are recommended for children with ASD. Learning more about the brain, immune system, and gut connections could assist in early diagnosis and treatment of this devastating neurodevelopmental disorders as an early intervention in ASD could improve a child's overall development. We gathered data from relevant previously published articles on PubMed to evaluate the role of the gut microbiota and the immune system on the development of autism..
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Affiliation(s)
- Rayan M Lungba
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Seyad Zulficar Ali Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Family Medicine, Ministry of Health Oman, Salalah, OMN
| | - Uvie Ajibawo-Aganbi
- Faculty of Health Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Swathi Veliginti
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sania Saleem
- Research and Development, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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7
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Abstract
For decades, the focus of managing autoimmune hypothyroidism has been on thyroxine replacement. Correcting lab parameters such as thyroid stimulating hormone (TSH) has been a primary goal. The increasing prevalence of Hashimoto’s thyroiditis (HT) continues to impact the quality of life in patients. We believe a holistic approach to this disease entity, considering its underlying complex etiopathogenesis, would benefit patients. Nutraceuticals are combinations of essential nutrients and are becoming a part of novel medical treatments despite the lack of regulation. This review aims to present a concise summary of recent developments regarding minerals such as zinc, selenium, magnesium, iron, and their potential clinical benefit as nutraceuticals in patients with HT. We have explored the potential benefits and associations of these minerals in HT and thyroid function. We reviewed relevant articles, metanalyses, and clinical trials in literature platforms such as PubMed, PubMed Central, and Google Scholar. Significant data found in the literature suggesting a potential health benefit of these minerals in HT though there were many studies to the contrary. Many trials demonstrated the restoration of residual symptoms, reversal of HT-associated thyroid morphological changes, and improvement in thyroid functions. Many of these trials lack statistical power due to the small sample sizes, and their external validity may be questionable due to unaccounted confounding factors. In our opinion, to support an evidence-based holistic clinical approach, further scientific evidence is needed. The association of these elements in thyroid function necessitates more large scale pragmatic trials to elucidate the benefits of nutraceuticals in HT.
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Affiliation(s)
- Seyad Zulficar Ali Khan
- Research and Development, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Primary Care & Emergency, Ministry of Health Oman, Salalah, OMN
| | - Rayan M Lungba
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Uvie Ajibawo-Aganbi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Swathi Veliginti
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maria V Perez Bastidas
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sania Saleem
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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8
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Ajibawo-Aganbi U, Saleem S, Khan SZA, Veliginti S, Perez Bastidas MV, Lungba RM, Cancarevic I. Can Nutritional Adequacy Help Evade Neurodegeneration in Older Age? A Review. Cureus 2020; 12:e10921. [PMID: 33062461 PMCID: PMC7556684 DOI: 10.7759/cureus.10921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2022] Open
Abstract
There is an increase in susceptibility to chronic and debilitating diseases with aging. The reason for the underlying neuronal degeneration and normal aging of the brain remains elusive. Different research studies have been conducted to discover how the brain degenerates and the importance of vitamins' role in the neurocognitive decline. Comprehensive literature research was conducted using all relevant data available from PubMed and Google scholar for this article. There has been evidence linking the consumption of essential nutrients to preventing the disease conditions that result in cognitive decline. This article provides the latest scientific advances specific to how dietary nutrients and non-nutrient may affect cognitive aging. An adequate supply of nutrients like vitamin B2 (riboflavin), vitamin B12, vitamin E, essential fatty acid (omega-3 fatty acid), and flavonoids play a vital role in ensuring healthy aging, enhancing memory, and strengthening neuroprotection. These nutrients help in neurodegenerative diseases like Alzheimer's disease and Parkinson's. We recommend more research studies to determine the underlying mechanism of how these essential nutrients work in the prevention of cognitive decline. These studies will help provide the evidence needed for new dietary recommendations for combating these diseases that often affect aging patients.
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Affiliation(s)
- Uvie Ajibawo-Aganbi
- Health Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sania Saleem
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Seyad Zulficar Ali Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Family Medicine, Ministry of Health Oman, Salalah, OMN
| | - Swathi Veliginti
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maria V Perez Bastidas
- Pulmonary Research Department, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rayan M Lungba
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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