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Swanson J, Roat-Shumway S, Cohn T, Luchette FA, Abdelsattar Z, Baker MS. Esophageal cancer: Does inaccuracy in clinical staging affect our ability to reach optimal outcomes? Surgery 2024; 175:342-346. [PMID: 37932193 DOI: 10.1016/j.surg.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/26/2023] [Accepted: 08/16/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Pretreatment clinical staging is used to decide the course of treatment in early-stage esophageal cancer. Few studies assess the effect of inaccurate clinical staging on oncologic outcomes. METHODS We queried the National Cancer Database to identify patients undergoing esophagectomy for clinical stage cT1bN0 esophageal carcinoma between 2010 and 2019. Patients were categorized as being upstaged if, on final pathology, they had histopathologic disease that would have warranted treatment with neoadjuvant therapy. The textbook oncologic outcome was defined as margin-negative resection, 15 lymph nodes examined, a hospital stay of <21 days, no unplanned 30-day readmission or mortality, and stage-appropriate use of neoadjuvant therapy. RESULTS In total, 916 patients met inclusion criteria; 378 (41.2%) had a pathologic stage that differed from their pretreatment clinical stage. By multivariable regression, factors associated upstaging included: presentation between 2015 and 2019 (odds ratio 1.92 95% confidence interval [1.19, 3.13]), delay to esophagectomy of >30 days (odds ratio 2.38 95% confidence interval [1.13, 5.57]), larger tumor size (>2 cm relative to <2 cm, odds ratio 2.73 95% confidence interval [1.72, 4.39]), and poorly differentiated histology (odds ratio 2.79 95% confidence interval [1.75, 4.49]). The rate of textbook oncologic outcome assuming reliable clinical staging was 43.8%; accounting for upstaging, the rate of textbook oncologic outcome was 22.5% (P < .001). CONCLUSION In patients with cT1bN0 esophageal cancer, tumor size and histology are associated with the risk of inaccurate pretreatment clinical staging. Inaccuracies in clinical staging impact the rate at which providers achieve optimal oncologic outcomes.
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Affiliation(s)
- James Swanson
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | | | - Tyler Cohn
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT
| | - Zaid Abdelsattar
- Department of Cardiothoracic Surgery, Loyola University Medical Center, Loyola University Chicago, Stritch School of Medicine; Edward Hines Jr, Veterans Administration Medical Center, Maywood, IL
| | - Marshall S Baker
- Department of Surgery, Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT.
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Roat-Shumway S, Tonelli CM, Baker MS, Abdelsattar ZM. Prognosis of Unresected vs Resected Small Pulmonary Carcinoid Tumors. Ann Thorac Surg 2023; 116:553-561. [PMID: 37054928 DOI: 10.1016/j.athoracsur.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/13/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Previous studies have shown that overall survival after lung resection for pulmonary carcinoid tumors is favorable. It is unclear what the prognosis is for observation rather than resection for small carcinoid tumors. METHODS We queried the National Cancer Database to identify patients presenting with primary pulmonary carcinoid tumors between 2004 and 2017. We included patients with small (<3 cm) primary pulmonary carcinoids, who were observed or underwent a lung resection. To minimize confounding by indication, we used propensity score matching, while accounting for age, sex, race, insurance type, Charlson-Deyo comorbidity score, typical and atypical histology, tumor size, and year of diagnosis. We used Kaplan-Meier survival analyses to compare 5-year overall survival in the matched cohorts. RESULTS Of 8435 patients with small pulmonary carcinoids, 783 (9.3%) underwent observation and 7652 (91%) underwent surgical resection. After propensity score matching, surgical resection was associated with improved 5-year overall survival (66% vs 81%, P < .001). No significant difference in overall survival was found between wedge and anatomic resection (88% vs 88%, P = .83). In patients undergoing resection, lymph node sampling at the time of wedge and anatomic resection increased 5-year overall survival (90% vs 86%, P = .0042; 88% vs 82%, P = .04, respectively). CONCLUSIONS Surgical resection of small pulmonary carcinoids is associated with improved survival compared with observation. When surgical resection is performed, wedge and anatomic resection result in similar survival, and lymph node sampling improves survival.
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Affiliation(s)
| | - Celsa M Tonelli
- Stritch School of Medicine, Loyola University Chicago, Maywood Illinois; Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Marshall S Baker
- Stritch School of Medicine, Loyola University Chicago, Maywood Illinois; Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Zaid M Abdelsattar
- Stritch School of Medicine, Loyola University Chicago, Maywood Illinois; Department of Surgery, Loyola University Medical Center, Maywood, Illinois.
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Roat-Shumway S, Tonelli C, Singer M, Cohn T, Luchette FA, Abdelsattar Z, Baker MS. Is local excision an appropriate treatment modality in patients presenting with early-stage (cT1 N0 M0) rectal adenocarcinoma? Surgery 2023; 173:665-673. [PMID: 36273975 DOI: 10.1016/j.surg.2022.08.040] [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: 05/02/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined. METHODS We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods. RESULTS A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection. CONCLUSION In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.
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Affiliation(s)
- Siena Roat-Shumway
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL. https://twitter.com/sroatshumway
| | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Marc Singer
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Tyler Cohn
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL
| | - Zaid Abdelsattar
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL.
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Wroolie T, Roat-Shumway S, Watson K, Reiman E, Rasgon N. Effects of LDL Cholesterol and Statin Use on Verbal Learning and Memory in Older Adults at Genetic Risk for Alzheimer's Disease. J Alzheimers Dis 2020; 75:903-910. [PMID: 32390619 DOI: 10.3233/jad-191090] [Citation(s) in RCA: 4] [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] [Indexed: 02/05/2023]
Abstract
BACKGROUND The apolipoprotein epsilon 4 (APOE4) allele is a well-established genetic risk factor for Alzheimer's disease (AD). However, there are mixed findings as to how the APOE4 allele modifies the effects of both higher low-density lipoprotein cholesterol (LDL) and statin use on cognitive functioning. OBJECTIVE This study sought to examine the effects of LDL levels and statin use on verbal learning and memory, as modified by the presence of the APOE4 allele, in a sample of cognitively unimpaired, older adults at risk for AD. METHODS Neuropsychological, LDL, statin use, and APOE4 data were extracted from an ongoing longitudinal study at the Banner Alzheimer's Institute in Arizona. Participants were cognitively unimpaired based on Mini-Mental State Examination scores within a normal range, aged 47-75, with a family history of probable AD in at least one first-degree relative. RESULTS In the whole sample, higher LDL was associated with worse immediate verbal memory in APOE4 non-carriers, but did not have an effect on immediate verbal memory in APOE4 carriers. In APOE4 non-carriers, statin use was associated with better verbal learning, but did not have an effect on verbal learning in APOE4 carriers. Among women, higher LDL in APOE4 carriers was associated with worse verbal learning than in APOE4 non-carriers, and statin use in APOE4 non-carriers was associated with better verbal learning and immediate and delayed verbal memory but worse performances on these tasks in APOE4 carriers. CONCLUSION LDL and statin use may have differential effects on verbal learning and/or memory depending on genetic risk for AD. Women appear to be particularly vulnerable to statin use depending on their APOE4 status.
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Affiliation(s)
- Tonita Wroolie
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Siena Roat-Shumway
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Katie Watson
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Eric Reiman
- Banner Alzheimer's Institute, Stead Family Memory Center, Phoenix, AZ, USA
| | - Natalie Rasgon
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Robakis TK, Zhang S, Rasgon NL, Li T, Wang T, Roth MC, Humphreys KL, Gotlib IH, Ho M, Khechaduri A, Watson K, Roat-Shumway S, Budhan VV, Davis KN, Crowe SD, Ellie Williams K, Urban AE. Epigenetic signatures of attachment insecurity and childhood adversity provide evidence for role transition in the pathogenesis of perinatal depression. Transl Psychiatry 2020; 10:48. [PMID: 32066670 PMCID: PMC7026105 DOI: 10.1038/s41398-020-0703-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 11/16/2022] Open
Abstract
Early life adversity and insecure attachment style are known risk factors for perinatal depression. The biological pathways linking these experiences, however, have not yet been elucidated. We hypothesized that overlap in patterns of DNA methylation in association with each of these phenomena could identify genes and pathways of importance. Specifically, we wished to distinguish between allostatic-load and role-transition hypotheses of perinatal depression. We conducted a large-scale analysis of methylation patterns across 5 × 106 individual CG dinucleotides in 54 women participating in a longitudinal prospective study of perinatal depression, using clustering-based criteria for significance to control for multiple comparisons. We identified 1580 regions in which methylation density was associated with childhood adversity, 3 in which methylation density was associated with insecure attachment style, and 6 in which methylation density was associated with perinatal depression. Shorter telomeres were observed in association with childhood trauma but not with perinatal depression or attachment insecurity. A detailed analysis of methylation density in the oxytocin receptor gene revealed similar patterns of DNA methylation in association with perinatal depression and with insecure attachment style, while childhood trauma was associated with a distinct methylation pattern in this gene. Clinically, attachment style was strongly associated with depression only in pregnancy and the early postpartum, whereas the association of childhood adversity with depression was time-invariant. We concluded that the broad DNA methylation signature and reduced telomere length associated with childhood adversity could indicate increased allostatic load across multiple body systems, whereas perinatal depression and attachment insecurity may be narrower phenotypes with more limited DNA methylation signatures outside the CNS, and no apparent association with telomere length or, by extension, allostatic load. In contrast, the finding of matching DNA methylation patterns within the oxytocin receptor gene for perinatal depression and attachment insecurity is consistent with the theory that the perinatal period is a time of activation of existing attachment schemas for the purpose of structuring the mother-child relationship, and that such activation may occur in part through specific patterns of methylation of the oxytocin receptor gene.
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Affiliation(s)
- Thalia K Robakis
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA.
| | - Siming Zhang
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
- Stanford University Department of Genetics, Stanford, CA, USA
| | - Natalie L Rasgon
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
| | | | - Tao Wang
- AccuraScience, LLC, Johnston, IN, USA
| | - Marissa C Roth
- Vanderbilt University Department of Psychology, Nashville, TN, USA
| | | | - Ian H Gotlib
- Stanford University Department of Psychology, Stanford, CA, USA
| | - Marcus Ho
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
| | | | - Katherine Watson
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
| | - Siena Roat-Shumway
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
| | - Vena V Budhan
- Palo Alto University Graduate School of Psychology, Palo Alto, CA, USA
| | - Kasey N Davis
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA
| | - Susan D Crowe
- Stanford University Department of Obstetrics & Gynecology, Stanford, CA, USA
| | | | - Alexander E Urban
- Stanford University Department of Psychiatry and Behavioral Sciences, Stanford, CA, USA.
- Stanford University Department of Genetics, Stanford, CA, USA.
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Wroolie TE, Roat-Shumway S, Watson K, Rasgon N. DIFFERENTIAL EFFECTS OF STATINS ON COGNITION IN WOMEN AT RISK FOR ALZHEIMER’S DISEASE. Innov Aging 2019. [PMCID: PMC6844976 DOI: 10.1093/geroni/igz038.3171] [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] [Indexed: 11/13/2022] Open
Abstract
It is well established that the apolipoprotein epsilon 4 allele (APOE4) and being female are risk factors for late onset Alzheimer’s disease (AD) and declines in verbal learning and memory are early cognitive symptoms of conversion to AD. Because of conflicting findings regarding the effects of statins on cognition, this study examined statin use with respect to verbal learning and memory by APOE4 status in a sample of cognitively unimpaired women at risk for AD. Neuropsychological, statin use, and APOE4 data were utilized as a secondary analysis from an ongoing longitudinal study at the Banner Alzheimer’s Institute in Arizona. Subjects were cognitively unimpaired women aged 47-75 with a family history of probable AD in at least one first-degree relative. Neuropsychological outcome variables included total learning, immediate memory, and delayed memory scores from the Rey Auditory Verbal Learning Test (RAVLT). Statin use was defined by use of a cholesterol lowering drug at study enrollment. APOE4 status was defined by presence of at least one APOE4 allele. Linear regression analyses were conducted to determine existence of interactions between statin use and APOE4 status on cognition. Statistically significant interactions were found between statin use and APOE4 status in RAVLT total learning and immediate memory. Statin use in women APOE4 non-carriers was associated with better verbal learning and immediate memory performances whereas statin use in women APOE4 carriers was associated with worse performances on these same tasks. Conclusions. Findings suggest that sex and APOE4 status may be important factors in consideration of statin use.
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Affiliation(s)
- Tonita E Wroolie
- Stanford University, School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, California, United States
| | - Siena Roat-Shumway
- Stanford University, School of Medicine, Stanford, California, United States
| | - Katie Watson
- Stanford University, School of Medicine, Stanford, California, United States
| | - Natalie Rasgon
- Stanford University, School of Medicine, Stanford, California, United States
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7
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Roat-Shumway S, Wroolie TE, Watson K, Schatzberg AF, Rasgon NL. Cognitive effects of mifepristone in overweight, euthymic adults with depressive disorders. J Affect Disord 2018; 239:242-246. [PMID: 30025313 DOI: 10.1016/j.jad.2018.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/17/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Previous studies have shown that individuals with mood disorders have a higher prevalence of both hypercortisolemia and insulin resistance. Insulin resistance is posited to contribute to the cognitive deficits observed in individuals who have depression. However, the mechanistic relationship between cortisol and insulin within the central nervous system remains to be further elucidated. This study aimed to evaluate the effects of the antiglucocorticoid agent, mifepristone, on metabolic function and cognitive performance in individuals receiving treatment for depressive disorders who were euthymic at baseline. METHODS Participants were administered a 600 mg/day dose of mifepristone for 28 days. Oral glucose tolerance tests (OGTTs) and cognitive assessments measuring verbal memory and executive functioning were administered at baseline and after 28 days of treatment. RESULTS Improvements in attention and verbal learning were associated with reduction of fasting plasma glucose (FPG) in response to mifepristone treatment. LIMITATIONS Limitations include the open-label design of this study and a small sample size. CONCLUSIONS The findings from this study suggest that improvement in fasting plasma glucose levels, upon administration of mifepristone, is associated with the improvement in early input of verbal information. Further studies are warranted in order to better evaluate the use of mifepristone or other antiglucocorticoid agents in treatment of mood disorders characterized by metabolic dysfunction.
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Affiliation(s)
- S Roat-Shumway
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States
| | - T E Wroolie
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States
| | - K Watson
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States
| | - A F Schatzberg
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States
| | - N L Rasgon
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States.
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Watson KT, Wroolie TE, Tong G, Foland-Ross LC, Frangou S, Singh M, McIntyre RS, Roat-Shumway S, Myoraku A, Reiss AL, Rasgon NL. Neural correlates of liraglutide effects in persons at risk for Alzheimer's disease. Behav Brain Res 2018; 356:271-278. [PMID: 30099030 DOI: 10.1016/j.bbr.2018.08.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [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: 05/11/2018] [Revised: 07/30/2018] [Accepted: 08/08/2018] [Indexed: 12/12/2022]
Abstract
Insulin resistance (IR) is a metabolic state preceding development of type 2 diabetes (DM2), cardiovascular disease, and neurodegenerative disorders, including Alzheimer's Disease (AD). Liraglutide, a glucagon-like peptide-1 (GLP) agonist, is an insulin-sensitizing agent with neuroprotective properties, as shown in animal studies. The purpose of this double-blinded, placebo-controlled study was to examine the neural effects of administration of liraglutide in cognitively normal late middle-aged individuals with subjective cognitive complaints (half of subjects had family history of AD). Seed-based resting state connectivity using functional magnetic resonance imaging (fMRI) was conducted before and after 12 weeks of liraglutide treatment or placebo. Neuropsychological testing was conducted before and after treatment to determine whether there were any potential behavioral correlates to neural changes. RESULTS At baseline (time point 1), higher fasting plasma glucose (FPG) was associated with decreased connectivity between bilateral hippocampal and anterior medial frontal structures. At time point 2, we observed significant improvement in intrinsic connectivity within the default mode network (DMN) in the active group relative to placebo. There were no detectable cognitive differences between study groups after this duration of treatment. To our knowledge, this is the first placebo-controlled study to report neural effects of liraglutide in a middle-aged population with subjective cognitive complaints. Larger and longer duration studies are warranted to determine whether liraglutide has neuroprotective benefits in individuals at risk for AD.
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Affiliation(s)
- Kathleen T Watson
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Tonita E Wroolie
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabby Tong
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lara C Foland-Ross
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sophia Frangou
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manpreet Singh
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Siena Roat-Shumway
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Alison Myoraku
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Allan L Reiss
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie L Rasgon
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
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