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Schuster K, Staffeld A, Zimmermann A, Böge N, Lang S, Kuhla A, Frintrop L. Starvation in Mice Induces Liver Damage Associated with Autophagy. Nutrients 2024; 16:1191. [PMID: 38674881 PMCID: PMC11053507 DOI: 10.3390/nu16081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/03/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Anorexia nervosa (AN) induces organ dysfunction caused by malnutrition, including liver damage leading to a rise in transaminases due to hepatocyte damage. The underlying pathophysiology of starvation-induced liver damage is poorly understood. We investigate the effect of a 25% body weight reduction on murine livers in a mouse model and examine possible underlying mechanisms of starvation-induced liver damage. Female mice received a restricted amount of food with access to running wheels until a 25% weight reduction was achieved. This weight reduction was maintained for two weeks to mimic chronic starvation. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were measured spectrophotometrically. Liver fat content was analyzed using an Oil Red O stain, and liver glycogen was determined using a Periodic acid-Schiff (PAS) stain. Immunohistochemical stains were used to investigate macrophages, proliferation, apoptosis, and autophagy. Starvation led to an elevation of AST and ALT values, a decreased amount of liver fat, and reduced glycogen deposits. The density of F4/80+ macrophage numbers as well as proliferating KI67+ cells were decreased by starvation, while apoptosis was not altered. This was paralleled by an increase in autophagy-related protein staining. Increased transaminase values suggest the presence of liver damage in the examined livers of starved mice. The observed starvation-induced liver damage may be attributed to increased autophagy. Whether other mechanisms play an additional role in starvation-induced liver damage remains to be investigated.
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Affiliation(s)
- Katharina Schuster
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Anna Staffeld
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Annelie Zimmermann
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Natalie Böge
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Stephan Lang
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Angela Kuhla
- Rudolf-Zenker-Institute for Experimental Surgery, Medical University Rostock, 18057 Rostock, Germany
| | - Linda Frintrop
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
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Cuntz U, Voderholzer U. Liver Damage Is Related to the Degree of Being Underweight in Anorexia Nervosa and Improves Rapidly with Weight Gain. Nutrients 2022; 14:nu14122378. [PMID: 35745110 PMCID: PMC9230663 DOI: 10.3390/nu14122378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The present study investigates the relationship between hypertransaminasemia and malnutrition on the basis of a very large number of patients. We assume that the level of transaminases not only reflects the extent of underlying liver cell damage but also provides information about the metabolic situation under conditions of energy deficiency. Methods: We present an observational study in two different samples. The first sample consists of 3755 patients (mean age 22.7 years, Range 12−73 years; mean BMI 15.4 kg/m2, range 8.1−25.7) out of a total of 4212 patients with anorexia nervosa treated in the Roseneck Clinic within five years for whom a complete admission laboratory was available. The second sample was obtained from a special ward for medically at-risk patients with eating disorders. During the period in question, four hundred and ten patients with anorexia nervosa were treated. One hundred and forty-two female patients (mean age 26.4 years, Range 18−63 years; mean BMI 11.5 kg/m2, range 8.4−13) had a BMI of thirteen or less and a complete data set was obtained at admission and weekly in the following four weeks after admission. Results: The increase in liver transaminases shows a very high correlation with weight in sample one (N = 3755). The analysis of variance shows highly significant (<0.001) correlations with an F-value of 55 for GOT/AST and 63 for GPT/ALT. Nevertheless, the variance within the groups with the same BMI is quite high. With re-nutrition in sample two, GOT/AST decreased on average from 71 U/L to 26 U/L (MANOVA F 10.7, p < 0.001) and GPT/ALT from 88 to 41 U/L (F = 9.9, p < 0.001) within four weeks. Discussion: Below a BMI of about 13, the nutritional status of the patients becomes so critical that the energy supply of the patient is increasingly dependent on the autophagy of the liver, which can be seen in the very strong increase in transaminases here. Refeeding leads very quickly to the normalisation of the transaminases and, thus, a stabilisation of the metabolism leading also to a decrease in autophagy.
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Affiliation(s)
- Ulrich Cuntz
- Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany;
- Forschungsprogramm für Psychotherapieevaluation im komplexen Therapiesetting, PMU Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
- Correspondence:
| | - Ulrich Voderholzer
- Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany;
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität München (LMU), 80336 Munich, Germany
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Liver disease in obesity and underweight: the two sides of the coin. A narrative review. Eat Weight Disord 2021; 26:2097-2107. [PMID: 33150534 DOI: 10.1007/s40519-020-01060-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Malnutrition, whether characterized by not enough or too much nutrient intake, is detrimental to the liver. We herein provide a narrative literature revision relative to hepatic disease occurrence in over or undernourished subjects, to shed light on the paradox where both sides of malnutrition lead to similar liver dysfunction and fat accumulation. METHODS Medline, EMBASE, and Cochrane Library were searched for publications up to July 2020. Articles discussing the association between both chronic and acute liver pathology and malnutrition were evaluated together with studies reporting the dietary intake in subjects affected by malnutrition. RESULTS The association between overnutrition and non-alcoholic fatty liver disease (NAFLD) is well recognized, as the beneficial effects of calorie restriction and very low carbohydrate diets. Conversely, the link between undernutrition and liver injury is more complex and less understood. In developing countries, early exposure to nutrient deficiency leads to marasmus and kwashiorkor, accompanied by fatty liver, whereas in developed countries anorexia nervosa is a more common form of undernutrition, associated with liver injury. Weight gain in undernutrition is associated with liver function improvement, whereas no study on the impact of macronutrient distribution is available. We hypothesized a role for very low carbohydrate diets in the management of undernutrition derived liver pathology, in addition to the established one in overnutrition-related NAFLD. CONCLUSIONS Further studies are warranted to update the knowledge regarding undernutrition-related liver disease, and a specific interest should be paid to macronutrient distribution both in the context of refeeding and relative to its role in the development of hepatic complications of anorexia nervosa. LEVEL OF EVIDENCE Narrative review, Level V.
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Schalla MA, Stengel A. Gastrointestinal alterations in anorexia nervosa - A systematic review. EUROPEAN EATING DISORDERS REVIEW 2019; 27:447-461. [DOI: 10.1002/erv.2679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/20/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Martha A. Schalla
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Berlin Germany
| | - Andreas Stengel
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Berlin Germany
- Department of Psychosomatic Medicine and Psychotherapy; Medical University Hospital Tübingen; Tübingen Germany
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Abstract
Exacerbation of liver enzymes after the initiation of feeding in malnourished patients is caused by refeeding syndrome or persistent starvation. There are no definite clinical markers for distinguishing between the two conditions. We herein report a 63-year-old woman with starvation-induced liver enzyme elevation. Her body weight was inversely associated with the liver enzyme levels after refeeding, which was a different course from refeeding syndrome. Normalization of liver enzymes ensued as the caloric intake increased and weight gain progressed. Daily changes in body weight can be a useful clinical marker for distinguishing between refeeding syndrome and starvation-induced liver enzyme elevation.
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Affiliation(s)
- Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Aisa Yoshizaki
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Yukihiro Imai
- Department of Pathology, Kobe City Medical Center General Hospital, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Japan
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Gibson D, Drabkin A, Krantz MJ, Mascolo M, Rosen E, Sachs K, Welles C, Mehler PS. Critical gaps in the medical knowledge base of eating disorders. Eat Weight Disord 2018; 23:419-430. [PMID: 29681012 DOI: 10.1007/s40519-018-0503-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.
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Affiliation(s)
- Dennis Gibson
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Anne Drabkin
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Mori J Krantz
- Division of Cardiology, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | | | - Elissa Rosen
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Katherine Sachs
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Christine Welles
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Philip S Mehler
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Eating Recovery Center, Denver, 7351E Lowry Blvd, Denver, CO, 80230, USA.
- , Denver, USA.
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Abstract
Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.
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Norris ML, Harrison ME, Isserlin L, Robinson A, Feder S, Sampson M. Gastrointestinal complications associated with anorexia nervosa: A systematic review. Int J Eat Disord 2016; 49:216-37. [PMID: 26407541 DOI: 10.1002/eat.22462] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed. METHOD Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards. RESULTS A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated. DISCUSSION GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.
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Affiliation(s)
- Mark L Norris
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Megan E Harrison
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Leanna Isserlin
- Department of Psychiatry, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy Robinson
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Feder
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Margaret Sampson
- Library and Media Services, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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9
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Riley EN, Davis HA, Combs JL, Jordan CE, Smith GT. Nonsuicidal Self-injury as a Risk Factor for Purging Onset: Negatively Reinforced Behaviours that Reduce Emotional Distress. EUROPEAN EATING DISORDERS REVIEW 2016; 24:78-82. [PMID: 26373703 PMCID: PMC4681665 DOI: 10.1002/erv.2407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/21/2015] [Accepted: 08/24/2015] [Indexed: 11/07/2022]
Abstract
Both nonsuicidal self-injury (NSSI) and purging behaviour are thought to involve harm to the self. The acquired capability for self-harm model holds that engaging in one self-harming behaviour increases the capability to tolerate harm to the self, thus increasing risk for engaging on other such behaviours. In addition, both behaviours are thought to serve the similar function of relief from distress. We thus tested whether engagement in one of these behaviours predicts the subsequent onset of the other. In a longitudinal design, 1158 first-year college women were assessed for purging and NSSI at two time points. Engagement in NSSI at time 1 predicted the college onset of purging behaviour 9 months later (OR = 2.20, p < .04, CI = 1.07-4.19) beyond prediction from time 1 binge behaviour, and purging behaviour at time 1 predicted the subsequent onset of NSSI (OR = 6.54, p < .01, CI = 1.71-25.04). These findings are consistent with the acquired capability for harm model and with the possibility that the two behaviours serve a similar function.
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Affiliation(s)
- Elizabeth N. Riley
- The University of Kentucky Department of Psychology 125 Kastle Hall Lexington, KY 40506-0044
| | - Heather A. Davis
- The University of Kentucky Department of Psychology 125 Kastle Hall Lexington, KY 40506-0044
| | - Jessica L. Combs
- The University of Kentucky Department of Psychology 125 Kastle Hall Lexington, KY 40506-0044
| | - Carol E. Jordan
- The University of Kentucky Department of Psychology 125 Kastle Hall Lexington, KY 40506-0044
| | - Gregory T. Smith
- The University of Kentucky Department of Psychology 125 Kastle Hall Lexington, KY 40506-0044
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Vootla VR, Daniel M. Abnormal Liver Function Tests in an Anorexia Nervosa Patient and an Atypical Manifestation of Refeeding Syndrome. Case Rep Gastroenterol 2015; 9:261-5. [PMID: 26351414 PMCID: PMC4560322 DOI: 10.1159/000437321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Refeeding syndrome is defined as electrolyte and fluid abnormalities that occur in significantly malnourished patients when they are refed orally, enterally, or parenterally. The principal manifestations include hypophosphatemia, hypokalemia, vitamin deficiencies, volume overload and edema. This can affect multiple organ systems, such as the cardiovascular, pulmonary, or neurological systems, secondary to the above-mentioned abnormalities. Rarely, patients may develop gastrointestinal symptoms and show abnormal liver function test results. We report the case of a 52-year-old woman with anorexia nervosa who developed refeeding syndrome and simultaneous elevations of liver function test results, which normalized upon the resolution of the refeeding syndrome.
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Affiliation(s)
- Vamshidhar R Vootla
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, N.Y., USA
| | - Myrta Daniel
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, N.Y., USA
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Johansson AK, Norring C, Unell L, Johansson A. Eating disorders and biochemical composition of saliva: a retrospective matched case-control study. Eur J Oral Sci 2015; 123:158-64. [PMID: 25780814 PMCID: PMC6680160 DOI: 10.1111/eos.12179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 12/02/2022]
Abstract
This study aimed to compare the biochemical composition of saliva from patients with eating disorders (EDs) with saliva from control subjects with no ED. All patients who initiated outpatient treatment in an ED clinic during a 12‐month period were invited to participate. Of the 65 patients who started treatment during the period, 54 (50 female patients/four male patients; mean age: 21.5 yr) agreed to participate. The controls were 54 sex‐ and age‐matched patients from a dental health clinic. All participants completed a questionnaire and underwent dental clinical examinations, including laboratory analyses of saliva. The proportion of subjects with unstimulated salivary hyposalivation was lower in the ED group and not correlated with intake of xerogenic drugs. Significant differences in the biochemical composition of saliva were found almost exclusively in the unstimulated state, with albumin, inorganic phosphate, aspartate aminotransferase (ASAT), chloride, magnesium, and total protein all being significantly higher in the ED group. Conditional logistic regression showed that higher ASAT and total protein concentrations were relatively good predictors of ED, with sensitivity and specificity of 65% and 67%, respectively. In conclusion, elevated salivary concentrations of ASAT and total protein may serve as indicators of ED as well as of disease severity. Future studies are needed to corroborate these initial findings.
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Affiliation(s)
- Ann-Katrin Johansson
- Department of Clinical Dentistry - Cariology, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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12
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Liver autophagy in anorexia nervosa and acute liver injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:701064. [PMID: 25250330 PMCID: PMC4163421 DOI: 10.1155/2014/701064] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 08/04/2014] [Indexed: 02/07/2023]
Abstract
Autophagy, a lysosomal catabolic pathway for long-lived proteins and damaged organelles, is crucial for cell homeostasis, and survival under stressful conditions. During starvation, autophagy is induced in numerous organisms ranging from yeast to mammals, and promotes survival by supplying nutrients and energy. In the early neonatal period, when transplacental nutrients supply is interrupted, starvation-induced autophagy is crucial for neonates' survival. In adult animals, autophagy provides amino acids and participates in glucose metabolism following starvation. In patients with anorexia nervosa, autophagy appears initially protective, allowing cells to copes with nutrient deprivation. However, when starvation is critically prolonged and when body mass index reaches 13 kg/m(2) or lower, acute liver insufficiency occurs with features of autophagic cell death, which can be observed by electron microscopy analysis of liver biopsy samples. In acetaminophen overdose, a classic cause of severe liver injury, autophagy is induced as a protective mechanism. Pharmacological enhancement of autophagy protects against acetaminophen-induced necrosis. Autophagy is also activated as a rescue mechanism in response to Efavirenz-induced mitochondrial dysfunction. However, Efavirenz overdose blocks autophagy leading to liver cell death. In conclusion, in acute liver injury, autophagy appears as a protective mechanism that can be however blocked or overwhelmed.
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Kim YR, Son MH, Nah JC, Park HA. Medical findings in women with anorexia nervosa in a korean population. Psychiatry Investig 2013; 10:101-7. [PMID: 23798956 PMCID: PMC3687042 DOI: 10.4306/pi.2013.10.2.101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/03/2013] [Accepted: 01/24/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population. METHODS We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design. RESULTS In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density. CONCLUSION Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.
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Affiliation(s)
- Youl-Ri Kim
- Department of Neuropsychiatry, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
- Institute for Gender Research, Seoul National University, Seoul, Republic of Korea
| | - Myung Ha Son
- Department of Neuropsychiatry, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
| | - Jong Chun Nah
- Department of Internal Medicine, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
| | - Hyun Ah Park
- Department of Family Medicine, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
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14
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Hanachi M, Melchior JC, Crenn P. Hypertransaminasemia in severely malnourished adult anorexia nervosa patients: risk factors and evolution under enteral nutrition. Clin Nutr 2012; 32:391-5. [PMID: 22986227 DOI: 10.1016/j.clnu.2012.08.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/14/2012] [Accepted: 08/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND & AIMS Aminotransferase abnormalities have been reported in malnourished patients with anorexia nervosa (AN). The aim of this study was to identify prevalence and risk factors of hyperaminotransferasemia in an adult cohort of AN patients and to describe evolution during nutritional rehabilitation with enteral nutrition for a period of 4 weeks. METHODS Retrospective study of all consecutive malnourished (BMI <16) AN adult patients, without previous liver diseases or hepatotoxic drugs or alcohol consumption, hospitalized for enteral nutrition in a single center between 1998 and 2008. Hypertransaminasemia was defined by an increase in AST and (or) ALT >2N. RESULTS In all, 126 AN patients (117 W, 9 M), age 30 ± 10.8 years, were included. At admission, 54 (43%) patients presented hypertransaminasemia. In univariate analysis, risk factors for hypertransaminasemia were: lower BMI (11.2 ± 2 vs. 13 ± 2, p < 0.0001) and age (28 ± 9 vs. 32 ± 12, p < 0.05), male sex (p < 0.05) and the pure restrictive form (p = 0.07). In multivariate analysis only BMI, at a threshold of 12, remained significant [OR 3.7, CI: 95% 2.24-5.2]. Normalization of aminotransferases at the end of week 4 of enteral nutrition was obtained in 96%. Only 2/54 patients (4%) presented a worsening of aminotransferases during the refeeding period, including one that died of liver failure. None of the patients without hypertransaminasemia admission presented a subsequent elevation. At the end of the 4-week refeeding period, the increase in BMI was greater in patients without hypertransaminasemia than in those with it (2.0 ± 0.8 vs. 1.5 ± 1.0, p < 0.0001). CONCLUSION Elevated transaminases is common in severe malnourished AN patients. Four risk factors were identified: young age, low BMI (the only independent factor in multivariate analysis), the pure restrictive form of the disease and male sex. After 4 weeks of enteral nutrition the evolution is in most cases favourable, albeit with a lower increase in BMI, but can be severe. The long-term evolution remains to be determined.
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Affiliation(s)
- Mouna Hanachi
- Université de Versailles Saint-Quentin-en-Yvelines, EA 4497, Faculté de Médecine, PIFO, France
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15
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Bridet L, Jose Beitia Martin J, Luis Cabriada Nuno J. Acute Liver Damage and Anorexia Nervosa: A Case Report and Review of the Literature. Euroasian J Hepatogastroenterol 2012. [DOI: 10.5005/jp-journals-10018-1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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16
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Giordano F, Arnone S, Santeusanio F, Pampanelli S. Brief elevation of hepatic enzymes due to liver ischemia in anorexia nervosa. Eat Weight Disord 2010; 15:e294-7. [PMID: 21406954 DOI: 10.1007/bf03325312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abnormal liver function is occasionally observed in patients affected by anorexia nervosa. Although numerous studies report a strong relation between malnutrition and liver damage, the pathogenesis remains still unclear. We describe a case of a young girl with severe anorexia nervosa who developed acute liver damage with multiorgan involvement during extremely poor nutritional status. In this patient severe malnutrition constituted a predisposing factor for multiorgan dysfunction. In the absence of other identifiable factors, we hypothesized that a marked increase in liver enzymes and other biochemical abnormalities could be a consequence of a precipitating cause as acute hypoperfusion, suggested by clinical symptoms (marked dehydration, hypotension, bradycardia, hypothermia) and laboratory data. Rapid normalization of liver function tests and other biochemical parameters with rehydration and gradual nutritional support confirmed this hypothesis.
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Affiliation(s)
- F Giordano
- Department of Internal Medicine, Endocrinology and Metabolic Sciences, University of Perugia, Italy
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Okuda M, Kunitsugu I, Yoshitake N, Hinoda Y, Suehiro Y, Okuda Y, Hobara T. Variance in the transaminase levels over the body mass index spectrum in 10- and 13-year-olds. Pediatr Int 2010; 52:813-9. [PMID: 20487366 DOI: 10.1111/j.1442-200x.2010.03167.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transaminase levels increase with body mass index (BMI) and also with an extreme drop in the BMI, as in the case of patients with anorexia nervosa. We examined these levels over the BMI spectrum in Japanese 10- and 13-year-olds. METHODS Fifth- and eighth-grade students (n= 3747) from all schools in Shunan City, Japan, between 2006 and 2008 were included in the study. BMI z-score and serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured. RESULTS The ALT and GGT levels increased with z-BMI values in the boys and 10-year-old girls (P≤ 0.001). In the 13-year-old girls, only the ALT levels increased with the z-BMI values (P= 0.018). Similarly, the proportion of subjects with elevated ALT and GGT levels increased with the z-BMI values (p(trend) < 0.05). The AST levels were negatively associated with BMI in the girls (P < 0.001). Among the boys, these levels were elevated at the highest z-BMI values and slightly elevated at lower values, but not significantly. These associations did not change after adjustments for confounders. Generalized additive model analyses revealed that transaminase had non-linear relationships with z-BMI, except for the AST levels in the girls. CONCLUSION The elevated ALT and GGT levels were associated with high BMI in both sexes. In the same study population, however, AST increased in the girls with low BMI and in the boys with high BMI.
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Affiliation(s)
- Masayuki Okuda
- Department of Environmental Safety, Yamaguchi University, Ube, Japan.
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Vignaud M, Constantin JM, Ruivard M, Villemeyre-Plane M, Futier E, Bazin JE, Annane D. Refeeding syndrome influences outcome of anorexia nervosa patients in intensive care unit: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R172. [PMID: 20920160 PMCID: PMC3219274 DOI: 10.1186/cc9274] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 07/02/2010] [Accepted: 09/28/2010] [Indexed: 02/06/2023]
Abstract
Introduction Data on the epidemiology and management of anorexia nervosa (AN) in the intensive care unit (ICU) are scarce. The aim of this study was to evaluate the prevalence and associated morbidity and mortality of AN in French ICUs. Methods We randomly selected 30 ICUs throughout France. Thereafter, we retrospectively analyzed all patients with AN admitted to any of these 30 ICUs between May 2006 and May 2008. We considered demographic data, diagnosis at admission and complications occurring during the stay, focusing on refeeding syndrome and management of refeeding. Results Eleven of the 30 ICUs participated in the retrospective study, featuring 68 patients, including 62 women. Average body mass index at the admission was 12 ± 3 kg/m2. Twenty one were mechanically ventilated, mainly for neurological reasons. The reported average calorie intake was 22.3 ± 13 kcal/kg/24 h. Major diagnoses at admission were metabolic problems, refeeding survey and voluntary drug intoxication and infection. The most common complications were metabolic, hematological, hepatic, and infectious events, of which 10% occurred during refeeding. Seven patients developed refeeding syndrome. At day one, the average calorie intake was higher for patients who developed refeeding syndrome (23.2 ± 5 Kcal/kg/j; n = 7) versus patients without refeeding syndrome (14.1 ± 3 Kcal/kg/j; n = 61) P = 0.02. Seven patients died, two from acute respiratory distress syndrome and five from multiorgan-failure associated with major hydroelectrolytic problems. Conclusions The frequency of AN in ICU patients is very low and the crude mortality in this group is about 10%. Prevention and early-detection of refeeding syndrome is the key point.
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Affiliation(s)
- Marie Vignaud
- General ICU, Estaing Hospital, University Hospital of Clermont-Ferrand, 1 Place Lucie Aubrac, 63000 Clermont-Ferrand, France.
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Liver enzymes in children and adolescents with eating disorders. J Pediatr 2009; 155:153; author reply 153-4. [PMID: 19559313 DOI: 10.1016/j.jpeds.2009.01.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 01/29/2009] [Indexed: 11/20/2022]
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Goldstein MA, Herzog DB, Misra M, Sagar P. Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain. N Engl J Med 2008; 359:1272-83. [PMID: 18799562 DOI: 10.1056/nejmcpc0804641] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mark A Goldstein
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, USA
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Montagnese C, Scalfi L, Signorini A, De Filippo E, Pasanisi F, Contaldo F. Cholinesterase and other serum liver enzymes in underweight outpatients with eating disorders. Int J Eat Disord 2007; 40:746-50. [PMID: 17610252 DOI: 10.1002/eat.20432] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The present study aimed to evaluate serum liver enzymes in underweight outpatients with anorexia nervosa (A-NERV) or eating disorders not otherwise specified (EDNOS). METHOD Serum alanine amino transferase (ALT), aspartate amino transferase (AST), lactic dehydrogenase (LDH), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and cholinesterase (CHE) were determined in 97 patients with A-NERV, 66 patients with EDNOS, and 56 controls. RESULTS In the A-NERV group AST, LDH, and GGT were higher, as compared with controls, and inversely related to weight, while ALP and CHE were lower. AST and GGT increased and CHE decreased in patients with EDNOS. Hypertransaminasemia occurred in 14.4 and 15.2%, and low CHE in 29.9% of the A-NERV group and 13.6% and EDNOS group, respectively. Three or more abnormalities were found in 9.3% of patients with A-NERV and 7.5% of those with EDNOS. CONCLUSION Abnormalities in serum liver enzymes are common in outpatients with eating disorders plus underweight. CHE might be considered as a marker of the effects of primary malnutrition on liver function.
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Affiliation(s)
- Concetta Montagnese
- Human Nutrition, Department of Food Science, Federico II University, Naples, Italy
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De Caprio C, Alfano A, Senatore I, Zarrella L, Pasanisi F, Contaldo F. Severe acute liver damage in anorexia nervosa: two case reports. Nutrition 2006; 22:572-5. [PMID: 16600819 DOI: 10.1016/j.nut.2006.01.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2005] [Revised: 12/13/2005] [Accepted: 01/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Two female patients (18 and 30 y old, body mass indexes 14.1 and 13.2 kg/m2) with severe, restrictive anorexia nervosa developed sudden severe liver damage. In addition to overt protein-energy malnutrition, they showed marked hypotension, bradycardia, dry skin, acrocyanosis, and hypothermia. Most common causes of liver failure, such as hepatotropic viruses, hepatotoxic drugs, alcohol, cannabis, and cocaine abuse, were excluded. METHODS Therapeutic intervention consisted of immediate plasma volume support, progressive parenteral or oral nutritional rehabilitation, and parenteral potassium and phosphorus supplements to avoid the refeeding syndrome. RESULTS AND CONCLUSION Improvement of initial clinical symptoms and rapid recovery of liver enzymes after this type of treatment suggest that severe liver damage in anorexia nervosa may be secondary to acute hypoperfusion.
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Affiliation(s)
- Carmela De Caprio
- Interuniversity Center for Obesity and Eating Disorders, Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy
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Swenne I. The significance of routine laboratory analyses in the assessment of teenage girls with eating disorders and weight loss. Eat Weight Disord 2004; 9:269-78. [PMID: 15844399 DOI: 10.1007/bf03325081] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Routine laboratory investigations that had been performed at disease assessment on 327 teenage girls with eating disorders and weight loss were analyzed. The laboratory investigations included erythrocyte sedimentation rate (ESR), blood haemoglobin concentration (Hb), white blood cell count (WBC), platelet count, serum alkaline phosphatase (ALP) activity, serum aspartate aminotransferase (ASAT) activity, serum alanine aminotransferase (ALAT) activity, serum albumin concentration, glycated haemoglobin (HbA1c) and serum concentrations of sodium, potassium, magnesium, calcium (corrected for albumin), inorganic phosphate, creatinine and urea. The results were for ESR, Hb, WBC, platelet count, ALP, ASAT, ALAT, inorganic phosphate, creatinine, urea and HBA1C related to weight and (ongoing) weight loss. The variations of the biochemical measurements were, however, largely within reference ranges, weight and weight changes predicted the biochemical measurements only to a small degree and in individual patients the results of the analyses often suggested normality. These analyses may therefore not be suited to assess the degree of weight loss and starvation in eating disorders. They may, however, be useful for the exclusion of other diseases which could show weight loss and biochemical abnormalities.
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Affiliation(s)
- I Swenne
- Department of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden.
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Abstract
Eating disorders are prevalent in adolescents and are associated with significant medical and psychiatric morbidity. Amenorrhoea, one of the cardinal features of anorexia nervosa, is the most likely reason for consulting the gynaecologist. Amenorrhoea in a young woman should alert the gynaecologist to the possibility of an underlying eating disorder. Osteopenia is a potentially irreversible complication of prolonged amenorrhoea and a low oestrogen state. Eating disorders are best managed by a team approach, with the team comprising a physician, nutritionist and therapist. Oestrogen replacement therapy has not been shown to be an effective treatment for osteopenia in anorexia nervosa and the gynaecologist should avoid simply prescribing oestrogen replacement therapy without referring the patient for comprehensive treatment of the eating disorder. Nutritional rehabilitation, weight restoration and resumption of spontaneous menses are the mainstay of medical management. Calcium and vitamin D supplementation and moderate weight-bearing exercise should be prescribed where indicated. Newer therapeutic options for the treatment of osteopenia include DHEA, IGF-1 and alendronate.
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Affiliation(s)
- Neville H Golden
- Eating Disorders Center, Division of Adolescent Medicine, Schneider Children's Hospital, Long Island Jewish Medical Centre, New Hyde Park, NY, 11040, USA.
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Wakui S, Odagiri Y, Takamiya T, Inoue S, Kato R, Ohya Y, Shimomitsu T. Relation between self-reported weight cycling history, dieting and bio-behavioral health in Japanese adult males. Environ Health Prev Med 2002; 6:248-55. [PMID: 21432342 PMCID: PMC2723476 DOI: 10.1007/bf02897977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2001] [Accepted: 08/08/2001] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Epidemiological findings suggest that weight fluctuations are associated with unfavorable health outcomes compared with stable weight. However, the interrelationship between the weight cycling history and dieting status in a non-clinical male trial on the risk for bio-behavioral health is unclear. OBJECTIVE The purpose of this study was to examine the relation between weight cycling history as a result of intentional weight loss and bio-behavioral health in Japanese adult males. METHOD A cross-sectional study was performed on a group of 146 Japanese working males (47.5±9.3 yr.). Each subject completed a series of self-reported questionnaires in which information about weight cycling history, current dieting practices, life-styles, and social background were assessed. Results of the physical check up were used to assess biological parameters. Self-reported weight cycling was defined as intentionally losing 10% of one's weight and regaining the lost weight. RESULTS Cyclers reported a significantly greater incidence of current dieting and recent weight gain compared with non-cyclers. Taking regular meals, eating breakfast everyday, and not eating snacks between meals every day were significantly less frequent among cyclers compared with non-cyclers after controlling for BMI. The adjusted odds ratio for AST abnormality was 5.46 (95% CI: 1.08-27.67), ALT abnormality was 3.31 (95% CI: 1.24-8.78), and γ-GTP was 3.38 (95% CI: 1.07-10.67) among cyclers, compared with noncyclers. CONCLUSION These findings suggest that a history of weight cycling in men, regardless of current weight status, is associated with adverse bio-behavioral health. The risk for several liver enzyme abnormalities associated with weight cycling history was substantial, independent of relative body weight and lifestyle factors.
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Affiliation(s)
- Sawako Wakui
- Department of Preventive Medicine & Public Health, Tokyo Medical University, Japan, 6-1-1 Shinjuku, Shinjuku-ku, 160-8402, Tokyo, Japan
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