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Conlon C, Li YJ, Ahmad J, Barnhart H, Fontana RJ, Ghabril M, Hayashi PH, Kleiner DE, Lee WM, Navarro V, Odin JA, Phillips EJ, Stolz A, Vuppalanchi R, Halegoua-DeMarzio D. Clinical characteristics and HLA associations of azithromycin-induced liver injury. Aliment Pharmacol Ther 2024. [PMID: 38988034 DOI: 10.1111/apt.18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Azithromycin (AZ) is a widely used antibiotic. The aim of this study was to characterise the clinical features, outcomes, and HLA association in patients with drug-induced liver injury (DILI) due to AZ. METHODS The clinical characteristics of individuals with definite, highly likely, or probable AZ-DILI enrolled in the US Drug-Induced Liver Injury Network (DILIN) were reviewed. HLA typing was performed using an Illumina MiSeq platform. The allele frequency (AF) of AZ-DILI cases was compared to population controls, other DILI cases, and other antibiotic-associated DILI cases. RESULTS Thirty cases (4 definite, 14 highly likely, 12 probable) of AZ-DILI were enrolled between 2004 and 2022 with a median age of 46 years, 83% white, and 60% female. Median duration of AZ treatment was 5 days. Latency was 18.5 days. 73% were jaundiced at presentation. The injury pattern was hepatocellular in 60%, cholestatic in 27%, and mixed in 3%. Ten cases (33%) were severe or fatal; 90% of these were hepatocellular. Two patients required liver transplantation. One patient with chronic liver disease died of hepatic failure. Chronic liver injury developed in 17%, of which 80% had hepatocellular injury at onset. HLA-DQA1*03:01 was significantly more common in AZ-DILI versus population controls and amoxicillin-clavulanate DILI cases (AF: 0.29 vs. 0.11, p = 0.001 and 0.002, respectively). CONCLUSION Azithromycin therapy can lead to rapid onset of severe hepatic morbidity and mortality in adult and paediatric populations. Hepatocellular injury and younger age were associated with worse outcomes. HLA-DQA1*03:01 was significantly more common in AZ cases compared to controls.
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Affiliation(s)
- Caroline Conlon
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yi-Ju Li
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jawad Ahmad
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Huiman Barnhart
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Marwan Ghabril
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - David E Kleiner
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - William M Lee
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victor Navarro
- Jefferson Health, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Joseph A Odin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Andrew Stolz
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dina Halegoua-DeMarzio
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Nakase T, Guerra G, Ostrom QT, Ge T, Melin B, Wrensch M, Wiencke JK, Jenkins RB, Eckel-Passow JE, Bondy ML, Francis SS, Kachuri L. Genome-wide Polygenic Risk Scores Predict Risk of Glioma and Molecular Subtypes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.10.24301112. [PMID: 38260701 PMCID: PMC10802631 DOI: 10.1101/2024.01.10.24301112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Polygenic risk scores (PRS) aggregate the contribution of many risk variants to provide a personalized genetic susceptibility profile. Since sample sizes of glioma genome-wide association studies (GWAS) remain modest, there is a need to find efficient ways of capturing genetic risk factors using available germline data. Methods We developed a novel PRS (PRS-CS) that uses continuous shrinkage priors to model the joint effects of over 1 million polymorphisms on disease risk and compared it to an approach (PRS-CT) that selects a limited set of independent variants that reach genome-wide significance (P<5×10-8). PRS models were trained using GWAS results stratified by histological (10,346 cases, 14,687 controls) and molecular subtype (2,632 cases, 2,445 controls), and validated in two independent cohorts. Results PRS-CS was consistently more predictive than PRS-CT across glioma subtypes with an average increase in explained variance (R2) of 21%. Improvements were particularly pronounced for glioblastoma tumors, with PRS-CS yielding larger effect sizes (odds ratio (OR)=1.93, P=2.0×10-54 vs. OR=1.83, P=9.4×10-50) and higher explained variance (R2=2.82% vs. R2=2.56%). Individuals in the 95th percentile of the PRS-CS distribution had a 3-fold higher lifetime absolute risk of IDH mutant (0.63%) and IDH wildtype (0.76%) glioma relative to individuals with average PRS. PRS-CS also showed high classification accuracy for IDH mutation status among cases (AUC=0.895). Conclusions Our novel genome-wide PRS may improve the identification of high-risk individuals and help distinguish between prognostic glioma subtypes, increasing the potential clinical utility of germline genetics in glioma patient management.
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Affiliation(s)
- Taishi Nakase
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Geno Guerra
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Quinn T. Ostrom
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Tian Ge
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for Precision Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Beatrice Melin
- Department of Radiation Sciences, Oncology Umeå University, Umeå, Sweden
| | - Margaret Wrensch
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John K. Wiencke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Robert B. Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Melissa L. Bondy
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephen S. Francis
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Linda Kachuri
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
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Zhong S, Yang W, Zhang Z, Xie Y, Pan L, Ren J, Ren F, Li Y, Xie H, Chen H, Deng D, Lu J, Li H, Wu B, Chen Y, Peng F, Puduvalli VK, Sai K, Li Y, Cheng Y, Mou Y. Association between viral infections and glioma risk: a two-sample bidirectional Mendelian randomization analysis. BMC Med 2023; 21:487. [PMID: 38053181 PMCID: PMC10698979 DOI: 10.1186/s12916-023-03142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Glioma is one of the leading types of brain tumor, but few etiologic factors of primary glioma have been identified. Previous observational research has shown an association between viral infection and glioma risk. In this study, we used Mendelian randomization (MR) analysis to explore the direction and magnitude of the causal relationship between viral infection and glioma. METHODS We conducted a two-sample bidirectional MR analysis using genome-wide association study (GWAS) data. Summary statistics data of glioma were collected from the largest meta-analysis GWAS, involving 12,488 cases and 18,169 controls. Single-nucleotide polymorphisms (SNPs) associated with exposures were used as instrumental variables to estimate the causal relationship between glioma and twelve types of viral infections from corresponding GWAS data. In addition, sensitivity analyses were performed. RESULTS After correcting for multiple tests and sensitivity analysis, we detected that genetically predicted herpes zoster (caused by Varicella zoster virus (VZV) infection) significantly decreased risk of low-grade glioma (LGG) development (OR = 0.85, 95% CI: 0.76-0.96, P = 0.01, FDR = 0.04). No causal effects of the other eleven viral infections on glioma and reverse causality were detected. CONCLUSIONS This is one of the first and largest studies in this field. We show robust evidence supporting that genetically predicted herpes zoster caused by VZV infection reduces risk of LGG. The findings of our research advance understanding of the etiology of glioma.
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Affiliation(s)
- Sheng Zhong
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Wenzhuo Yang
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Zhiyun Zhang
- Department of Plastic Surgery, The First Hospital of Jilin University, Changchun, 130000, People's Republic of China
| | - Yangyiran Xie
- Vanderbilt University School of Medicine, Vanderbilt University, 1161 21St Ave S # D3300, Nashville, TN, 37232, USA
| | - Lin Pan
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Jiaxin Ren
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Chang Chun, People's Republic of China
| | - Fei Ren
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Yifan Li
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Haoqun Xie
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Hongyu Chen
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Davy Deng
- Dana Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Jie Lu
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Hui Li
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Chang Chun, People's Republic of China
| | - Bo Wu
- Department of Orthopaedics, The First Hospital of Jilin University, No.71, Street Xinmin Road, Chaoyang District, Changchun, Jilin, People's Republic of China
| | - Youqi Chen
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Fei Peng
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Vinay K Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Ke Sai
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China.
| | - Yunqian Li
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, People's Republic of China.
| | - Ye Cheng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Yonggao Mou
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China.
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James LM, Georgopoulos AP. Positive Association Between the Immunogenetic Human Leukocyte Antigen (HLA) Profiles of Multiple Sclerosis and Brain Cancer. Neurosci Insights 2023; 18:26331055231214543. [PMID: 38046672 PMCID: PMC10693228 DOI: 10.1177/26331055231214543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Previous research has documented elevated risk of brain cancer in patients with multiple sclerosis (MS). Separately, human leukocyte antigen (HLA) has been implicated in protection or susceptibility for both conditions. The aim of the current study was to assess a possible role of shared immunogenetic influence on risk of MS and brain cancer. We first identified an immunogenetic profile for each condition based on the covariance between the population frequency of 127 high-resolution HLA alleles and the population prevalence of each condition in 14 Continental Western European countries and then evaluated the correspondence between MS and brain cancer immunogenetic profiles. Also, since each individual carries 12 HLA alleles (2 × 6 genes), we estimated HLA protection and susceptibility for MS and brain cancer at the individual level. We found that the immunogenetic profiles of MS and brain cancer were highly correlated overall (P < .001) and across all 6 HLA genes with the strongest association observed for DRB1, followed by DQB1 and HLA-A. These findings of immunogenetic overlap between MS and brain cancer are discussed in light of the role of HLA in the immune system response to viruses and other foreign antigens.
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Affiliation(s)
- Lisa M James
- Department of Veterans Affairs Health Care System, The HLA Research Group, Brain Sciences Center, Minneapolis, MN, USA
- Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Apostolos P Georgopoulos
- Department of Veterans Affairs Health Care System, The HLA Research Group, Brain Sciences Center, Minneapolis, MN, USA
- Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
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5
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Francis SS, Guerra G, Hansen HM, Wendt G, Kachuri L, Wiencke JK, Wrensch M. Inherited polymorphisms in the Human Leukocyte Antigen Region modify the association between varicella-zoster virus antibody reactivity and glioma prognosis. Neuro Oncol 2023; 25:1910-1912. [PMID: 37595256 PMCID: PMC10547499 DOI: 10.1093/neuonc/noad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Affiliation(s)
- Stephen S Francis
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Geno Guerra
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Helen M Hansen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - George Wendt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Linda Kachuri
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
- Stanford Cancer Institute, Stanford University, Stanford, California, USA
| | - John K Wiencke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Margaret Wrensch
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Zhou J, Xie T, Shan H, Cheng G. HLA-DQA1 expression is associated with prognosis and predictable with radiomics in breast cancer. Radiat Oncol 2023; 18:117. [PMID: 37434241 DOI: 10.1186/s13014-023-02314-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 07/05/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND High HLA-DQA1 expression is associated with a better prognosis in many cancers. However, the association between HLA-DQA1 expression and prognosis of breast cancer and the noninvasive assessment of HLA-DQA1 expression are still unclear. This study aimed to reveal the association and investigate the potential of radiomics to predict HLA-DQA1 expression in breast cancer. METHODS In this retrospective study, transcriptome sequencing data, medical imaging data, clinical and follow-up data were downloaded from the TCIA ( https://www.cancerimagingarchive.net/ ) and TCGA ( https://portal.gdc.cancer.gov/ ) databases. The clinical characteristic differences between the high HLA-DQA1 expression group (HHD group) and the low HLA-DQA1 expression group were explored. Gene set enrichment analysis, Kaplan‒Meier survival analysis and Cox regression were performed. Then, 107 dynamic contrast-enhanced magnetic resonance imaging features were extracted, including size, shape and texture. Using recursive feature elimination and gradient boosting machine, a radiomics model was established to predict HLA-DQA1 expression. Receiver operating characteristic (ROC) curves, precision-recall curves, calibration curves, and decision curves were used for model evaluation. RESULTS The HHD group had better survival outcomes. The differentially expressed genes in the HHD group were significantly enriched in oxidative phosphorylation (OXPHOS) and estrogen response early and late signalling pathways. The radiomic score (RS) output from the model was associated with HLA-DQA1 expression. The area under the ROC curves (95% CI), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the radiomic model were 0.866 (0.775-0.956), 0.825, 0.939, 0.7, 0.775, and 0.913 in the training set and 0.780 (0.629-0.931), 0.659, 0.81, 0.5, 0.63, and 0.714 in the validation set, respectively, showing a good prediction effect. CONCLUSIONS High HLA-DQA1 expression is associated with a better prognosis in breast cancer. Quantitative radiomics as a noninvasive imaging biomarker has potential value for predicting HLA-DQA1 expression.
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Affiliation(s)
- JingYu Zhou
- Department of Radiology, Peking University Shenzhen Hospital, LianHua Road, Shenzhen, 518000, Guangdong, China
| | - TingTing Xie
- Department of Radiology, Peking University Shenzhen Hospital, LianHua Road, Shenzhen, 518000, Guangdong, China
| | - HuiMing Shan
- Department of Radiology, Peking University Shenzhen Hospital, LianHua Road, Shenzhen, 518000, Guangdong, China
| | - GuanXun Cheng
- Department of Radiology, Peking University Shenzhen Hospital, LianHua Road, Shenzhen, 518000, Guangdong, China.
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7
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Guerra G, McCoy L, Hansen HM, Rice T, Molinaro AM, Wiemels JL, Wiencke JK, Wrensch M, Francis SS. Antibodies to varicella-zoster virus and three other herpesviruses and survival in adults with glioma. Neuro Oncol 2023; 25:1047-1057. [PMID: 36610073 PMCID: PMC10237424 DOI: 10.1093/neuonc/noac283] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Lifetime exposure to the varicella-zoster virus (VZV) has been consistently inversely associated with glioma risk, however, the relationship of VZV with survival in adults with glioma has not been investigated. In this study, we analyzed the survival of adults with glioma in relation to their antibody measurements to 4 common herpes viral infections, including VZV, measured post-diagnosis. METHODS We analyzed IgG antibody measurements to VZV, cytomegalovirus (CMV), herpes simplex virus 1/2 (HSV), and Epstein-Barr virus (EBV) collected from 1378 adults with glioma diagnosed between 1991 and 2010. Blood was obtained a median of 3 months after surgery. Associations of patient IgG levels with overall survival were estimated using Cox models adjusted for age, sex, self-reported race, surgery type, dexamethasone usage at blood draw, and tumor grade. Models were stratified by recruitment series and meta-analyzed to account for time-dependent treatment effects. RESULTS VZV antibody seropositivity was associated with improved survival outcomes in adults with glioma (Hazard ratio, HR = 0.70, 95% Confidence Interval 0.54-0.90, P = .006). Amongst cases who were seropositive for VZV antibodies, survival was significantly improved for those above the 25th percentile of continuous reactivity measurements versus those below (HR = 0.76, 0.66-0.88, P = .0003). Antibody seropositivity to EBV was separately associated with improved survival (HR = 0.71, 0.53-0.96, P = .028). Antibody positivity to 2 other common viruses (CMV, HSV) was not associated with altered survival. CONCLUSIONS Low levels of VZV or EBV antibodies are associated with poorer survival outcomes for adults with glioma. Differential immune response rather than viral exposure may explain these findings.
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Affiliation(s)
- Geno Guerra
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lucie McCoy
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Helen M Hansen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Terri Rice
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Joseph L Wiemels
- Center for Genetic Epidemiology, Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - John K Wiencke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Institute of Human Genetics, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Margaret Wrensch
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Institute of Human Genetics, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Stephen S Francis
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
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