Ménière's disease: new guidelines, subtypes, imaging, and more

Allergic diseases and Meniere's disease: a bidirectional Mendelian randomization

OBJECTIVES

Allergic diseases and Meniere's disease found to have a possible link in observational study. However, the potential causal relationship between the two is unclear. Therefore, we aimed to explore the causal relationship between allergic diseases and Meniere's disease using a new data analysis technique called bidirectional Mendelian randomization study.

METHOD

Summary-level statistics for Meniere's disease and three allergic diseases (asthma, allergic rhinitis, eczema/dermatitis) were obtained from large-scale genome-wide association studies. The inverse variance weighted method was used as the primary measure, supplemented by MR-Egger regression and the weighted median method. To ensure the reliability of the conclusions, Cochran's Q, MR-Egger intercept, MR-PRESSO test, leave-one-out test, and MR Steiger test were used.

RESULTS

Inverse-variance weighted method showed asthma (p = 0.008, OR = 3.908, 95% CI 1.424-10.724, adjust_p = 0.024), allergic rhinitis (p = 0.026, OR = 24.714, 95% CI 1.479-412.827, adjust_p = 0.026) and eczema/dermatitis (p = 0.019, OR = 3725.954, 95% CI 3.795 to 3,658,399.580, adjust_p = 0.029) all had a significant effect on Meniere's disease. Reverse Mendelian randomization studies have shown that Meniere's disease does not increase the risk of three allergic diseases. Sensitivity analysis showed no horizontal pleiotropy and heterogeneity for each trait.

CONCLUSION

Our Mendelian randomization analysis supports a positive causal relationship between three allergic diseases (asthma, allergic rhinitis, eczema/dermatitis) and Meniere's disease. This suggests that physicians should pay more attention to the Meniere's patient's allergy history and consider allergy avoidance as part of their treatment plan.

LEVEL OF EVIDENCE

Mendelian Randomized (MR) studies are second only to randomized controlled trials in terms of the level of evidence.

Expression of AQP8 in Serum of Patients With Meniere's Disease and Its Value in Evaluating the Degree of Hydrolabyrinth and Predicting Prognosis

OBJECTIVE

This study aims to explore the role of serum aquaporin 8 (AQP8) expression in evaluating the degree of hydrolabyrinth and predicting prognosis in patients with Meniere's disease.

METHODS

One hundred and five patients diagnosed with Meniere's disease in our hospital were enrolled in the Meniere's disease group. Another 102 healthy subjects were enrolled as the control group. The expression of serum AQP8 mRNA was determined by the quantitative real-time PCR (qRT-PCR) method. Receiver operating characteristic (ROC) curve analysis was carried out to analyse the predictive value of serum AQP8 mRNA expression for poor prognosis in Meniere's disease patients. Multivariate logistic regression was used to analyse the influencing factors of poor prognosis in patients with Meniere's disease.

RESULTS

The expression level of serum AQP8 mRNA in the Meniere's disease group was significantly higher than that in the control group (p < 0.05). In the severe hydrops group, serum AQP8 mRNA expression levels were higher than in the mild hydrops group and the no endolymphatic hydrops group. Additionally, the mild hydrops group had higher serum AQP8 mRNA levels than the no endolymphatic hydrops group (p < 0.05). The disease course, proportion of severe hydrops and serum AQP8 mRNA expression were all higher in the poor prognosis group compared to the good prognosis group (p < 0.05). The area under the curve (AUC) for serum AQP8 mRNA in predicting poor prognosis in Meniere's disease patients was 0.812 (95%CI: 0.702-0.922).

CONCLUSION

AQP8 mRNA is associated with the degree of hydrolabyrinth in patients with Meniere's disease and plays an important role in predicting prognosis.

Restriction of salt, alcohol and coffee intake and Ménière's disease: insight from Mendelian randomization study

Background

Restricting salt, caffeine, and alcohol intake is commonly recommended as a first-line treatment for patients with Ménière's disease (MD). However, it remains unclear whether these interventions effectively improve symptoms of MD. Therefore, we conducted a bidirectional two-sample Mendelian randomization (MR) analysis to evaluate the relationship between these dietary modifications and MD.

Methods

Summary statistics for salt added to food, alcohol consumption, coffee consumption, and MD were sourced from the United Kingdom Biobank, GSCAN, and the FinnGen study, involving up to 941,280 participants. The main analyses were performed using the random-effects inverse-variance weighted (IVW) approach and were complemented by four additional methods. Multiple sensitivity analyses were performed to validate the findings, and both forward and reverse MR analyses were employed to address potential reverse causality bias.

Results

The primary MR results using the IVW method revealed that salt added to food (OR = 0.719, 95% CI: 0.429-1.206; p = 0.211), alcohol consumption (OR = 0.834, 95% CI: 0.427-1.628; p = 0.595), and coffee consumption (OR = 0.852, 95% CI: 0.555-1.306; p = 0.461) were not significantly correlated with MD. In reverse analysis, no evidence of significant effect was found from MD to salt added to food (OR = 1.000, 95% CI: 0.993-1.007; p = 0.957), alcohol consumption (OR = 0.998, 95% CI: 0.987-1.008; p = 0.682), and coffee consumption (OR = 0.998, 95% CI: 0.985-1.011; p = 0.72).

Conclusion

This MR analysis did not identify convincing evidence to support the idea that restricting salt, caffeine, and alcohol intake is beneficial for the treatment of MD.

Comparative analysis of vestibular endolymphatic hydrops grading methods and hearing loss in Ménière's disease: a retrospective MRI study using 3D-real inversion recovery sequence

PURPOSE

To compare the correlation between different grading methods of vestibular endolymphatic hydrops (EH) and the severity of hearing loss in Ménière's disease (MD), and evaluate the diagnostic value of these methods in diagnosing MD.

METHODS

This retrospective study included 30 patients diagnosed with MD from June 2021 to August 2023. All patients underwent inner ear MR gadolinium-enhanced imaging using three-dimensional (3D)-real inversion recovery sequences and pure-tone audiometry. The EH levels were independently evaluated according to the classification methods outlined by Nakashima et al. (Acta Otolaryngol Suppl 5-8, 2009. https://doi.org/10.1080/00016480902729827 ) (M1), Fang et al. (J Laryngol Otol 126:454-459, 2012. https://doi.org/10.1017/S0022215112000060 ) (M2), Barath et al. (Am J Neuroradiol 35:1387-1392, 2014. https://doi.org/10.3174/ajnr.A3856 ), (M3), Liu et al. (Front Surg 9:874971, 2022. https://doi.org/10.3389/fsurg.2022.874971 ), (M4), and Bernaerts et al. (Neuroradiology 61:421-429, 2019. https://doi.org/10.1007/s00234-019-02155-7 ) (M5), with a subsequent comparison of interobserver agreement. After achieving a consensus, an analysis was performed to explore the correlations between vestibular EH grading using different methods, the average hearing thresholds at low-mid, high-, and full frequencies and clinical stages. The diagnostic capabilities of these methods for MD were then compared.

RESULTS

The interobserver consistency of M2-M5 was superior to that of M1. The EH grading based on M4 showed a significant correlation with the average hearing thresholds at low-mid, high-, and full frequencies and clinical stages. M1, M2, M3, and M5 correlated with some parameters. A receiver operating characteristic curve analysis indicated that M5 significantly outperformed M1, M2, M3, and M4 in terms of diagnostic efficiency for MD.

CONCLUSION

M4 showed the strongest correlation with the degree of hearing loss in patients with MD, whereas M5 showed the highest diagnostic performance.

Applications of Machine Learning in Meniere's Disease Assessment Based on Pure-Tone Audiometry

OBJECTIVE

To apply machine learning models based on air conduction thresholds of pure-tone audiometry for automatic diagnosis of Meniere's disease (MD) and prediction of endolymphatic hydrops (EH).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary medical center.

METHODS

Gadolinium-enhanced magnetic resonance imaging sequences and pure-tone audiometry data were collected. Subsequently, basic and multiple analytical features were engineered based on the air conduction thresholds of pure-tone audiometry. Later, 5 classical machine learning models were trained to diagnose MD using the engineered features. The models demonstrating excellent performance were also selected to predict EH. The model's effectiveness in MD diagnosis was compared with experienced otolaryngologists.

RESULTS

First, the winning light gradient boosting (LGB) machine learning model trained by multiple features demonstrates a remarkable performance on the diagnosis of MD, achieving an accuracy rate of 87%, sensitivity of 83%, specificity of 90%, and a robust area under the receiver operating characteristic curve of 0.95, which compares favorably with experienced clinicians. Second, the LGB model, with an accuracy of 78% on EH prediction, outperformed the other 3 machine learning models. Finally, a feature importance analysis reveals a pivotal role of the specific pure-tone audiometry features that are essential for both MD diagnosis and EH prediction. Highlighted features include standard deviation and mean of the whole-frequency hearing, the peak of the audiogram, and hearing at low frequencies, notably at 250 Hz.

CONCLUSION

An efficient machine learning model based on pure-tone audiometry features was produced to diagnose MD, which also showed the potential to predict the subtypes of EH. The innovative approach demonstrated a game-changing strategy for MD screening and promising cost-effective benefits for the health care enterprise.

Electroencephalography microstate alterations reflect potential double-edged cognitive adaptation in Ménière's disease

PURPOSE

To explore the microstate characteristics and underlying brain network activity of Ménière's disease (MD) patients based on high-density electroencephalography (EEG), elucidate the association between microstate dynamics and clinical manifestation, and explore the potential of EEG microstate features as future neurobiomarkers for MD.

METHODS

Thirty-two patients diagnosed with MD and 29 healthy controls (HC) matched for demographic characteristics were included in the study. Dysfunction and subjective symptom severity were assessed by neuropsychological questionnaires, pure tone audiometry, and vestibular function tests. Resting-state EEG recordings were obtained using a 256-channel EEG system, and the electric field topographies were clustered into four dominant microstate classes (A, B, C, and D). The dynamic parameters of each microstate were analyzed and utilized as input for a support vector machine (SVM) classifier to identify significant microstate signatures associated with MD. The clinical significance was further explored through Spearman correlation analysis.

RESULTS

MD patients exhibited an increased presence of microstate class C and a decreased frequency of transitions between microstate class A and B, as well as between class A and D. The transitions from microstate class A to C were also elevated. Further analysis revealed a positive correlation between equilibrium scores and the transitions from microstate class A to C under somatosensory challenging conditions. Conversely, transitions between class A and B were negatively correlated with vertigo symptoms. No significant correlations were detected between these characteristics and auditory test results or emotional scores. Utilizing the microstate features identified via sequential backward selection, the linear SVM classifier achieved a sensitivity of 86.21% and a specificity of 90.61% in distinguishing MD patients from HC.

CONCLUSIONS

We identified several EEG microstate characteristics in MD patients that facilitate postural control yet exacerbate subjective symptoms, and effectively discriminate MD from HC. The microstate features may offer a new approach for optimizing cognitive compensation strategies and exploring potential neurobiological markers in MD.

ChatGPT Responses to Frequently Asked Questions on Ménière's Disease: A Comparison to Clinical Practice Guideline Answers

Objective

Evaluate the quality of responses from Chat Generative Pre-Trained Transformer (ChatGPT) models compared to the answers for "Frequently Asked Questions" (FAQs) from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines (CPG) for Ménière's disease (MD).

Study Design

Comparative analysis.

Setting

The AAO-HNS CPG for MD includes FAQs that clinicians can give to patients for MD-related questions. The ability of ChatGPT to properly educate patients regarding MD is unknown.

Methods

ChatGPT-3.5 and 4.0 were each prompted with 16 questions from the MD FAQs. Each response was rated in terms of (1) comprehensiveness, (2) extensiveness, (3) presence of misleading information, and (4) quality of resources. Readability was assessed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease Score (FRES).

Results

ChatGPT-3.5 was comprehensive in 5 responses whereas ChatGPT-4.0 was comprehensive in 9 (31.3% vs 56.3%, P = .2852). ChatGPT-3.5 and 4.0 were extensive in all responses (P = 1.0000). ChatGPT-3.5 was misleading in 5 responses whereas ChatGPT-4.0 was misleading in 3 (31.3% vs 18.75%, P = .6851). ChatGPT-3.5 had quality resources in 10 responses whereas ChatGPT-4.0 had quality resources in 16 (62.5% vs 100%, P = .0177). AAO-HNS CPG FRES (62.4 ± 16.6) demonstrated an appropriate readability score of at least 60, while both ChatGPT-3.5 (39.1 ± 7.3) and 4.0 (42.8 ± 8.5) failed to meet this standard. All platforms had FKGL means that exceeded the recommended level of 6 or lower.

Conclusion

While ChatGPT-4.0 had significantly better resource reporting, both models have room for improvement in being more comprehensive, more readable, and less misleading for patients.

Association Between Vestibular Aqueduct Morphology and Meniere's Disease

OBJECTIVE

To investigate the relationship between vestibular aqueduct (VA) morphology and Meniere's disease (MD) using ultrahigh-resolution computed tomography (U-HRCT).

METHODS

Retrospective data were collected from 34 patients (40 ears) diagnosed with MD in our hospital who underwent temporal bone U-HRCT with isotropic 0.05-mm resolution, magnetic resonance with gadolinium-enhanced, and pure-tone audiometry; 34 age- and sex-matched controls (68 ears) who underwent U-HRCT were also included. VA patency was qualitatively classified as locally not shown (grade 1), locally faintly shown (grade 2), or clearly shown throughout (grade 3). The width of the outer orifice and VA length and angle were quantitatively measured. Differences in VA morphology between the MD and control groups were analyzed. The correlations between VA morphology and the degrees of hearing loss and endolymphatic hydrops (EH) were also analyzed.

RESULTS

VA was classified as grades 1-3 in 11, 17, and 12 ears in the MD group and 5, 26, and 37 ears in the control group, respectively. The patency differed significantly between the groups (p < 0.01). The width of the outer orifice and length of VA were significantly smaller in the MD group than those in the control group (p < 0.05). Both VA patency and length were correlated with the degree of EH in the cochlea and the vestibule (p < 0.05). No difference was found between VA morphology and the degree of hearing loss (p > 0.05).

CONCLUSION

The morphological characteristics of VA were found to be associated with the occurrence of MD and the degree of EH.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3349-3354, 2024.

Late/delayed gadolinium enhancement in MRI after intravenous administration of extracellular gadolinium-based contrast agents: is it worth waiting?

The acquisition of images minutes or even hours after intravenous extracellular gadolinium-based contrast agents (GBCA) administration ("Late/Delayed Gadolinium Enhancement" imaging; in this review, further termed LGE) has gained significant prominence in recent years in magnetic resonance imaging. The major limitation of LGE is the long examination time; thus, it becomes necessary to understand when it is worth waiting time after the intravenous injection of GBCA and which additional information comes from LGE. LGE can potentially be applied to various anatomical sites, such as heart, arterial vessels, lung, brain, abdomen, breast, and the musculoskeletal system, with different pathophysiological mechanisms. One of the most popular clinical applications of LGE regards the assessment of myocardial tissue thanks to its ability to highlight areas of acute myocardial damage and fibrotic tissues. Other frequently applied clinical contexts involve the study of the urinary tract with magnetic resonance urography and identifying pathological abdominal processes characterized by high fibrous stroma, such as biliary tract tumors, autoimmune pancreatitis, or intestinal fibrosis in Crohn's disease. One of the current areas of heightened research interest revolves around the possibility of non-invasively studying the dynamics of neurofluids in the brain (the glymphatic system), the disruption of which could underlie many neurological disorders.

Symptom networks analysis among people with Meniere's disease: Application for nursing care

Objectives

This study aimed to explore and visualize the relationships among multiple symptoms in patients with Meniere's disease (MD) and aid clinical nurses in the design of accurate, individualized interventions.

Methods

This study included 790 patients with MD at the Eye and ENT Hospital of Fudan University from October 2014 to December 2021. A self-designed symptom checklist was used to assess 15 MD-related symptoms and construct contemporaneous networks with all 15 symptoms in R software. Qgraph package and Fruchterman-Reingold layout were used for network visualization. Bootstrapping methods were performed to assess network accuracy and stability, and three centrality indices were adopted to describe relationships among symptoms.

Results

Symptom networks showed good accuracy and stability. "Anxiety and nervousness"(98.2%), "aural fullness"(84.4%) and "tinnitus"(82.7%) were the common symptom in MD patients, while "tinnitus", "aural fullness" and "decline in word recognition", were more serious. MD patients with longer disease duration had higher prevalence and severity for all symptoms (P < 0.05). Symptom networks showed good accuracy and stability. "Decline in word recognition," "fatigue," and "anxiety and nervousness" were at the center of the symptom networks, which had the largest strength values and closeness. "Decline in word recognition," "headache," and "spatial discrimination and poor orientation" were the symptoms with the highest betweenness with the strongest bridging effect. The ≥1-year disease group exhibited higher centralities for "drop attack" and "anxiety and nervousness," and a lower centrality for "headache" compared with the <1-year disease group.

Conclusions

The symptom networks of MD patients with varying disease durations were revealed. Clinicians and nurses must provide precision interventions tailored to modifying symptom severity and centrality. Nursing interventions should focus on word recognition issues and associated discomfort in MD patients with multiple symptoms.

Causality between alcohol usually taken with meals and Meniere disease: A 2-sample Mendelian randomization study

The recurrence of Meniere disease (MD) strongly affects patient quality of life. Identifying the risk factors for MD is highly important for its prevention and treatment. Previous studies have suggested that alcohol intake may play a role in the development of MD. However, recent studies have shown that the causal relationship between alcohol consumption and MD remains controversial. In this paper, the Mendelian randomization (MR) method was used to determine the causal relationship between alcohol consumption usually consumed with meals and MD, with the aim of providing suggestions for alcohol intake management in individuals with MD and helping in the prevention and treatment of MD. Two-sample MR was used to investigate the causal relationship between alcohol usually taken with meals and MD. We used a dataset from a publicly available large-scale genome-wide association study (GWAS). Inverse variance weighting (IVW), MR-Egger, simple weighting, weighted weighting and the weighted median method were used for analysis. The final results showed that IVW (OR = 0.991, 95% CI: 0.983-0.998, P = .016) results suggested that there was statistical significance, but MR-Egger (OR = 0.978, 95% CI: 0.886-1.080, P = .679), weighted median methods (OR = 0.994, 95% CI: 0.985-1.004, P = .307) and Simple mode (OR = 0.995, 95% CI: 0.980-1.010, P = .566), Weighted mode (OR = 0.995, 95% CI: 0.981-1.010, P = .557) found no significant causal relationship. The results suggest that alcohol usually taken with meals may be negatively correlated with MD.

Meniere's disease: Pathogenesis, treatments, and emerging approaches for an idiopathic bioenvironmental disorder

Meniere's disease (MD) is a severe inner ear condition known by debilitating symptoms, including spontaneous vertigo, fluctuating and progressive hearing loss, tinnitus, and aural fullness or pressure within the affected ear. Prosper Meniere first described the origins of MD in the 1860s, but its underlying mechanisms remain largely elusive today. Nevertheless, researchers have identified a key histopathological feature called Endolymphatic Hydrops (ELH), which refers to the excessive buildup of endolymph fluid in the membranous labyrinth of the inner ear. The exact root of ELH is not fully understood. Still, it is believed to involve several biological and bioenvironmental etiological factors such as genetics, autoimmunity, infection, trauma, allergy, and new theories, such as saccular otoconia blocking the endolymphatic duct and sac. Regarding treatment, there are no reliable and definitive cures for MD. Most therapies focus on managing symptoms and improving the overall quality of patients' life. To make significant advancements in addressing MD, it is crucial to gain a fundamental understanding of the disease process, laying the groundwork for more effective therapeutic approaches. This paper provides a comprehensive review of the pathophysiology of MD with a focus on old and recent theories. Current treatment strategies and future translational approaches (with low-level evidence but promising results) related to MD are also discussed, including patents, drug delivery, and nanotechnology, that may provide future benefits to patients suffering from MD.

The effect of vascular risk factors on the efficacy of endolymphatic sac decompression surgery for Meniere's disease: a retrospective cohort study

Objectives

This study aimed to investigate the effect of vascular risk factors on the outcomes of endolymphatic sac decompression (ESD) surgery in patients with Meniere's disease.

Methods

The study included 56 patients with Meniere's disease, who had undergone unilateral ESD surgery. The patients' vascular risk factors were assessed based on the preoperative 10-year atherosclerotic cardiovascular diseases risk classification. Those with no or low risk were defined as the low-risk group, while those with medium, high, or very high risk were defined as the high-risk group. The correlation between the vascular risk factors and ESD efficacy was evaluated by the comparison of vertigo control grade between the two groups. The functional disability score was also assessed to investigate whether ESD improved the quality of life in Meniere's disease patients with vascular risk factors.

Results

After ESD, 78.95 and 81.08% of patients from the low-risk and high-risk groups, respectively, demonstrated at least grade B vertigo control; no statistically significant difference was observed (p = 0.96). The postoperative functional disability scores in both groups were significantly lower compared with those before surgery (p < 0.01), with a median decrease of two (1, 2) points in both groups. No statistically significant difference between the two groups was observed (p = 0.65).

Conclusion

Vascular risk factors have little effect on the efficacy of ESD in patients with Meniere's disease. Patients with one or more vascular risk factors can still experience a not poor vertigo control and improved quality of life after ESD.

A bibliometric and visualization study of Meniere's disease: Current status and global hotspots and emerging trends

BACKGROUND

Meniere's disease (MD) is a clinical condition characterized by endolymphatic hydrops. Persistent symptoms negatively affect patients mood, and the underlying etiology remains unclear. It is necessary to comprehensively understand the relevant publications, review the history and current status of research, and analyze hotspots and frontiers of research on MD.

METHODS

We retrieved literature on Meniere's disease from 2003 to 2022 from the Web of Science database and extracted the data. Data visualization and analysis was conducted using Cite Space, VOS viewer, an online web tool, and Microsoft Office Power Point 2019.

RESULTS

In total, 2847 publications were analyzed. The number of annual publications was relatively stable, with an accelerated upward trend over the past 5 years. The country with the most publications was USA (751, 26.38%), while the University of Munich contributed more publications than any other institution (117, 4.11%). The article titled "Diagnostic criteria for Meniere's disease" by Lopez-Escamez J et al in 2015 was the most cited and co-cited publication, and also had the top co-cited references with the strongest citation bursts. Naganawa S was the author with the most publications (85, 2.99%). The top 3 journals and co-cited journals were Otology Neurotology, Acta Oto Laryngologica, and Laryngoscope. Recently, the key theme words were "sensorineural hearing loss," "therapy," "intratympanic injection method," "vestibular-evoked myogenic potentials," "vestibular migraine," "magnetic resonance imaging," and "meniere's disease."

CONCLUSIONS

The US has the largest number of publications and research institutions, many European countries have high-quality journals, and Japan has the highest number of scholars. The international opinion on Meniere's disease is relatively uniform. The stepped-therapy for MD is scientific and clear. Intratympanic injection of steroids and intratympanic injection of gentamicin are commonly used, but steroids are considered safer. Saccular dysfunction may be more common in patients with MD than in those with utricular dysfunctions. It is worth paying attention to study the relationship between MD and vestibular migraine through headache. Progress in magnetic resonance imaging technology is still required for the imaging diagnosis of MD.

Smoking Is Positively Related and Alcohol Consumption Is Negatively Related to an Increased Risk of Meniere's Disease

A few prior researchers presumed the impacts of smoking and alcohol on the risk of Meniere’s disease (MD). This study investigated the relationship between smoking, alcohol consumption, and obesity with Meniere’s disease in an adult population. The ≥40-year-old population in the Korean National Health Insurance Service-Health Screening Cohort 2002−2019 was analyzed. A total of 15,208 patients with MD were matched with 499,658 comparison participants. The current smoking, alcohol consumption, and past medical histories were collected. Body mass index (BMI) was grouped into underweight, normal, overweight, obese I, and obese II. The odds of histories of smoking and alcohol consumption and the BMI group for MD were analyzed using conditional logistic regression analysis. These associations were further analyzed in subgroups of age, sex, smoking, alcohol consumption, and BMI. In the overall adult population, smoking and alcohol consumption did not show an association with MD. Being underweight was linked with lower odds for MD (adjusted OR [aOR] = 0.80, 95% CI = 0.68−0.93, p = 0.004). In the male group, smoking was positively associated with MD (aOR = 1.08, 95% CI = 1.00−1.17, p = 0.043), while alcohol consumption was negatively related to MD (aOR = 0.87, 95% CI = 0.81−0.94, p < 0.001). Being underweight was related to a lower risk of MD. In adult men, smoking was predicted to increase, while alcohol consumption was predicted to decrease the risk of MD.