1
|
Xiao L, Lin S, Zhan F. Effects of ankylosing spondylitis on cardiovascular disease: aMendelian randomization study. Front Genet 2024; 15:1359829. [PMID: 38988833 PMCID: PMC11233707 DOI: 10.3389/fgene.2024.1359829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/30/2024] [Indexed: 07/12/2024] Open
Abstract
Objective Accumulating evidence suggests that patients with ankylosing spondylitis (AS) have an elevated risk for cardiovascular disease (CVD) and cardiovascular death, however, whether AS has causal effects on the risk of CVD is unclear.Two-sample Mendelian randomization (MR) was utilizedto examine the probable causal link between them. Methods Summary statistics from publicly released genome-wide association studies (GWAS) was used to perform MR analyses. Genetically predicted AS was selected as the exposure variable from published GWAS meta-analyses. CVD was adopted as the outcome variable. The inverse variant weighted method was employed to obtain the casual estimates. The robustness of the results was also examined by evaluating the pleiotropy and heterogeneity of single-nucleotide polymorphisms. Results According to MR analyses, genetic susceptibility to AS was associated with a high risk of heart failure and ischemic stroke, while negativelygenetic susceptibility was found between AS and peripheral atherosclerosis. No statistical relationship was found between AS and venous thromboembolism, atrial fibrillation, coronary atherosclerosis, and valvular heart disease. Sensitivity analysis showed no evidence of horizontal pleiotropy or heterogeneity. Conclusion The present study suggests that AS exerts causal effects on the risk of CVD, including heart failure, ischemic stroke, and peripheral atherosclerosis.
Collapse
Affiliation(s)
- Lu Xiao
- Department of Rheumatology, The Fifth People's Hospital of Wuxi, Affiliated Wuxi Fifth Hospital of Jiangnan University, Wuxi, China
| | - Shudian Lin
- Department of Rheumatology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Feng Zhan
- Department of Rheumatology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| |
Collapse
|
2
|
Li S, Sun D, Wang R, Du Q, Chen H, Shi Z, Zhou H. Causal association between multiple sclerosis and severe COVID-19: A bidirectional Mendelian randomization study. J Neuroimmunol 2024; 391:578352. [PMID: 38704884 DOI: 10.1016/j.jneuroim.2024.578352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/14/2024] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Shuangjie Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Dongren Sun
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Rui Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qin Du
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hongxi Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ziyan Shi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China.
| |
Collapse
|
3
|
Sun D, Zhang Y, Wang R, Du Q, Shi Z, Chen H, Wang X, Zhou H. Causal effects of gut microbiota on multiple sclerosis: A two-sample Mendelian randomization study. Brain Behav 2024; 14:e3593. [PMID: 38898610 PMCID: PMC11186842 DOI: 10.1002/brb3.3593] [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: 01/11/2024] [Revised: 03/13/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Gut microbiota alterations in multiple sclerosis (MS) patients have been reported in observational studies, but whether these associations are causal is unclear. OBJECTIVE We performed a Mendelian randomization study (MR) to assess the causal effects of gut microbiota on MS. METHODS Independent genetic variants associated with 211 gut microbiota phenotypes were selected as instrumental variables from the largest genome-wide association studies (GWAS) previously published by the MiBioGen study. GWAS data for MS were obtained from the International Multiple Sclerosis Genetics Consortium (IMSGC) for primary analysis and the FinnGen consortium for replication and collaborative analysis. Sensitivity analyses were conducted to evaluate heterogeneity and pleiotropy. RESULTS After inverse-variance-weighted and sensitivity analysis filtering, seven gut microbiota with potential causal effects on MS were identified from the IMSGC. Only five metabolites remained significant associations with MS when combined with the FinnGen consortium, including genus Anaerofilum id.2053 (odds ratio [OR] = 1.141, 95% confidence interval [CI]: 1.021-1.276, p = .021), Ruminococcus2 id.11374 (OR = 1.190, 95% CI: 1.007-1.406, p = .042), Ruminococcaceae UCG003 id.11361 (OR = 0.822, 95% CI: 0.688-0.982, p = .031), Ruminiclostridium5 id.11355 (OR = 0.724, 95% CI: 0.585-0.895, p = .003), Anaerotruncus id.2054 (OR = 0.772, 95% CI: 0.634-0.940, p = .010). CONCLUSION Our MR analysis reveals a potential causal relationship between gut microbiota and MS, offering promising avenues for advancing mechanistic understanding and clinical investigation of microbiota-mediated MS.
Collapse
Affiliation(s)
- Dongren Sun
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Yangyang Zhang
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Rui Wang
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Qin Du
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Ziyan Shi
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Hongxi Chen
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Xiaofei Wang
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Hongyu Zhou
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| |
Collapse
|
4
|
Loonstra FC, de Ruiter LRJ, Strijbis EMM, de Jong BA, Uitdehaag BMJ. The association between weight during early life and multiple sclerosis onset in a nationwide Dutch birth year cohort. Nutr Neurosci 2024; 27:499-505. [PMID: 37409581 DOI: 10.1080/1028415x.2023.2225271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND The relationship between being overweight during early life and disease course in multiple sclerosis (MS) is unresolved. We investigated the association between being overweight or obese during early life (childhood and adolescence) and MS case status, age of first symptom onset and onset type in people with MS (pwMS) of the same birth year. METHODS We enrolled 363 PwMS and 125 healthy controls (HC) from Project Y, a Dutch population-based cross-sectional cohort study including all PwMS born in 1966 and age and sex-matched HC. The associations between weight during childhood and adolescence (non-overweight vs. overweight or obese) and MS, age at symptom onset and onset type (relapsing vs. progressive) were assessed using logistic and linear regressions. In addition, sex-separated associations were explored. RESULTS Being overweight or obese during childhood (OR = 2.82, 95% CI 1.17-6.80) and adolescence (OR = 2.45, 95% CI 1.13-5.34) was associated with developing MS. Furthermore, being overweight or obese during adolescence was associated with a younger age of onset (β = -0.11, p = 0.041). Of all 47 patients with a primary progressive (PP) onset type, only one patient (2.1%) was overweight or obese during childhood, whereas 45 patients with a relapsing remitting (RR) onset (14.3%) were overweight or obese during childhood (PP vs. RR p = 0.017; PP vs. HC p = 0.676; RR vs. HC, p = 0.015). However, using logistic regression analysis we did not find evidence of a significant association. CONCLUSION In a nationwide population-based birth year cohort, being overweight or obese during childhood or adolescence is associated with MS prevalence and an earlier age of onset, but does not seem to associate with the type of onset.
Collapse
Affiliation(s)
- Floor C Loonstra
- MS Center Amsterdam, Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lodewijk R J de Ruiter
- MS Center Amsterdam, Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Eva M M Strijbis
- MS Center Amsterdam, Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Brigit A de Jong
- MS Center Amsterdam, Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bernard M J Uitdehaag
- MS Center Amsterdam, Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
5
|
Ciężki S, Odyjewska E, Bossowski A, Głowińska-Olszewska B. Not Only Metabolic Complications of Childhood Obesity. Nutrients 2024; 16:539. [PMID: 38398863 PMCID: PMC10892374 DOI: 10.3390/nu16040539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
The increasing incidence of obesity in the pediatric population requires attention to its serious complications. It turns out that in addition to typical, well-known metabolic complications, obesity as a systemic disease carries the risk of equally serious, although less obvious, non-metabolic complications, such as cardiovascular diseases, polycystic ovary syndrome, chronic kidney disease, asthma, thyroid dysfunction, immunologic and dermatologic conditions, and mental health problems. They can affect almost all systems of the young body and also leave their mark in adulthood. In addition, obesity also contributes to the exacerbation of existing childhood diseases. As a result, children suffering from obesity may have a reduced quality of life, both physically and mentally, and their life expectancy may be shortened. It also turns out that, in the case of obese pregnant girls, the complications of obesity may also affect their unborn children. Therefore, it is extremely important to take all necessary actions to prevent the growing epidemic of obesity in the pediatric population, as well as to treat existing complications of obesity and detect them at an early stage. In summary, physicians treating a child with a systemic disease such as obesity must adopt a holistic approach to treatment.
Collapse
Affiliation(s)
- Sebastian Ciężki
- Department of Pediatrics, Endocrinology, and Diabetology with Cardiology Division, Medical University of Bialystok, 15-274 Białystok, Poland
| | - Emilia Odyjewska
- Department of Pediatrics, Endocrinology, and Diabetology with Cardiology Division, Medical University of Bialystok, 15-274 Białystok, Poland
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, and Diabetology with Cardiology Division, Medical University of Bialystok, 15-274 Białystok, Poland
| | - Barbara Głowińska-Olszewska
- Department of Pediatrics, Endocrinology, and Diabetology with Cardiology Division, Medical University of Bialystok, 15-274 Białystok, Poland
| |
Collapse
|
6
|
Bove R, Sutton P, Nicholas J. Women's Health and Pregnancy in Multiple Sclerosis. Neurol Clin 2024; 42:275-293. [PMID: 37980119 DOI: 10.1016/j.ncl.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Multiple sclerosis has a 3:1 female-to-male predominance and commonly presents in young adult women. The hormonal changes in women throughout their lifetime do affect the underlying pathology of multiple sclerosis, and the needs of women therefore change with age. Although multiple sclerosis does not adversely affect fertility or pregnancy, there are many factors to consider when caring for women throughout family planning, pregnancy, and the postpartum period. The care of these women and complex decisions regarding disease-modifying therapy use in family planning should be individualized and comprehensive.
Collapse
Affiliation(s)
- Riley Bove
- UCSF Weill Institute for Neurosciences, 1651 Fourth Street, San Francisco, CA 94158, USA
| | - Paige Sutton
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA.
| | - Jacqueline Nicholas
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA
| |
Collapse
|
7
|
Jacobs BM, Tank P, Bestwick JP, Noyce AJ, Marshall CR, Mathur R, Giovannoni G, Dobson R. Modifiable risk factors for multiple sclerosis have consistent directions of effect across diverse ethnic backgrounds: a nested case-control study in an English population-based cohort. J Neurol 2024; 271:241-253. [PMID: 37676298 PMCID: PMC10769990 DOI: 10.1007/s00415-023-11971-0] [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: 08/05/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Multiple sclerosis is a leading cause of non-traumatic neurological disability among young adults worldwide. Prior studies have identified modifiable risk factors for multiple sclerosis in cohorts of White ethnicity, such as infectious mononucleosis, smoking, and obesity during adolescence/early adulthood. It is unknown whether modifiable exposures for multiple sclerosis have a consistent impact on risk across ethnic groups. AIM To determine whether modifiable risk factors for multiple sclerosis have similar effects across diverse ethnic backgrounds. METHODS We conducted a nested case-control study using data from the UK Clinical Practice Research Datalink. Multiple sclerosis cases diagnosed from 2001 until 2022 were identified from electronic healthcare records and matched to unaffected controls based on year of birth. We used stratified logistic regression models and formal statistical interaction tests to determine whether the effect of modifiable risk factors for multiple sclerosis differed by ethnicity. RESULTS We included 9662 multiple sclerosis cases and 118,914 age-matched controls. The cohort was ethnically diverse (MS: 277 South Asian [2.9%], 251 Black [2.6%]; Controls: 5043 South Asian [5.7%], 4019 Black [4.5%]). The age at MS diagnosis was earlier in the Black (40.5 [SD 10.9]) and Asian (37.2 [SD 10.0]) groups compared with White cohort (46.1 [SD 12.2]). There was a female predominance in all ethnic groups; however, the relative proportion of males was higher in the South Asian population (proportion of women 60.3% vs 71% [White] and 75.7% [Black]). Established modifiable risk factors for multiple sclerosis-smoking, obesity, infectious mononucleosis, low vitamin D, and head injury-were consistently associated with multiple sclerosis in the Black and South Asian cohorts. The magnitude and direction of these effects were broadly similar across all ethnic groups examined. There was no evidence of statistical interaction between ethnicity and any tested exposure, and no evidence to suggest that differences in area-level deprivation modifies these risk factor-disease associations. These findings were robust to a range of sensitivity analyses. CONCLUSIONS AND RELEVANCE Established modifiable risk factors for multiple sclerosis are applicable across diverse ethnic backgrounds. Efforts to reduce the population incidence of multiple sclerosis by tackling these risk factors need to be inclusive of people from diverse ethnicities.
Collapse
Affiliation(s)
- Benjamin M Jacobs
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Pooja Tank
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
| | - Jonathan P Bestwick
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
| | - Alastair J Noyce
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Charles R Marshall
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Rohini Mathur
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Gavin Giovannoni
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
- Blizard Institute, Queen Mary University London, London, UK
| | - Ruth Dobson
- Centre for Preventive Neurology, Wolfson Institute of Population Health, Queen Mary University London, London, EC1M 6BQ, UK.
- Department of Neurology, Royal London Hospital, London, UK.
| |
Collapse
|
8
|
Papetti L, Panella E, Monte G, Ferilli MAN, Tarantino S, Checchi MP, Valeriani M. Pediatric Onset Multiple Sclerosis and Obesity: Defining the Silhouette of Disease Features in Overweight Patients. Nutrients 2023; 15:4880. [PMID: 38068737 PMCID: PMC10707944 DOI: 10.3390/nu15234880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Obesity has been suggested as an environmental risk factor for multiple sclerosis (MS) and may negatively effect the progression of the disease. The aim of this study is to determine any correlation between overweight/obesity and the clinical and neuroradiological features at the onset of pediatric onset multiple sclerosis (POMS). Were included patients referred to the POMS Unit of the Bambino Gesù Children's Hospital between June 2012 and June 2021. The diagnosis of MS with an onset of less than 18 years was required. For all included subjects, we considered for the analysis the following data at the onset of symptoms: general data (age, sex, functional system compromised by neurological signs, weight and height), brain and spinal magnetic resonance imaging (MRI), cerebrospinal fluid exams. We identified 55 pediatric cases of POMS and divided them into two groups according to the body mass index (BMI): 60% were healthy weight (HW) and 40% were overweight/obese (OW/O). OW/O patients experienced a two-year age difference in disease onset compared to the HW patients (12.7 ± 3.8 years vs. 14.6 ± 4.1 years; p < 0.05). Onset of polyfocal symptoms was seen more frequently in OW/O patients than in HW (72.7% vs. 21.2%; p < 0.05). The pyramidal functions were involved more frequently in the OW/O group than in the HW group (50% vs. 25%; p < 0.005). Black holes were detected more frequently in OW/O patients in onset MRI scans compared to the HW group (50% vs. 15.5%; p < 0.05). Our findings suggest that being overweight/obese affects the risk of developing MS at an earlier age and is associated with an unfavorable clinical-radiological features at onset. Weight control can be considered as a preventive/therapeutic treatment.
Collapse
Affiliation(s)
- Laura Papetti
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Elena Panella
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Hospital of Rome, Tor Vergata University, 00133 Rome, Italy;
| | - Gabriele Monte
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Michela Ada Noris Ferilli
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Samuela Tarantino
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Martina Proietti Checchi
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Massimiliano Valeriani
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
- Center for Sensory Motor Interaction, Aalborg University, DK-9220 Aalborg, Denmark
| |
Collapse
|
9
|
Misicka E, Gunzler D, Albert J, Briggs FBS. Characterizing causal relationships of visceral fat and body shape on multiple sclerosis risk. Mult Scler Relat Disord 2023; 79:104964. [PMID: 37659350 PMCID: PMC10873055 DOI: 10.1016/j.msard.2023.104964] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Epidemiologic studies have established obesity as a risk factor for multiple sclerosis (MS). These studies relied on body-mass index (BMI) and body size silhouettes as the primary measures of obesity. Unfortunately, the causal mechanisms through which obesity confers MS risk are not yet known. OBJECTIVES To investigate the causal effects of multiple specific measures of body fat on MS risk in populations of European descent, using Mendelian randomization (MR). METHODS MR is a genetic instrumental variable analysis utilizing genome-wide association (GWA) summary statistics to infer causality between phenotypes. MR analyses were performed to investigate the relationships between seven measures of body fat (BMI, waist-hip ratio, visceral adipose tissue [VAT], subcutaneous adipose tissue, and arm-, leg-, and trunk-fat to total body fat ratio) and MS risk. RESULTS Only BMI and VAT were significantly associated with MS risk in separate MR analyses (βBMI=0.27, pBMI<0.001; βVAT=0.28, pVAT=0.006). High correlation between BMI and VAT instruments suggest that two-sample MR associations for BMI and VAT likely capture the same causal mechanisms. CONCLUSIONS BMI and VAT were causally associated with MS risk in European populations, though their effects do not appear independent, suggesting overlap in the role of overall body mass and visceral obesity in MS pathogenesis.
Collapse
Affiliation(s)
- Elina Misicka
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Douglas Gunzler
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Center for Health Care Research and Policy, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Jeffrey Albert
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Farren B S Briggs
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.
| |
Collapse
|
10
|
Nociti V, Romozzi M. The Importance of Managing Modifiable Comorbidities in People with Multiple Sclerosis: A Narrative Review. J Pers Med 2023; 13:1524. [PMID: 38003839 PMCID: PMC10672087 DOI: 10.3390/jpm13111524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory, degenerative demyelinating disease of the central nervous system (CNS) of unknown etiology that affects individuals in their early adulthood. In the last decade, life expectancy for people with MS (PwMS) has almost equaled that of the general population. This demographic shift necessitates a heightened awareness of comorbidities, especially the ones that can be prevented and modified, that can significantly impact disease progression and management. Vascular comorbidities are of particular interest as they are mostly modifiable health states, along with voluntary behaviors, such as smoking and alcohol consumption, commonly observed among individuals with MS. Vascular risk factors have also been implicated in the etiology of cerebral small vessel disease. Furthermore, differentiating between vascular and MS lesion load poses a significant challenge due to overlapping clinical and radiological features. This review describes the current evidence regarding the range of preventable and modifiable comorbidities and risk factors and their implications for PwMS.
Collapse
Affiliation(s)
- Viviana Nociti
- Centro Sclerosi Multipla, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marina Romozzi
- Centro Sclerosi Multipla, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| |
Collapse
|
11
|
Baker JL, Bjerregaard LG. Advancing precision public health for obesity in children. Rev Endocr Metab Disord 2023; 24:1003-1010. [PMID: 37055611 PMCID: PMC10101815 DOI: 10.1007/s11154-023-09802-8] [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] [Accepted: 03/12/2023] [Indexed: 04/15/2023]
Abstract
Worldwide, far too many children and adolescents are living with the disease of obesity. Despite decades of public health initiatives, rates are still rising in many countries. This raises the question of whether precision public health may be a more successful approach to preventing obesity in youth. In this review, the objective was to review the literature on precision public health in the context of childhood obesity prevention and to discuss how precision public health may advance the field of childhood obesity prevention. As precision public health is a concept that is still evolving and not fully identifiable in the literature, a lack of published studies precluded a formal review. Therefore, the approach of using a broad interpretation of precision public health was used and recent advances in childhood obesity research in the areas of surveillance and risk factor identification as well as intervention, evaluation and implementation using selected studies were summarized. Encouragingly, big data from a multitude of designed and organic sources are being used in new and innovative ways to provide more granular surveillance and risk factor identification in obesity in children. Challenges were identified in terms of data access, completeness, and integration, ensuring inclusion of all members of society, ethics, and translation to policy. As precision public health advances, it may yield novel insights that can contribute to strong policies acting in concert that ultimately lead to the prevention of obesity in children.
Collapse
Affiliation(s)
- Jennifer L Baker
- Center for Clinical Research and Prevention, Copenhagen University Hospital- Bispebjerg and Frederiksberg, Frederiksberg, Denmark.
| | - Lise G Bjerregaard
- Center for Clinical Research and Prevention, Copenhagen University Hospital- Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| |
Collapse
|
12
|
Fazia T, Baldrighi GN, Nova A, Bernardinelli L. A systematic review of Mendelian randomization studies on multiple sclerosis. Eur J Neurosci 2023; 58:3172-3194. [PMID: 37463755 DOI: 10.1111/ejn.16088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 07/20/2023]
Abstract
Mendelian randomization (MR) is a powerful approach for assessing the causal effect of putative risk factors on an outcome, using genetic variants as instrumental variables. The methodology and application developed in the framework of MR have been dramatically improved, taking advantage of the many public genome-wide association study (GWAS) data. The availability of summary-level data allowed to perform numerous MR studies especially for complex diseases, pinpointing modifiable exposures causally related to increased or decreased disease risk. Multiple sclerosis (MS) is a complex multifactorial disease whose aetiology involves both genetic and non-genetic risk factors and their interplay. Previous observational studies have revealed associations between candidate modifiable exposures and MS risk; although being prone to confounding, and reverse causation, these studies were unable to draw causal conclusions. MR analysis addresses the limitations of observational studies and allows to establish reliable and accurate causal conclusions. Here, we systematically reviewed the studies evaluating the causal effect, through MR, of genetic and non-genetic exposures on MS risk. Among 107 papers found, only 42 were eligible for final evaluation and qualitative synthesis. We found that, above all, low vitamin D levels and high adult body mass index (BMI) appear to be uncontested risk factors for increased MS risk.
Collapse
Affiliation(s)
- Teresa Fazia
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Andrea Nova
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Luisa Bernardinelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| |
Collapse
|
13
|
Dinov D, Brenton JN. Environmental Influences on Risk and Disease Course in Pediatric Multiple Sclerosis. Semin Pediatr Neurol 2023; 46:101049. [PMID: 37451747 PMCID: PMC10351032 DOI: 10.1016/j.spen.2023.101049] [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: 02/15/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 07/18/2023]
Abstract
Pediatric multiple sclerosis (MS) accounts for 3%-10% of all patients diagnosed with MS. Complex interplay between environmental factors impacts the risk for MS and may also affect disease course. Many of these environmental factors are shared with adult-onset MS. However, children with MS are in closer temporal proximity to the biological onset of MS and have less confounding environmental exposures than their adult counterparts. Environmental factors that contribute to MS risk include: geographical latitude, viral exposures, obesity, vitamin deficiencies, smoking, air pollution, perinatal factors, gut microbiome, and diet. More recently, research efforts have shifted to studying the impact of these risk determinants on the clinical course of MS. In this article we will examine relevant environmental risk determinants of pediatric MS and review the current knowledge on how these factors may contribute to pediatric MS disease evolution.
Collapse
Affiliation(s)
- Darina Dinov
- Department of Neurology, Virginia Commonwealth University, Richmond, VA
| | - James Nicholas Brenton
- Division of Child Neurology, Department of Neurology, University of Virginia, Charlottesville, VA.
| |
Collapse
|
14
|
Ge A, Sun Y, Kiker T, Zhou Y, Ye K. A metabolome-wide Mendelian randomization study prioritizes potential causal circulating metabolites for multiple sclerosis. J Neuroimmunol 2023; 379:578105. [PMID: 37207441 PMCID: PMC10237183 DOI: 10.1016/j.jneuroim.2023.578105] [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: 12/15/2022] [Revised: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
To prioritize circulating metabolites that likely play causal roles in the pathogenesis of multiple sclerosis (MS). Two-sample Mendelian randomization analysis was performed to estimate the causal effects of 571 circulating metabolites on the risk of MS. Genetic instruments for circulating metabolites were obtained from three previous genome-wide association studies (GWAS) of the blood metabolome (N = 7824; 24,925; and 115,078; respectively), while genetic associations with MS were from a large GWAS by the International Multiple Sclerosis Genetics Consortium (14,802 cases and 26,703 control). The primary analysis was performed with the multiplicative random-effect inverse variance-weighted method, while multiple sensitivity analyses were conducted with the weighted median, weighted mode, MR-Egger, and MR-PRESSO. A total of 29 metabolites had suggestive evidence of causal associations with MS. Genetically instrumented levels of serine (OR = 1.56, 95% CI = 1.25-1.95), lysine (OR = 1.18, 95% CI = 1.01-1.38), acetone (OR = 2.45, 95% CI = 1.02-5.90), and acetoacetate (OR = 2.47, 95% CI = 1.14-5.34) were associated with a higher MS risk. Total cholesterol and phospholipids in large very-low-density lipoprotein were associated with a lower MS risk (OR = 0.83, 95% CI = 0.69-1.00; OR = 0.80, 95% CI = 0.68-0.95), but risk-increasing associations (OR = 1.20, 95% CI = 1.04-1.40; OR = 1.13, 95% CI = 1.00-1.28) were observed for the same two lipids in very large high-density lipoprotein. Our metabolome-wide Mendelian randomization study prioritized a list of circulating metabolites, such as serine, lysine, acetone, acetoacetate, and lipids, that likely have causal associations with MS.
Collapse
Affiliation(s)
- Angela Ge
- Lower Merion High School, Ardmore, PA, USA; Department of Genetics, Franklin College of Arts and Sciences, University of Georgia, Athens, GA, USA
| | - Yitang Sun
- Department of Genetics, Franklin College of Arts and Sciences, University of Georgia, Athens, GA, USA
| | - Thaddaeus Kiker
- Department of Genetics, Franklin College of Arts and Sciences, University of Georgia, Athens, GA, USA; Sunny Hills High School, Fullerton, CA, USA
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Kaixiong Ye
- Department of Genetics, Franklin College of Arts and Sciences, University of Georgia, Athens, GA, USA; Institute of Bioinformatics, University of Georgia, Athens, GA, USA.
| |
Collapse
|
15
|
Zeng R, Jiang R, Huang W, Wang J, Zhang L, Ma Y, Wu Y, Meng M, Lan H, Lian Q, Leung FW, Sha W, Chen H. Dissecting shared genetic architecture between obesity and multiple sclerosis. EBioMedicine 2023; 93:104647. [PMID: 37300932 PMCID: PMC10363440 DOI: 10.1016/j.ebiom.2023.104647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Observational studies have associated obesity with an increased risk of multiple sclerosis (MS). However, the role of genetic factors in their comorbidity remains largely unknown. Our study aimed to investigate the shared genetic architecture underlying obesity and MS. METHODS By leveraging data from genome-wide association studies, we investigated the genetic correlation of body mass index (BMI) and MS by linkage disequilibrium score regression and genetic covariance analyser. The casualty was identified by bidirectional Mendelian randomisation. Linkage disequilibrium score regression in specifically expressed genes and multimarker analysis of GenoMic annotation was utilised to explore single-nucleotide polymorphism (SNP) enrichment at the tissue and cell-type levels. Shared risk SNPs were derived using cross-trait meta-analyses and Heritability Estimation from Summary Statistics. We explored the potential functional genes using summary-data-based Mendelian randomization (SMR). The expression profiles of the risk gene in tissues were further examined. FINDINGS We found a significantly positive genetic correlation between BMI and MS, and the causal association of BMI with MS was supported (β = 0.22, P = 8.03E-05). Cross-trait analysis yielded 39 shared risk SNPs, and the risk gene GGNBP2 was consistently identified in SMR. We observed tissue-specific level SNP heritability enrichment for BMI mainly in brain tissues for MS in immune-related tissues, and cell-type-specific level SNP heritability enrichment in 12 different immune cell types in brain, spleen, lung, and whole blood. The expressions of GGNBP2 were significantly altered in the tissues of patients with obesity or MS compared to those of control subjects. INTERPRETATION Our study indicates the genetic correlation and shared risk genes between obesity and MS. These findings provide insights into the potential mechanisms behind their comorbidity and the future development of therapeutics. FUNDING This work was funded by the National Natural Science Foundation of China (82171698, 82170561, 81300279, and 81741067), the Program for High-level Foreign Expert Introduction of China (G2022030047L), the Natural Science Foundation for Distinguished Young Scholars of Guangdong Province (2021B1515020003), Natural Science Foundation of Guangdong Province (2022A1515012081), the Foreign Distinguished Teacher Program of Guangdong Science and Technology Department (KD0120220129), the Climbing Programme of Introduced Talents and High-level Hospital Construction Project of Guangdong Provincial People's Hospital (DFJH201803, KJ012019099, KJ012021143, and KY012021183), and in part by VA Clinical Merit and ASGE clinical research funds (FWL).
Collapse
Affiliation(s)
- Ruijie Zeng
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Rui Jiang
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China; School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Wentao Huang
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
| | - Jiaxuan Wang
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lijun Zhang
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Yuying Ma
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
| | - Yanjun Wu
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
| | - Meijun Meng
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hekui Lan
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Qizhou Lian
- Faculty of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Cord Blood Bank, Guangzhou Institute of Eugenics and Perinatology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China; State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong SAR, China
| | - Felix W Leung
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, USA.
| | - Weihong Sha
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China; School of Medicine, South China University of Technology, Guangzhou 510006, China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China.
| | - Hao Chen
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China; School of Medicine, South China University of Technology, Guangzhou 510006, China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China.
| |
Collapse
|
16
|
Li H, Chen K, Yang L, Wang Q, Zhang J, He J. The role of plasma cortisol in dementia, epilepsy, and multiple sclerosis: A Mendelian randomization study. Front Endocrinol (Lausanne) 2023; 14:1107780. [PMID: 37008911 PMCID: PMC10050717 DOI: 10.3389/fendo.2023.1107780] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/28/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Many clinical studies have shown a correlation between plasma cortisol and neurological disorders. This study explored the causal relationship between plasma cortisol and dementia, epilepsy and multiple sclerosis based on Mendelian randomization (MR) method. METHODS Data were taken from the summary statistics of a genome-wide association study, FinnGen consortium and United Kingdom Biobank. Dementia, epilepsy, and multiple sclerosis were used as outcomes, and genetic variants associated with plasma cortisol were used as instrumental variables. The main analysis was performed using the inverse variance weighted method, and the results were assessed according to the odds ratio (OR) and 95% confidence interval. Heterogeneity tests, pleiotropy tests, and leave-one-out method were conducted to evaluate the stability and accuracy of the results. RESULTS In two-sample MR analysis, the inverse variance weighted method showed that plasma cortisol was associated with Alzheimer's disease (AD) [odds ratio (95% confidence interval) = 0.99 (0.98-1.00), P = 0.025], vascular dementia (VaD) [odds ratio (95% confidence interval) = 2.02 (1.00-4.05), P = 0.049)], Parkinson's disease with dementia (PDD) [odds ratio (95% confidence interval) = 0.24 (0.07-0.82), P = 0.023] and epilepsy [odds ratio (95% confidence interval) = 2.00 (1.03-3.91), P = 0.042]. There were no statistically significant associations between plasma cortisol and dementia with Lewy bodies (DLB), frontotemporal dementia (FTD) and multiple sclerosis. CONCLUSION This study demonstrates that plasma cortisol increase the incidence rates of epilepsy and VaD and decrease the incidence rates of AD and PDD. Monitoring plasma cortisol concentrations in clinical practice can help prevent diseases, such as AD, PDD, VaD and epilepsy.
Collapse
Affiliation(s)
- Haiqi Li
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Kaili Chen
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Le Yang
- Department of Endocrinology, Jilin Province People’s Hospital, Changchun, China
| | - Qiaoli Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiao Zhang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jinting He
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Jinting He,
| |
Collapse
|
17
|
Rahmani F, Ghezzi L, Tosti V, Liu J, Song SK, Wu AT, Rajamanickam J, Obert KA, Benzinger TL, Mittendorfer B, Piccio L, Raji CA. Twelve Weeks of Intermittent Caloric Restriction Diet Mitigates Neuroinflammation in Midlife Individuals with Multiple Sclerosis: A Pilot Study with Implications for Prevention of Alzheimer's Disease. J Alzheimers Dis 2023; 93:263-273. [PMID: 37005885 PMCID: PMC10460547 DOI: 10.3233/jad-221007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a prototype neuroinflammatory disorder with increasingly recognized role for neurodegeneration. Most first-line treatments cannot prevent the progression of neurodegeneration and the resultant disability. Interventions can improve symptoms of MS and might provide insights into the underlying pathology. OBJECTIVE To investigate the effect of intermittent caloric restriction on neuroimaging markers of MS. METHODS We randomized ten participants with relapsing remitting MS to either a 12-week intermittent calorie restriction (iCR) diet (n = 5) or control (n = 5). Cortical thickness and volumes were measured through FreeSurfer, cortical perfusion was measured by arterial spin labeling and neuroinflammation through diffusion basis spectrum imaging. RESULTS After 12 weeks of iCR, brain volume increased in the left superior and inferior parietal gyri (p: 0.050 and 0.049, respectively) and the banks of the superior temporal sulcus (p: 0.01). Similarly in the iCR group, cortical thickness improved in the bilateral medial orbitofrontal gyri (p: 0.04 and 0.05 in right and left, respectively), the left superior temporal gyrus (p: 0.03), and the frontal pole (p: 0.008) among others. Cerebral perfusion decreased in the bilateral fusiform gyri (p: 0.047 and 0.02 in right and left, respectively) and increased in the bilateral deep anterior white matter (p: 0.03 and 0.013 in right and left, respectively). Neuroinflammation, demonstrated through hindered and restricted water fractions (HF and RF), decreased in the left optic tract (HF p: 0.02), and the right extreme capsule (RF p: 0.007 and HF p: 0.003). CONCLUSION These pilot data suggest therapeutic effects of iCR in improving cortical volume and thickness and mitigating neuroinflammation in midlife adults with MS.
Collapse
Affiliation(s)
- Farzaneh Rahmani
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Laura Ghezzi
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Valeria Tosti
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Jingxia Liu
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University in St. Louis, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis, St. Louis, MO, USA
| | - Sheng-Kwei Song
- Department of Physics, Washington University in St. Louis, St. Louis, MO, USA
- Hope Center for Neurological Disorders, Washington University in St. Louis, St. Louis, MO, USA
| | - Anthony T. Wu
- Department of Physics, Washington University in St. Louis, St. Louis, MO, USA
- Hope Center for Neurological Disorders, Washington University in St. Louis, St. Louis, MO, USA
| | - Jayashree Rajamanickam
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Kathleen A. Obert
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Tammie L.S. Benzinger
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University in St. Louis, St. Louis, MO, USA
- Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University in St Louis, St. Louis, MO, USA
| | - Bettina Mittendorfer
- Department of Medicine, Division of Geriatrics and Nutritional Science, Washington University in St. Louis, St. Louis, MO, USA
| | - Laura Piccio
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
- Hope Center for Neurological Disorders, Washington University in St. Louis, St. Louis, MO, USA
- Brain and Mind Centre, School of Medical Sciences, The University of Sydney, NSW, Australia
- Charles Perkin Centre, The University of Sydney NSW, Australia
| | - Cyrus A. Raji
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University in St. Louis, St. Louis, MO, USA
- Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University in St Louis, St. Louis, MO, USA
| |
Collapse
|
18
|
Jacobs BM, Peter M, Giovannoni G, Noyce AJ, Morris HR, Dobson R. Towards a global view of multiple sclerosis genetics. Nat Rev Neurol 2022; 18:613-623. [PMID: 36075979 DOI: 10.1038/s41582-022-00704-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/09/2022]
Abstract
Multiple sclerosis (MS) is a neuroimmunological disorder of the CNS with a strong heritable component. The genetic architecture of MS susceptibility is well understood in populations of European ancestry. However, the extent to which this architecture explains MS susceptibility in populations of non-European ancestry remains unclear. In this Perspective article, we outline the scientific arguments for studying MS genetics in ancestrally diverse populations. We argue that this approach is likely to yield insights that could benefit individuals with MS from all ancestral groups. We explore the logistical and theoretical challenges that have held back this field to date and conclude that, despite these challenges, inclusion of participants of non-European ancestry in MS genetics studies will ultimately be of value to all patients with MS worldwide.
Collapse
Affiliation(s)
- Benjamin Meir Jacobs
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK. .,Department of Neurology, Royal London Hospital, London, UK.
| | - Michelle Peter
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Gavin Giovannoni
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK.,Department of Neurology, Royal London Hospital, London, UK.,Blizard Institute, Queen Mary University London, London, UK
| | - Alastair J Noyce
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK.,Department of Neurology, Royal London Hospital, London, UK.,Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Huw R Morris
- Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK.,Department of Neurology, Royal London Hospital, London, UK
| |
Collapse
|
19
|
Goris A, Vandebergh M, McCauley JL, Saarela J, Cotsapas C. Genetics of multiple sclerosis: lessons from polygenicity. Lancet Neurol 2022; 21:830-842. [PMID: 35963264 DOI: 10.1016/s1474-4422(22)00255-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 11/27/2022]
Abstract
Large-scale mapping studies have identified 236 independent genetic variants associated with an increased risk of multiple sclerosis. However, none of these variants are found exclusively in patients with multiple sclerosis. They are located throughout the genome, including 32 independent variants in the MHC and one on the X chromosome. Most variants are non-coding and seem to act through cell-specific effects on gene expression and splicing. The likely functions of these variants implicate both adaptive and innate immune cells in the pathogenesis of multiple sclerosis, provide pivotal biological insight into the causes and mechanisms of multiple sclerosis, and some of the variants implicated in multiple sclerosis also mediate risk of other autoimmune and inflammatory diseases. Genetics offers an approach to showing causality for environmental factors, through Mendelian randomisation. No single variant is necessary or sufficient to cause multiple sclerosis; instead, each increases total risk in an additive manner. This combined contribution from many genetic factors to disease risk, or polygenicity, has important consequences for how we interpret the epidemiology of multiple sclerosis and how we counsel patients on risk and prognosis. Ongoing efforts are focused on increasing cohort sizes, increasing diversity and detailed characterisation of study populations, and translating these associations into an understanding of the biology of multiple sclerosis.
Collapse
Affiliation(s)
- An Goris
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Laboratory for Neuroimmunology, Leuven, Belgium.
| | - Marijne Vandebergh
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Laboratory for Neuroimmunology, Leuven, Belgium
| | - Jacob L McCauley
- John P Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Janna Saarela
- Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway; Institute for Molecular Medicine Finland and Department of Clinical Genetics, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Chris Cotsapas
- Departments of Neurology and Genetics, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
20
|
Almramhi MM, Storm CS, Kia DA, Coneys R, Chhatwal BK, Wood NW. The role of body fat in multiple sclerosis susceptibility and severity: A Mendelian randomisation study. Mult Scler 2022; 28:1673-1684. [PMID: 35575213 DOI: 10.1177/13524585221092644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to explore the potential causal associations of body mass index, height, weight, fat mass, fat percentage and non-fat mass in the whole body, arms, legs and trunk (henceforth, 'anthropometric measures') with multiple sclerosis (MS) risk and severity. We also investigated the potential for reverse causation between anthropometric measures and MS risk. METHODS We conducted a two-sample univariable, multivariable and bidirectional Mendelian randomisation (MR) analysis. RESULTS A range of features linked to obesity (body mass index, weight, fat mass and fat percentage) were risk factors for MS development and worsened the disease's severity in MS patients. Interestingly, we were able to demonstrate that height and non-fat mass have no association with MS risk or MS severity. We demonstrated that the association between anthropometric measures and MS is not subject to bias from reverse causation. CONCLUSIONS Our findings provide evidence from human genetics that a range of features linked to obesity is an important contributor to MS development and MS severity, but height and non-fat mass are not. Importantly, these findings also identify a potentially modifiable factor that may reduce the accumulation of further disability and ameliorate MS severity.
Collapse
Affiliation(s)
- Mona M Almramhi
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK/Department of Medical Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Catherine S Storm
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Demis A Kia
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Rachel Coneys
- Department of Neurodegenerative Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Burleen K Chhatwal
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Nicholas W Wood
- Department of Clinical and Movement Neurosciences, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| |
Collapse
|
21
|
Hone L, Jacobs BM, Marshall C, Giovannoni G, Noyce A, Dobson R. Age-specific effects of childhood body mass index on multiple sclerosis risk. J Neurol 2022; 269:5052-5060. [PMID: 35532785 PMCID: PMC9363310 DOI: 10.1007/s00415-022-11161-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/31/2022]
Abstract
Objective Higher body mass index (BMI) during early life is thought to be a causal risk factor for multiple sclerosis (MS). We used longitudinal Mendelian randomisation (MR) to determine whether there is a critical window during which BMI influences MS risk. Methods Summary statistics for childhood BMI (n ~ 28,000 children) and for MS susceptibility were obtained from recent large genome-wide association studies (GWAS) (n = 14,802 MS, 26,703 controls). We generated exposure instruments for BMI during four non-overlapping age epochs (< 3 months, 3 months–1.5 years, 2–5 years, and 7–8 years) and performed MR using the inverse variance weighted method with standard sensitivity analyses. Multivariable MR was used to account for effects mediated via later-life BMI. Results For all age epochs other than birth, genetically determined higher BMI was associated with an increased liability to MS: Birth [Odds Ratio (OR) 0.81, 95% Confidence Interval (CI) 0.50–1.31, Number of Single-Nucleotide Polymorphisms (NSNPs) = 7, p = 0.39], Infancy (OR 1.18, 95% CI 1.04–1.33, NSNPs = 18, p = 0.01), Early childhood (OR 1.31, 95% CI 1.03–1.66, NSNPs = 4, p = 0.03), Later childhood (OR 1.34, 95% CI 1.08–1.66, NSNPs = 4, p = 0.01). Multivariable MR suggested that these effects may be mediated by effects on adult BMI. Conclusion We provide evidence using MR that genetically determined higher BMI during early life is associated with increased MS risk. This effect may be driven by shared genetic architecture with later-life BMI. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11161-4.
Collapse
Affiliation(s)
- Luke Hone
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Benjamin M Jacobs
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK.
- Department of Neurology, Royal London Hospital, London, UK.
| | - Charles Marshall
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Gavin Giovannoni
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
- Blizard Institute, Queen Mary University London, London, UK
| | - Alastair Noyce
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, London, UK
| |
Collapse
|
22
|
Vandebergh M, Dubois B, Goris A. Effects of Vitamin D and Body Mass Index on Disease Risk and Relapse Hazard in Multiple Sclerosis: A Mendelian Randomization Study. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/3/e1165. [PMID: 35393342 PMCID: PMC8990978 DOI: 10.1212/nxi.0000000000001165] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/06/2022] [Indexed: 01/14/2023]
Abstract
Background and Objectives Decreased vitamin D levels and obesity are associated with an increased risk for multiple sclerosis (MS). However, whether they also affect the disease course after onset remains unclear. With larger data sets now available, we used Mendelian randomization (MR) to determine whether serum 25-hydroxyvitamin D (25OHD) and body mass index (BMI) are causally associated with MS risk and, moving beyond susceptibility toward heterogeneity, with relapse hazard. Methods We used genetic variants from 4 distinct genome-wide association studies (GWASs) for serum 25OHD in up to 416,247 individuals and for BMI from a GWAS in 681,275 individuals. Applying 2-sample MR, we examined associations of 25OHD and BMI with the risk of MS, with summary statistics from the International Multiple Sclerosis Genetics Consortium GWAS in 14,802 MS cases and 26,703 controls. In addition, we examined associations with relapse hazard, with data from our GWAS in 506 MS cases. Results A 1-SD increase in genetically predicted natural-log transformed 25OHD levels decreased odds of MS up to 28% (95% CI: 12%–40%, p = 0.001) and decreased hazard for a relapse occurring up to 43% (95% CI: 15%–61%, p = 0.006). A 1-SD increase in genetically predicted BMI, corresponding to roughly 5 kg/m2, increased risk for MS with 30% (95% CI: 15%–47%, p = 3.76 × 10−5). On the contrary, we did not find evidence for a causal role of higher BMI with an increased hazard for occurrence of a relapse. Discussion This study supports causal effects of genetically predicted serum 25OHD concentrations and BMI on risk of MS. In contrast, serum 25OHD but not BMI is significantly associated with relapse hazard after onset. These findings might offer clinical implications for both prevention and treatment.
Collapse
Affiliation(s)
- Marijne Vandebergh
- From the Laboratory for Neuroimmunology (M.V., B.D., A.G.), Department of Neurosciences, Leuven Brain Institute, KU Leuven; and Department of Neurology (B.D.), University Hospitals Leuven, Belgium
| | - Bénédicte Dubois
- From the Laboratory for Neuroimmunology (M.V., B.D., A.G.), Department of Neurosciences, Leuven Brain Institute, KU Leuven; and Department of Neurology (B.D.), University Hospitals Leuven, Belgium
| | - An Goris
- From the Laboratory for Neuroimmunology (M.V., B.D., A.G.), Department of Neurosciences, Leuven Brain Institute, KU Leuven; and Department of Neurology (B.D.), University Hospitals Leuven, Belgium
| |
Collapse
|
23
|
Vandebergh M, Degryse N, Dubois B, Goris A. Environmental risk factors in multiple sclerosis: bridging Mendelian randomization and observational studies. J Neurol 2022; 269:4565-4574. [PMID: 35366084 DOI: 10.1007/s00415-022-11072-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
Abstract
Multiple sclerosis (MS) is a complex disease with both genetic variants and environmental factors involved in disease susceptibility. The main environmental risk factors associated with MS in observational studies include obesity, vitamin D deficiency, Epstein-Barr virus infection and smoking. As modifying these environmental and lifestyle factors may enable prevention, it is important to pinpoint causal links between these factors and MS. Leveraging genetics through the Mendelian randomization (MR) paradigm is an elegant way to inform prevention strategies in MS. In this review, we summarize MR studies regarding the impact of environmental factors on MS susceptibility, thereby paying attention to quality criteria which will aid readers in interpreting any MR studies. We draw parallels and differences with observational studies and randomized controlled trials and look forward to the challenges that such work presents going forward.
Collapse
Affiliation(s)
- Marijne Vandebergh
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49 bus 1022, 3000, Leuven, Belgium
| | - Nicolas Degryse
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49 bus 1022, 3000, Leuven, Belgium
| | - Bénédicte Dubois
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49 bus 1022, 3000, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - An Goris
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49 bus 1022, 3000, Leuven, Belgium.
| |
Collapse
|
24
|
Vandebergh M, Becelaere S, Dubois B, Goris A. Body Mass Index, Interleukin-6 Signaling and Multiple Sclerosis: A Mendelian Randomization Study. Front Immunol 2022; 13:834644. [PMID: 35386698 PMCID: PMC8978959 DOI: 10.3389/fimmu.2022.834644] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/25/2022] [Indexed: 12/14/2022] Open
Abstract
Objectives We explored whether genetically predicted increased body mass index (BMI) modulates multiple sclerosis (MS) risk through interleukin-6 (IL-6) signaling. Methods We performed a two-sample Mendelian randomization (MR) study using multiple genome-wide association studies (GWAS) datasets for BMI, IL-6 signaling, IL-6 levels and c-reactive protein (CRP) levels as exposures and estimated their effects on risk of MS from GWAS data from the International Multiple Sclerosis Genetics Consortium (IMSGC) in 14,802 MS cases and 26,703 controls. Results In univariable MR analyses, genetically predicted increased BMI and IL-6 signaling were associated with higher risk of MS (BMI: odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.15-1.47, p = 3.76 × 10-5; IL-6 signaling: OR = 1.51, 95% CI = 1.11-2.04, p = 0.01). Furthermore, higher BMI was associated with increased IL-6 signaling (β = 0.37, 95% CI = 0.32,0.41, p = 1.58 × 10-65). In multivariable MR analyses, the effect of IL-6 signaling on MS risk remained after adjusting for BMI (OR = 1.36, 95% CI = 1.11-1.68, p = 0.003) and higher BMI remained associated with an increased risk for MS after adjustment for IL-6 signaling (OR = 1.16, 95% CI =1.00-1.34, p = 0.046). The proportion of the effect of BMI on MS mediated by IL-6 signaling corresponded to 43% (95% CI = 25%-54%). In contrast to IL-6 signaling, there was little evidence for an effect of serum IL-6 levels or CRP levels on risk of MS. Conclusion In this study, we identified IL-6 signaling as a major mediator of the association between BMI and risk of MS. Further explorations of pathways underlying the association between BMI and MS are required and will, together with our findings, improve the understanding of MS biology and potentially lead to improved opportunities for targeted prevention strategies.
Collapse
Affiliation(s)
- Marijne Vandebergh
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Sara Becelaere
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Laboratory for Human Evolutionary Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | | | - Bénédicte Dubois
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - An Goris
- Laboratory for Neuroimmunology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| |
Collapse
|
25
|
Genetics and functional genomics of multiple sclerosis. Semin Immunopathol 2022; 44:63-79. [PMID: 35022889 DOI: 10.1007/s00281-021-00907-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory neurodegenerative disease with genetic predisposition. Over the last decade, genome-wide association studies with increasing sample size led to the discovery of robustly associated genetic variants at an exponential rate. More than 200 genetic loci have been associated with MS susceptibility and almost half of its heritability can be accounted for. However, many challenges and unknowns remain. Definitive studies of disease progression and endophenotypes are yet to be performed, whereas the majority of the identified MS variants are not yet functionally characterized. Despite these shortcomings, the unraveling of MS genetics has opened up a new chapter on our understanding MS causal mechanisms.
Collapse
|
26
|
Obesity and Multiple Sclerosis-A Multifaceted Association. J Clin Med 2021; 10:jcm10122689. [PMID: 34207197 PMCID: PMC8234028 DOI: 10.3390/jcm10122689] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/30/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Given the common elements in the pathophysiological theories that try to explain the appearance and evolution of obesity and multiple sclerosis, the association between the two pathologies has become an increasingly researched topic in recent years. On the one hand, there is the chronic demyelinating inflammation caused by the autoimmune cascade of multiple sclerosis, while on the other hand, according to the latest research, it has been shown that obesity shares an inflammatory component with most chronic diseases. METHODS The authors performed independent research of the available literature in the most important electronic databases (PubMed, Google Scholar, Embase, and Science Direct) in February 2021. After applying the exclusion criteria, the reviewers focused on the most relevant articles published during the last 10 years with respect to epidemiology and pathophysiology. RESULTS The data presented are a step forward in trying to elucidate the intricate relationship between obesity and MS, especially the causal relationship between childhood and adolescent obesity and MS, focusing on the epidemiological associations observed in the most relevant observational studies conducted in recent years. In the second part, the authors comment on the latest findings related to the pathophysiological mechanisms that may explain the correlations between obesity and multiple sclerosis, focusing also on the role of adipokines. CONCLUSIONS Based on available epidemiological data, obesity in early life appears to be strongly associated with a higher risk of MS development, independent of other risk factors. Although much research has been done on the pathophysiology of obesity, MS, their possible common mechanism, and the role of adipokines, further studies are needed in order to explain what remains unknown. No relevant data were found regarding the association between obesity, disability (high EDSS score), and mortality risk in MS patients. Thus, we consider that this topic should be elucidated in future research.
Collapse
|