Prolactin serum levels correlate with inflammatory status in drug-naïve first-episode schizophrenia

Blood concentrations of anterior pituitary hormones in drug-naïve people with first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

The role of anterior pituitary hormones - i.e., adrenocorticotropic hormone (ACTH), luteinizing and follicle stimulating hormones (LH and FSH), growth hormone (GH), prolactin (PRL), and thyroid-stimulating hormone (TSH) - in early schizophrenia and psychoses unclear. We thus performed a systematic review and meta-analysis on the blood concentrations of ACTH, LH and FSH, GH, PRL, and TSH in drug-naïve people with first-episode psychosis (FEP) as compared with healthy controls.

METHODS

We searched Embase, MEDLINE, and PsycInfo for articles indexed until September 2022. Data quality was appraised. Random-effects meta-analyses were carried out, generating pooled standardized mean differences (SMDs). Between-study heterogeneity was estimated using the I2 statistic. Sensitivity and meta-regression analyses were performed.

RESULTS

Twenty-six studies were included. Drug-naïve people with FEP, compared to healthy subjects, had higher blood concentrations of ACTH (k = 7; N = 548; SMD = 0.62; 95%CI: 0.29 to 0.94; p < 0.001; I2 = 60.9%) and PRL (k = 17; N = 1757; SMD = 0.85; 95%CI: 0.56 to 1.14; p < 0.001; I2 = 85.5%) as well as lower levels of TSH (k = 6; N = 677; SMD = -0.34; 95%CI: -0.54 to -0.14; p = 0.001; I2 = 29.1%). Meta-regressions did not show any moderating effect of age (p = 0.78), sex (p = 0.21), or symptom severity (p = 0.87) on PRL concentrations in drug-naïve FEP. Available data were not sufficient to perform meta-analyses on FSH, LH, and GH.

CONCLUSIONS

Drug-naïve people with FEP have altered ACTH, PRL, and TSH blood concentrations, supporting the hypothesis that an abnormal anterior pituitary hormone secretion may be involved in the onset of schizophrenia and psychoses. Further research is needed to elucidate the role of pituitary hormones in FEP.

Prolactin and morning cortisol concentrations in antipsychotic naïve first episode psychosis: A systematic review and meta-analysis

IMPORTANCE

Alterations in prolactin and cortisol levels have been reported in antipsychotic naïve patients with first episode psychosis (FEP). However, it has been studied in very small samples, and inter-group variability has never been studied before.

OBJECTIVE

To provide estimates of standardized mean differences (SMD) and inter-group variability for prolactin, cortisol awakening response (CAR) and morning cortisol concentrations in antipsychotic naïve FEP (AN-FEP) patients and healthy controls (HC).

DATA SOURCES

BIOSIS, KCI, MEDLINE, Russian Science Citation Index, SciELO, Cochrane, PsycINFO, Web of Science were searched from inception to February 28, 2022.

STUDY SELECTION

Peer-reviewed cohort studies that reported on prolactin or cortisol blood concentrations in AN- FEP patients and HC were included.

DATA EXTRACTION AND SYNTHESIS

Study characteristics, means and standard deviations (SD) were extracted from each article. Inter group differences in magnitude of effect were estimated using Hedges g. Inter-group variability was estimated with the coefficient of variation ratio (CVR). In both cases estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using meta-regression. PRISMA guideline was followed (No. CRD42022303555).

MAIN OUTCOMES AND MEASURES

Prolactin, CAR and morning cortisol blood concentrations in AN-FEP group in relation to HC group.

RESULTS

Fourteen studies for prolactin (N = 761 for AN-FEP group, N = 687 for HC group) and twelve studies for morning cortisol (N = 434 for AN-FEP group, N = 528 for HC group) were included. No studies were found in CAR in AN-FEP patients. Mean SMD for prolactin blood concentration was 0.88 (95% CI 0.57, 1.20) for male and 0.56 (95% CI 0.26, 0.87) for female. As a group, AN-FEP presented greater inter-group variability for prolactin levels than HC (CVR=1.28, 95% CI 1.02, 1.62). SMD for morning cortisol concentrations was non-significant: 0.34 (95% CI -0.01, 0.69) and no inter-group variability significant differences were detected: CVR= 1.05 (95% CI 0.91, 1.20). Meta-regression analyses for age and quality were non-significant. Funnel plots did not suggest a publication bias.

CONCLUSIONS AND RELEVANCE

Increased prolactin levels were found in AN-FEP patients. A greater inter-group variability in the AN-FEP group suggests the existence of patient subgroups with different prolactin levels. No significant abnormalities were found in morning cortisol levels. Further research is needed to clarify whether prolactin concentrations could be used as an illness biomarker.

Reversal of oxidative stress, cytokine toxicity and DNA fragmentation by quercetin in dizocilpine-induced animal model of Schizophrenia

Quercetin, a polyphenolic compound found in a variety of plant products possesses various biological activities and beneficial effects on human health. Schizophrenia (SZ) is one of the neuropsychiatric disorders in human beings with rapid mortality and intense morbidity which can be treated with antipsychotics, but these commercial drugs exert adverse effects and have less efficacy to treat the full spectrum of SZ. The present study was conducted to evaluate neuroprotective effects of quercetin in the preventive and therapeutic treatment of SZ. Quercetin was administered as pre- and post-regimens at the dose of 50 mg/kg in dizocilpine-induced SZ rat model for two weeks. Rats were then subjected for the assessment of different behaviors followed by biochemical, neurochemical, and inflammatory marker analyses. The present findings revealed that quercetin significantly reverses the effects of dizocilpine-induced psychosis-like symptoms in all behavioral assessments as well as it also combats oxidative stress. This flavonoid also regulates dopaminergic, serotonergic, and glutamatergic neurotransmission. A profound effect on inflammatory cytokines and decreased %DNA fragmentation was also observed following the administration of quercetin. The findings suggest that quercetin can be considered as a preventive as well as therapeutic strategy to attenuate oxidative stress and cytokine toxicity, regulate neurotransmission, and prevent enhanced DNA fragmentation that can lead to the amelioration of psychosis-like symptoms in SZ.

Influence of antipsychotics on metabolic syndrome risk in patients with schizophrenia

OBJECTIVE

Many studies so far have shown that antipsychotic therapy may have an effect on the development of metabolic syndrome in patients diagnosed with schizophrenia. Our goal was to determine whether our respondents are at risk for developing metabolic syndrome and who is more predisposed to it.

METHODS

In a stable phase, 60 patients diagnosed with schizophrenia were equally divided into three groups according to the drug (risperidone, clozapine, and aripiprazole monotherapy). Control group had 20 healthy examinees. Patients were evaluated first using The Positive and Negative Syndrome Scale (PANSS). Prolactin, lipid status, glycemia, insulin, cytokine values (IL-33, TGF-β, and TNF-α) and C-reactive protein (CRP) were measured. Also, Body mass index (BMI), Homeostatic Model Assesment for Insulin Resistance (HOMA index), waist and hip circumference (WHR) and blood pressure (TA) measurement were performed in the study.

RESULTS

Patients treated with risperidone compared to healthy control subjects and aripiprazol group of patients had statistically significant difference in prolactin levels. In clozapine group compared to healthy control group values of HDL cholesterol and glucose level were statistically significant different. In aripiprazole group compared to healthy control group value of BMI was statistically significant different. Statistically significant correlations were found in TNF-α with glucose and HOMA index in risperidone treated patients and with BMI in clozapine group of patients; IL-33 with glucose in risperidone and with BMI in clozapine group of patients and TGF-β with glucose in risperidone group, with insulin and HOMA index in clozapine group and statistically significant negative correlation with LDL cholesterol in aripiprazole group of patients.

CONCLUSION

Patients on risperidone and clozapine therapy may be at greater risk of developing metabolic syndrome than patients treated with aripiprazole. Statistically significant difference in concentration of TNF-α and TGF-β was in the group of patients treated with risperidone compared to healthy control group.

The effect of berberine adjunctive treatment on glycolipid metabolism in patients with schizophrenia: A randomized, double-blind, placebo-controlled clinical trial

Previous studies have shown that berberine can improve metabolic disturbances in non-psychiatric patients, but no clinical research has been conducted in schizophrenia. This study was a randomized, double-blind, placebo-controlled clinical trial. Eligible patients diagnosed with schizophrenia were randomized to receive placebo or berberine (900mg/day) as an adjunctive treatment for eight weeks. Peripheral glycolipid metabolism parameters were measured at baseline, week 4, and week 8. Sixty-five patients were included, and forty-nine patients completed the 8-week trial. Berberine led to significant declines in total cholesterol, low-density lipoprotein cholesterol, fasting serum insulin, and insulin resistance(all p<0.05) compared with placebo. Baseline body mass index and serum prolactin concentration could predict the effect of berberine on insulin resistance. Berberine adjunctive treatment may reduce the risk of glycolipid metabolic disturbances in patients with schizophrenia.

Relation between self-perceived stress, psychopathological symptoms and the stress hormone prolactin in emerging psychosis

BACKGROUND

Psychosocial stress and the stress hormone prolactin are assumed to play an important role in the pathogenesis of schizophrenia and related psychoses, and have been frequently observed to be increased in antipsychotic-naïve patients with a clinical high risk for psychosis (CHR-P) or first episode of psychosis (FEP). The aim of this study was to further elucidate the relationships between self-perceived stress, psychopathological symptoms and prolactin levels in these patients.

METHODS

In this cross-sectional study, 45 healthy controls, 31 CHR-P patients and 87 FEP patients were recruited from two different study centers. Prolactin was measured under standardized conditions between 8 and 10 am. All patients were antipsychotic-naïve and not taking any prolactin influencing medication. Self-perceived stress during the last month was measured with the perceived stress scale (PSS-10) immediately before blood taking.

RESULTS

Both CHR-P and FEP patients showed significantly higher levels of self-perceived stress and prolactin than controls. Hyperprolactinemia (i.e. prolactin levels above the reference range) was observed in 26% of CHR-P and 45% of FEP patients. Self-perceived stress was significantly positively associated with affective symptoms, but not with other symptoms. There was no significant association between self-perceived stress and prolactin levels.

CONCLUSION

Our results confirm that CHR-P and FEP patients have higher stress levels than healthy controls and frequently have hyperprolactinemia, independent of antipsychotic medication. However, although it is well established that prolactin increases in response to stress, our results do not support the notion that increased prolactin levels in these patients are due to stress.

Spirulina platensis reduces the schizophrenic-like symptoms in rat model by restoring altered APO-E and RTN-4 protein expression in prefrontal cortex

AIMS

Schizophrenia (SZ) is recognized as a neuropsychiatric disorder in humans with accelerated mortality and profound morbidity followed with impairments in social as well as vocational functioning. Though various antipsychotics are being considered as approved treatment therapy for the psychotic symptoms of SZ but they also exert adverse effects and also lack efficacy in treating full spectrum of the disorder. Spirulina platensis (blue-green algae), a nutritional supplement, constitutes a variety of multi-nutrients and possesses a large number of neuroprotective activities. Therefore, present experimental work was designed to evaluate the neuroprotective effects of spirulina in ameliorating the psychosis-like symptoms in dizocilpine-induced rat model of SZ.

MATERIALS AND METHODS

The spirulina was tested as preventive and therapeutic regimen at the dose of 180 mg/kg. After pre- and post-treatment with spirulina, rats were subjected to behavioral assessments followed by biochemical and neurochemical estimations. Biomarkers including APO-E, RTN-4, TNF-α, and IL-6 were also estimated using ELISA.

KEY FINDINGS

Present results showed that administration of spirulina not only improved behavioral deficits induced by dizocilpine but it also regulates neurotransmission, oligodendrocyte dysfunction and APO-E over expression. Moreover, it also restores the immune response dysfunction by reducing inflammatory cytokines.

SIGNIFICANCE

Thus, from present findings it may be suggested that spirulina aids in ameliorating the psychosis-like symptoms induced by dizocilpine in animal model possibly via regulation of neurotransmission and other biomarkers that are extensively used to uncover the etiopathology of SZ. Hence, blue-green algae can be used as an effective therapy for preventive or therapeutic measures in SZ.

Maternal immune activation induces sustained changes in fetal microglia motility

Maternal infection or inflammation causes abnormalities in brain development associated with subsequent cognitive impairment and in an increased susceptibility to schizophrenia and autism spectrum disorders. Maternal immune activation (MIA) and increases in serum cytokine levels mediates this association via effects on the fetal brain, and microglia can respond to maternal immune status, but consensus on how microglia may respond is lacking and no-one has yet examined if microglial process motility is impaired. In this study we investigated how MIA induced at two different gestational ages affected microglial properties at different developmental stages. Immune activation in mid-pregnancy increased IL-6 expression in embryonic microglia, but failed to cause any marked changes in morphology either at E18 or postnatally. In contrast MIA, particularly when induced earlier (at E12), caused sustained alterations in the patterns of microglial process motility and behavioral deficits. Our research has identified an important microglial property that is altered by MIA and which may contribute to the underlying pathophysiological mechanisms linking maternal immune status to subsequent risks for cognitive disease.

Prolactin levels in drug-naïve first episode nonaffective psychosis patients compared with healthy controls. Sex differences

Recent studies have found hyperprolactinemia in first episode psychotic patients that had not previously received antipsychotic treatment (drug-naïve). Our goal was to learn whether there were differences in baseline prolactin concentrations between drug-naïve psychotic patients and healthy controls, as well as to study possible gender differences in the prolactin elevation. A cross-sectional study was conducted that included 61 drug-naïve psychosis patients and 45 healthy controls (aged between 14-55 years old). A blood sample was extracted between 8 and 10 a.m. Prolactin levels and TSH were determined. The Perceived Stress Scale (PSS) was conducted across the sample. This study showed significantly higher levels of prolactin in drug-naïve patients compared to healthy controls. These results were maintained after controlling prolactin levels for sex, age, THC consumption, baseline TSH, and PSS. A significant correlation between prolactin and PSS was not observed. Significant differences in prolactin levels between men and women were not observed. These results are clinically important because if elevated baseline prolactin levels are detected in these patients, it will be necessary to initiate neuroleptics that do not increase this hormone. There was no evidence that stress was related to an increase in prolactin at the onset of psychosis.

Identification of risk factors for suicidal ideation in patients with schizophrenia

Patients with schizophrenia have a high risk for suicide, and therefore, identification of risk factors for suicidal ideation (SI) may be helpful to reduce suicide rate. This study aimed to detect which clinical symptoms and biochemical parameters were most strongly associated with SI. A total of 174 patients and 35 healthy controls were enrolled in our study. Patients were evaluated by the Positive and Negative Syndrome Scale (PANSS), Scale of Assessment Negative Symptoms (SANS) and the Calgary Depression Scale for Schizophrenia (CDSS) for psychiatric and depressive symptoms, and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) for cognitive function. We examined the levels of prolactin (PRL) and metabolic parameters in all participants. Our results showed a significantly increased level of PRL in patients compared to the controls before (t = 10.414, P < 0.001) and after (F = 31.308, P < 0.001) covariates were controlled for. In addition, we found that patients with SI had significantly higher PRL levels than those without SI (t = 2.586, P = 0.011). And there were positive correlations between serum PRL levels (r = 0.194, P = 0.010), serum fasting triglyceride levels (TG) (r = 0.188, P = 0.013), and RBANS visuospatial skill subscores (r = 0.162, P = 0.036) and SI severity. Finally, the stepwise multiple linear regression analysis revealed that SI severity was significantly associated with PRL levels, fasting TG levels and RBANS visuospatial skill subscores. This study provides support that greater cognitive ability, specifically visuospatial skill, PRL and TG, may confer an elevated risk for more severe SI in schizophrenia patients.

Diverse definitions of the early course of schizophrenia-a targeted literature review

Schizophrenia is a debilitating psychiatric disorder and patients experience significant comorbidity, especially cognitive and psychosocial deficits, already at the onset of disease. Previous research suggests that treatment during the earlier stages of disease reduces disease burden, and that a longer time of untreated psychosis has a negative impact on treatment outcomes. A targeted literature review was conducted to gain insight into the definitions currently used to describe patients with a recent diagnosis of schizophrenia in the early course of disease ('early' schizophrenia). A total of 483 relevant English-language publications of clinical guidelines and studies were identified for inclusion after searches of MEDLINE, MEDLINE In-Process, relevant clinical trial databases and Google for records published between January 2005 and October 2015. The extracted data revealed a wide variety of terminology and definitions used to describe patients with 'early' or 'recent-onset' schizophrenia, with no apparent consensus. The most commonly used criteria to define patients with early schizophrenia included experience of their first episode of schizophrenia or disease duration of less than 1, 2 or 5 years. These varied definitions likely result in substantial disparities of patient populations between studies and variable population heterogeneity. Better agreement on the definition of early schizophrenia could aid interpretation and comparison of studies in this patient population and consensus on definitions should allow for better identification and management of schizophrenia patients in the early course of their disease.

Influence of olanzapine on serum prolactin levels and BMI in female patients with schizophrenia

OBJECTIVES

It has been well documented that elevation of serum prolactin (PRL) level and weight gain are common in patients receiving treatment with atypical antipsychotics. The existing evidences show that serum PRL is elevated in schizophrenic patients treated with olanzapine. However, little is known about the long-term effects of olanzapine on PRL levels and weight gain in female patients with schizophrenia.

MATERIALS AND METHODS

This study addressed this issue by investigating the relationship between serum PRL level and body mass index (BMI). Seventy-nine female patients with first-episode schizophrenia were recruited and received olanzapine monotherapy for 12 weeks. Serum PRL level and BMI were measured at baseline and at 4, 8, 12 weeks. Thirty-five age-matched healthy female individuals were recruited as controls. The severity of psychiatric symptoms was evaluated using the Positive and Negative Syndrome Scale.

RESULTS

The olanzapine treatment for 12 weeks significantly increased serum PRL (P<0.01) level and BMI (P<0.01). A positive correlation between the pre- and posttreatment changes in serum PRL level and BMI was observed (r=0.247, P=0.028).

CONCLUSION

Our findings suggest that PRL might conceivably modulate weight gain in female patients with schizophrenia receiving olanzapine treatment; however, the exact mechanism remains unclear.

Cancer Immune Equilibrium and Schizophrenia Have Similar Interferon-γ, Tumor Necrosis Factor-α, and Interleukin Expression: A Tumor Model of Schizophrenia

For at least a century, a debate has continued as to whether cancer risk is reduced in schizophrenia. Genetic studies have also suggested the 2 conditions may share protein transcriptional pathways. The author predicted that if the pathophysiology of schizophrenia confers protection from cancer, then the immunology of schizophrenia should reflect a state of tumor suppression, ie, the opposite of tumor escape. To examine this possibility, the author performed a literature search for measurements of cytokines in drug-naïve first episode subjects with schizophrenia for comparison with cytokine expression in tumor escape vs tumor suppression. The comparison showed that instead of either tumor suppression or escape, schizophrenia appears to be in a state of tumor equilibrium. Based on this finding, the author hypothesized that the clinical presentation of schizophrenia may involve cell transformation similar to an early stage of cancer initiation or an attenuated tumorigenesis. While this condition could reflect the presence of an actual tumor such as an ovarian teratoma causing anti-NMDA receptor encephalitis, it would only explain a small percentage of cases. To find a more likely tumor model, the author then compared the cytokine profile of schizophrenia to individual cancers and found the best match was melanoma. To demonstrate the viability of the theory, the author compared the hallmarks, emerging hallmarks, and enabling characteristics of melanoma to schizophrenia and found that many findings in schizophrenia are understood if schizophrenia is a condition of attenuated tumorigenesis.

Prolactin concentrations in antipsychotic-naïve patients with schizophrenia and related disorders: A meta-analysis

OBJECTIVE

The use of dopaminergic antagonist antipsychotics is associated with hyperprolactinemia, but some studies have found increased prolactin concentrations in antipsychotic-naive patients with schizophrenia and related disorders. We conducted a systematic review and meta-analysis of studies of prolactin in antipsychotic-naïve patient with these disorders (PRISMA No. CRD42015016337).

DATA SOURCES

PubMed (Medline), PsycInfo, and Web of Science were searched for articles from 1950 to the present in English.

STUDY SELECTION

Seven studies of males (N=141 for patients, N=191 for control subjects) and five studies of females (N=67 and N=116) met criteria for inclusion: data on blood prolactin concentrations for both control subjects and antipsychotic-naive patients with schizophrenia or a related disorder, with data available separately for males and females.

DATA EXTRACTION

Data was extracted from the papers by one author and independently verified by a second.

RESULTS

The mean effect size for males was 1.02 (95% CI, 0.77, 1.26; p<0.001) and 0.43 for females (95% CI 0.11, 0.76; p<0.01). Meta-regression analyses for age, smoking, body mass index (BMI), year of publication, and cortisol were not significant. Funnel plots did not suggest the presence of a publication bias.

CONCLUSIONS

Our meta-analyses found significantly increased prolactin levels in both male and female antipsychotic-naïve patients with schizophrenia and related disorders. The small number of studies and limited matching for potentially confounding variables in some of the studies were limitations of this analysis. Prolonged hyperprolactinemia may lead to sexual dysfunction and osteoporosis, and some antipsychotics cause additional elevation of prolactin concentrations.

Interaction of BDNF with cytokines in chronic schizophrenia

Brain-derived neurotrophic factor (BDNF) interacts with cytokines. Although both BDNF and cytokines occur at abnormal levels in schizophrenia patients, their interactions have not yet been examined. We therefore compared serum BDNF, TNF-α, interleukin (IL)-2, IL-6, and IL-8 levels in 92 chronically medicated schizophrenia patients and 60 healthy controls. We correlated these serum levels within these subject groups with each other and with clinical symptoms assessed according to the Positive and Negative Syndrome Scale (PANSS). Compared to the control group, the schizophrenia patients had significantly lower BDNF and TNF-α levels, and higher IL-2, IL-6, and IL-8 levels. The patients also showed a significant positive correlation between BDNF and both IL-2 and IL-8 levels, and low BDNF and TNF-α levels together were associated with poor performance on the PANSS cognitive factor. Thus, an interaction between cytokines and neurotrophic factors may be implicated in the pathophysiology of chronic schizophrenia. In particular, the cytokine TNF-α may interact with BNDF causing cognitive impairment.

IL-6, IL-18, sIL-2R, and TNFα proinflammatory markers in depression and schizophrenia patients who are free of overt inflammation

Major depressive disorder (MDD) and schizophrenia are associated with inflammatory processes. Studies have shown that these disorders exhibit increase in the level of one or more proinflammatory markers. However, these studies did not exclude patients with obvious inflammation (i.e., CRP>6mg/L). Therefore, a comprehensive study should include those inflammatory disorders. In the present study, the inflammatory natures of MDD and schizophrenia were investigated. To achieve this goal, serum levels of interleukin-6 (IL-6), interleukin-18 (IL-18), tumor necrosis factor alpha (TNFα), and soluble interleukin 2 receptor (sIL-2R) in depressed and schizophrenic patients were obtained and compared with those of the control group. Results showed a significant increase (p<0.05) in serum levels of IL-6, IL-18, TNFα, and sIL-2R in MDD and schizophrenic patients compared with the control group. Also patients with schizophrenia group showed higher levels of the inflammatory markers than MDD and control groups. The current study concluded that the immunological response in the MDD and schizophrenic patients groups was significantly stimulated. These disorders may be considered an inflammatory disorder because of elevated levels of proinflammatory cytokines in spite of lacking an overt inflammation. Furthermore results of this study suggested the possibility of the use of anti-inflammatory drugs as adjuvant therapy in schizophrenic and depressive disorders.

Biomarker identification and effect estimation on schizophrenia - a high dimensional data analysis

Biomarkers have been examined in schizophrenia research for decades. Medical morbidity and mortality rates, as well as personal and societal costs, are associated with schizophrenia patients. The identification of biomarkers and alleles, which often have a small effect individually, may help to develop new diagnostic tests for early identification and treatment. Currently, there is not a commonly accepted statistical approach to identify predictive biomarkers from high dimensional data. We used space decomposition-gradient-regression (DGR) method to select biomarkers, which are associated with the risk of schizophrenia. Then, we used the gradient scores, generated from the selected biomarkers, as the prediction factor in regression to estimate their effects. We also used an alternative approach, classification and regression tree, to compare the biomarker selected by DGR and found about 70% of the selected biomarkers were the same. However, the advantage of DGR is that it can evaluate individual effects for each biomarker from their combined effect. In DGR analysis of serum specimens of US military service members with a diagnosis of schizophrenia from 1992 to 2005 and their controls, Alpha-1-Antitrypsin (AAT), Interleukin-6 receptor (IL-6r) and connective tissue growth factor were selected to identify schizophrenia for males; and AAT, Apolipoprotein B and Sortilin were selected for females. If these findings from military subjects are replicated by other studies, they suggest the possibility of a novel biomarker panel as an adjunct to earlier diagnosis and initiation of treatment.