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Nicol JTJ, Mazzoni E, Iaquinta MR, De Pace R, Gaboriaud P, Maximova N, Cason C, De Martino E, Mazziotta C, Coursaget P, Touzé A, Boz V, Comar M, Tognon M, Martini F. Prevalence of IgG antibodies against Malawi polyomavirus in patients with autoimmune diseases and lymphoproliferative disorders subjected to bone marrow transplantation. Front Immunol 2024; 14:1293313. [PMID: 38299147 PMCID: PMC10827882 DOI: 10.3389/fimmu.2023.1293313] [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: 09/13/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Human polyomaviruses (HPyVs) cause persistent/latent infections in a large fraction of the population. HPyV infections may cause severe diseases in immunocompromised patients. Malawi polyomavirus (MWPyV) is the 10th discovered human polyomavirus (HPyV 10). MWPyV was found in stool samples of healthy children. So far, the few investigations carried out on HPyV 10 did not find an association with human disease. Methods In this study, to verify the putative association between MWPyV and human diseases, MWPyV seroprevalence was investigated in patients affected by i) lymphoproliferative disorders (LPDs) and ii) immune system disorders, i.e., autoimmune diseases (ADs), and in iii) healthy subjects. An indirect ELISA, employing virus-like particles (VLPs) to detect serum IgG antibodies against MWPyV/HPyV 10, was carried out. The study also revealed the prevalence of another polyomavirus, Merkel cell polyomavirus (MCPyV). Results Sera from patients with distinct autoimmune diseases (n = 44; mean age 20 years) had a prevalence of MWPyV antibodies of 68%, while in patients with lymphoproliferative disorders (n = 15; mean age 14 years), subjected to bone marrow transplantation, the prevalence was 47%. In healthy subjects (n = 66; mean age 13 years), the prevalence of MWPyV antibodies was 67%. Our immunological investigation indicates that MWPyV/HPyV 10 seroconversion occurs early in life and MWPyV/HPyV 10 appears to be another polyomavirus ubiquitous in the human population. A significantly lower MWPyV antibody reactivity together with a lower immunological profile was detected in the sera of LPD patients compared with HS2 (*p < 0.05) (Fisher's exact test). LPD and AD patients have a similar MCPyV seroprevalence compared with healthy subjects. Discussion MWPyV seroprevalence indicates that this HPyV is not associated with lymphoproliferative and autoimmune diseases. However, the ability to produce high levels of antibodies against MWPyV appears to be impaired in patients with lymphoproliferative disorders. Immunological investigations indicate that MWPyV seroconversion occurs early in life. MCPyV appears to be a ubiquitous polyomavirus, like other HPyVs, in the human population.
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Affiliation(s)
- Jérôme T. J. Nicol
- UMR 1282 ISP Team Biologie des Infections à Polyomavirus, Faculty of Pharmacy, University of Tours, Tours, France
| | - Elisa Mazzoni
- Department of Chemical, Pharmaceutical and Agricultural Sciences, University of Ferrara, Ferrara, Italy
| | | | - Raffaella De Pace
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Pauline Gaboriaud
- UMR 1282 ISP Team Biologie des Infections à Polyomavirus, Faculty of Pharmacy, University of Tours, Tours, France
| | - Natalia Maximova
- Onco-Hematology Division, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Carolina Cason
- Department of Advanced Translational Microbiology, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Eleonora De Martino
- Laboratory of Pediatric Immunology, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Chiara Mazziotta
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Pierre Coursaget
- UMR 1282 ISP Team Biologie des Infections à Polyomavirus, Faculty of Pharmacy, University of Tours, Tours, France
| | - Antoine Touzé
- UMR 1282 ISP Team Biologie des Infections à Polyomavirus, Faculty of Pharmacy, University of Tours, Tours, France
| | - Valentina Boz
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Manola Comar
- Department of Advanced Translational Microbiology, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Mauro Tognon
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Fernanda Martini
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Laboratory for Technologies of Advanced Therapies, University of Ferrara, Ferrara, Italy
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Mohanraj U, Konttinen T, Salava A, Väkevä L, Ranki A, Söderlund-Venermo M. Significant Association of Cutavirus With Parapsoriasis en Plaques: High Prevalence Both in Skin Swab and Biopsy Samples. Clin Infect Dis 2023; 77:987-990. [PMID: 37234048 PMCID: PMC10552579 DOI: 10.1093/cid/ciad320] [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: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 05/27/2023] Open
Abstract
Cutavirus (CuV) is associated with cutaneous T-cell lymphoma (CTCL), of which parapsoriasis is a precursor. Our study reveals a significantly higher CuV-DNA prevalence in skin swabs of parapsoriasis patients (6/13; 46.2%) versus those of healthy adults (1/51; 1.96%). Eight patients (8/12; 66.7%) had CuV DNA in biopsied skin, and 4 developed CTCL.
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Affiliation(s)
| | - Tuomas Konttinen
- Department of Virology, University of Helsinki, Helsinki, Finland
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Alexander Salava
- Department of Dermatology, Allergology, and Venereology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Liisa Väkevä
- Department of Dermatology, Allergology, and Venereology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Annamari Ranki
- Department of Dermatology, Allergology, and Venereology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
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Merkel Cell Polyomavirus: Infection, Genome, Transcripts and Its Role in Development of Merkel Cell Carcinoma. Cancers (Basel) 2023; 15:cancers15020444. [PMID: 36672392 PMCID: PMC9857234 DOI: 10.3390/cancers15020444] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
The best characterized polyomavirus family member, i.e., simian virus 40 (SV40), can cause different tumors in hamsters and can transform murine and human cells in vitro. Hence, the SV40 contamination of millions of polio vaccine doses administered from 1955-1963 raised fears that this may cause increased tumor incidence in the vaccinated population. This is, however, not the case. Indeed, up to now, the only polyomavirus family member known to be the most important cause of a specific human tumor entity is Merkel cell polyomavirus (MCPyV) in Merkel cell carcinoma (MCC). MCC is a highly deadly form of skin cancer for which the cellular origin is still uncertain, and which appears as two clinically very similar but molecularly highly different variants. While approximately 80% of cases are found to be associated with MCPyV the remaining MCCs carry a high mutational load. Here, we present an overview of the multitude of molecular functions described for the MCPyV encoded oncoproteins and non-coding RNAs, present the available MCC mouse models and discuss the increasing evidence that both, virus-negative and -positive MCC constitute epithelial tumors.
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Epidemiology of Merkel Cell Polyomavirus Infection and Merkel Cell Carcinoma. Cancers (Basel) 2022; 14:cancers14246176. [PMID: 36551657 PMCID: PMC9776808 DOI: 10.3390/cancers14246176] [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: 11/16/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Merkel cell polyomavirus (MCPyV) is a ubiquitous virus replicating in human dermal fibroblasts. MCPyV DNA can be detected on healthy skin in 67−90% of various body sites, and intact virions are regularly shed from the skin. Infection occurs early in life, and seropositivity increases from 37 to 42% in 1- to 6-year-olds to 92% in adults. Merkel cell carcinoma (MCC) is a rare but very aggressive neuroendocrine tumor of the skin. It develops mainly on sun-exposed areas as a fast-growing, reddish nodule. Two MCC entities exist: about 80% of MCC are MCPyV-associated. Tumorigenesis is driven by viral integration into the host genome and MCPyV oncogene expression. In MCPyV-negative MCC, UV radiation causes extensive DNA damage leading to the deregulation of the cell cycle. In recent decades, MCC incidence rates have increased worldwide, e.g., in the United States, from 0.15 in 1986 to 0.7/100,000 in 2016. Risk factors for the development of MCC include male sex, older age (>75 years), fair skin, intense UV exposure, and immunosuppression. Projections suggest that due to aging populations, an increase in immunosuppressed patients, and enhanced UV exposure, MCC incidence rates will continue to rise. Early diagnosis and prompt treatment are crucial to reducing high MCC morbidity and mortality.
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Hasanzadeh A, Sadeghi F, Kamrani G, Mohammadi N, Vosough Z, Ranaee M, Tabarraei A, Yahyapour Y. Quantitative analysis of Merkel cell polyomavirus (MCPyV) genome in non-melanoma skin cancer and normal tumor margins. Braz J Microbiol 2022; 53:1987-1994. [PMID: 36279096 PMCID: PMC9679045 DOI: 10.1007/s42770-022-00850-x] [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: 07/16/2022] [Accepted: 10/12/2022] [Indexed: 01/13/2023] Open
Abstract
Merkel cell polyomavirus (MCPyV) is the cause of approximately 80% of Merkel cell carcinomas (MCC). The common types of non-melanoma skin cancer (NMSC) including squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are histologically similar to MCC. In the present study, 58 NMSC formalin-fixed paraffin-embedded tissue (FFPE) samples including 12 SCC, 46 BCC, and 58 FFPE samples of adjacent non-tumoral margins as the control were included. Determination of large tumor antigens (LTAg) copy number was performed by qReal-Time PCR as a viral copy number per cell to elucidate MCPyV carcinogenic role in non-melanoma skin cancer. Out of 58 samples, 36 (62%) cancerous and 22 (37.9%) normal tumor margins were positive for MCPyV LTAg. Median copy numbers of MCPyV LTAg among all NMSC samples and non-tumoral margins were 0.308×10-2 and 0.269×10-3 copies per cell respectively (P=0.001). In addition, although the viral load in the majority of samples was detected to be lower than one copy per cell, in 4 BCC samples, a viral load higher than one LTAg copy per cell was detected. The present study revealed that the detection of higher levels of MCPyV LTAg viral load in some BCC and SCC samples may be correlated with the role of MCPyV in some cases of BCC and SCC skin cancer.
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Affiliation(s)
- Ali Hasanzadeh
- Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Farzin Sadeghi
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Ghodsieh Kamrani
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Neda Mohammadi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Vosough
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Ranaee
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Alijan Tabarraei
- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Yousef Yahyapour
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
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Donà MG, Gheit T, Chiantore MV, Vescio MF, Luzi F, Rollo F, Accardi L, Cota C, Galati L, Romeo G, Giuliani M, Tommasino M, Di Bonito P. Prevalence of 13 polyomaviruses in actinic keratosis and matched healthy skin samples of immunocompetent individuals. Infect Agent Cancer 2022; 17:59. [PMID: 36457033 PMCID: PMC9714215 DOI: 10.1186/s13027-022-00472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Actinic keratosis (AK) is a precursor of cutaneous squamous cell carcinoma (cSCC). UV radiation is the major risk factor for AK, but certain human papillomaviruses (HPVs) of the beta genus are also involved in its development. Differently, the role of polyomaviruses (PyVs) in skin carcinogenesis is still debated. Fiftheen PyVs have been isolated from human tissues so far, including Merkel cell polyomavirus (MCPyV), the aetiological agent of Merkel cell carcinoma. METHODS The presence of 13 PyVs was assessed in skin samples from AK patients (n = 342). Matched fresh-frozen scrapings from healthy skin (HS) and AK lesions from 242 patients, and formalin-fixed paraffin-embedded AK biopsies from a different cohort of 100 patients were analyzed by multiplex PyVs genotyping assay. RESULTS The most frequent lesion site was the scalp in men (27.3%), and the cheek area in women (29.0%). Differences between men and women were significant for the scalp, the cheek area and the lips. Almost all the scrapings were PyV-positive (HS: 89.7%, AK: 94.6%; p = 0.04). The three most frequent PyVs were MCPyV, HPyV6 and JCPyV (HS: 87.2%, 58.7%, 6.6%, respectively; AK: 88.8%, 51.2%, 9.9%, respectively). HPyV9, TSPyV, BKPyV, HPyV7, LIPyV and SV40 were detected in < 2% of the scrapings. In most cases, matched HS and AK scrapings were both positive (MCPyV: 78.1%, HPyV6: 41.7%), or both negative for the individual genotypes (for the remaining PyVs). PyV prevalence in AK biopsies was 22.0%. Only MCPyV (21.0%) and HPyV6 (3.0%) were detected in these samples. CONCLUSIONS PyV prevalence in HS and AK scrapings was high, but detection of PyVs exclusively in AK scrapings was rare. PyV positivity rate in AK biopsies was modest. Further research is need to reach firm conclusions regarding the role of these viruses in AK development.
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Affiliation(s)
| | - Tarik Gheit
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | | | - Maria Fenicia Vescio
- Epidemiology Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Fabiola Luzi
- Plastic and Reconstructive Surgery, San Gallicano Dermatologic Institute IRCCS, Rome, Italy
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute, IRCCS, Rome, Italy
| | - Luisa Accardi
- EVOR Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Carlo Cota
- Department of Dermopathology, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Luisa Galati
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Giovanna Romeo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome-Polo Pontino, Latina, Italy
| | - Massimo Giuliani
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | | | - Paola Di Bonito
- EVOR Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
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Jeles K, Katona M, Csoma E. Seroprevalence of Four Polyomaviruses Linked to Dermatological Diseases: New Findings and a Comprehensive Analysis. Viruses 2022; 14:v14102282. [PMID: 36298837 PMCID: PMC9611179 DOI: 10.3390/v14102282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022] Open
Abstract
Our aim was to study the seroprevalence of human polyomaviruses (HPyV) linked to skin diseases. A total of 552 serum samples were analysed by the enzyme-linked immunosorbent assay to detect IgG antibodies against Merkel cell polyomavirus (MCPyV), HPyV6, HPyV7 and Trichodysplasia spinulosa-associated polyomavirus (TSPyV) using recombinant major capsid proteins of these viruses. The individuals (age 0.8−85 years, median 33) were sorted into seven age groups: <6, 6−10, 10−14, 14−21, 21−40, 40−60 and >60 years. The adulthood seroprevalence was 69.3%, 87.7%, 83.8% and 85% for MCPyV, HPyV6, HPyV7 and TSPyV, respectively. For all four polyomaviruses, there was increasing seropositivity with age until reaching the adulthood level. There was a significant increase in seroreactivity for those age groups in which the rate of already-infected individuals also showed significant differences. The adulthood seropositvity was relatively stable with ageing, except for TSPyV, for which elevated seropositivity was observed for the elderly (>60 years) age group. Since seroepidemiological data have been published with wide ranges for all the viruses studied, we performed a comprehensive analysis comparing the published age-specific seropositivities to our data. Although the cohorts, methods and even the antigens were variable among the studies, there were similar results for all studied polyomaviruses. For MCPyV, geographically distinct genotypes might exist, which might also result in the differences in the seroprevalence data. Additional studies with comparable study groups and methods are required to clarify whether there are geographical differences.
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Affiliation(s)
- Krisztina Jeles
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, 4032 Debrecen, Hungary
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., 4032 Debrecen, Hungary
| | - Melinda Katona
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, 4032 Debrecen, Hungary
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., 4032 Debrecen, Hungary
| | - Eszter Csoma
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., 4032 Debrecen, Hungary
- Correspondence:
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Silling S, Kreuter A, Wieland U. [Human polyomavirus-associated skin diseases]. Hautarzt 2022; 73:426-433. [PMID: 35482045 DOI: 10.1007/s00105-022-04993-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/30/2022]
Abstract
Of the 15 currently known human polyomaviruses (HPyV), eight have been found on healthy skin. Merkel cell polyomavirus (MCPyV), HPyV6, HPyV7, and to a lesser extent Saint Louis polyomavirus (STLPyV) are considered part of the human cutaneous virome. The most important cutaneous polyomavirus, MCPyV, causes the majority of Merkel cell carcinomas (MCC). MCC is a rare but very aggressive malignant skin tumor that affects both immunocompetent and immunosuppressed patients. A steady increase in incidence rates of this skin tumor has been observed in recent decades. MCC occurs primarily on sunlight-exposed skin of fair-skinned individuals. Risk factors for MCC development include immunosuppression and advanced age. In immunocompromised individuals, primary infection with trichodysplasia spinulosa-associated polyomavirus (TSPyV) can cause the very rare skin disease trichodysplasia spinulosa (TS). Keratin spines (spicules), mainly in the center of the face, clinically characterize this disease. Skin lesions associated with further HPyV have been described exclusively in immunocompromised individuals. For HPyV6 and HPyV7, cases of epithelial proliferation and pruritic dyskeratotic dermatitis have been published. HPyV9 and New Jersey polyomavirus (NJPyV-13) were each found in different skin lesions of individual patients. The role of these polyomaviruses in the development of the skin lesions is still unclear.
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Affiliation(s)
- Steffi Silling
- Institut für Virologie, Nationales Referenzzentrum für Papillom- und Polyomaviren, Universitätsklinikum Köln und Universität zu Köln, Fürst-Pückler-Str. 56, 50935, Köln, Deutschland
| | - Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, HELIOS St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland.,Klinik für Dermatologie, Venerologie und Allergologie, HELIOS St. Johannes Klinik Duisburg, Duisburg, Deutschland
| | - Ulrike Wieland
- Institut für Virologie, Nationales Referenzzentrum für Papillom- und Polyomaviren, Universitätsklinikum Köln und Universität zu Köln, Fürst-Pückler-Str. 56, 50935, Köln, Deutschland.
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Prevalence of MCPyV, HPyV6, HPyV7 and TSPyV in Actinic Keratosis Biopsy Specimens. Viruses 2022; 14:v14020427. [PMID: 35216020 PMCID: PMC8876850 DOI: 10.3390/v14020427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/04/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
To date, 14 human polyomaviruses (HPyVs) have been identified using high-throughput technologies. Among them, MCPyV, HPyV6, HPyV7 and TSPyV present a skin tropism, but a causal role in skin diseases has been established only for MCPyV as a causative agent of Merkel cell carcinoma (MCC) and TSPyV as an etiological agent of Trichodysplasia Spinulosa (TS). In the search for a possible role for cutaneous HPyVs in the development of skin malignant lesions, we investigated the prevalence of MCPyV, HPyV6, HPyV7 and TSPyV in actinic keratosis (AK), a premalignant skin lesion that has the potential to progress towards a squamous cell carcinoma (SCC). One skin lesion and one non-lesion skin from nine affected individuals were analyzed by qualitative PCR. MCPyV was detected in 9 out of 9 lesion biopsies and 6 out of 8 non-lesion biopsies. HPyV6 was detected only in healthy skin, while HPyV7 and TSPyV were not detected in any skin sample. These findings argue against a possible role of cutaneous HPyVs in AK. However, considering the small sample size analyzed, a definitive conclusion cannot be drawn. Longitudinal studies on large cohorts are warranted.
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