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Al Refaie A, Baldassini L, Mondillo C, Ceccarelli E, Tarquini R, Gennari L, Gonnelli S, Caffarelli C. Glucagon-like Peptide-1 Receptor Agonists and Diabetic Osteopathy: Another Positive Effect of Incretines? A 12 Months Longitudinal Study. Calcif Tissue Int 2024:10.1007/s00223-024-01240-1. [PMID: 38864922 DOI: 10.1007/s00223-024-01240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/22/2024] [Indexed: 06/13/2024]
Abstract
Diabetic osteopathy is a frequent complication in patients with type 2 diabetes mellitus (T2DM). The association between T2DM and increased fracture risk has led to study the impact of new antidiabetic drugs on bone metabolism. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are incretin mimetic drugs which have many pleiotropic properties. The relationship between GLP-1RAs and bone is very complex: while in vitro and animal studies have demonstrated a protective effect on bone, human studies are scarce. We led a 12 months longitudinal study evaluating bone changes in 65 patients withT2DM for whom a therapy with GLP-1RAs had been planned. Fifty-four T2DM patients completed the 12-month study period; of them, 30 had been treated with weekly dulaglutide and 24 with weekly semaglutide. One-year therapy with GLP-1RAs resulted in a significant reduction in weight and BMI. Bone mineral density (BMD), bone metabolism, trabecular bone score (TBS), adiponectin, and myostatin were evaluated before and after 12 months of GLP-1RAs therapy. After 12 months of therapy bone turnover markers and adiponectin showed a significant increase, while myostatin values showed a modest but significant reduction. BMD-LS by DXA presented a significant reduction while the reduction in BMD-LS by REMS was not significant and TBS values showed a marginal increase. Both DXA and REMS techniques showed a modest but significant reduction in femoral BMD. In conclusion, the use of GLP-1RAs for 12 months preserves bone quality and reactivates bone turnover. Further studies are needed to confirm whether GLP-1RAs could represent a useful therapeutic option for patients with T2DM and osteoporosis.
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Affiliation(s)
- Antonella Al Refaie
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
- Division of Internal Medicine I, San Giuseppe Hospital, 50053, Empoli, Italy
| | - Leonardo Baldassini
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Caterina Mondillo
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Elena Ceccarelli
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Roberto Tarquini
- Division of Internal Medicine I, San Giuseppe Hospital, 50053, Empoli, Italy
| | - Luigi Gennari
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Stefano Gonnelli
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Carla Caffarelli
- Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy.
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Liu D, Wang T, Zhao X, Chen J, Yang T, Shen Y, Zhou YD. Saturated fatty acids stimulate cytokine production in tanycytes via the PP2Ac-dependent signaling pathway. J Cereb Blood Flow Metab 2024; 44:985-999. [PMID: 38069840 DOI: 10.1177/0271678x231219115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
The hypothalamic tanycytes are crucial for free fatty acids (FFAs) detection, storage, and transport within the central nervous system. They have been shown to effectively respond to fluctuations in circulating FFAs, thereby regulating energy homeostasis. However, the precise molecular mechanisms by which tanycytes modulate lipid utilization remain unclear. Here, we report that the catalytic subunit of protein phosphatase 2 A (PP2Ac), a serine/threonine phosphatase, is expressed in tanycytes and its accumulation and activation occur in response to high-fat diet consumption. In vitro, tanycytic PP2Ac responds to palmitic acid (PA) exposure and accumulates and is activated at an early stage in an AMPK-dependent manner. Furthermore, activated PP2Ac boosts hypoxia-inducible factor-1α (HIF-1α) accumulation, resulting in upregulation of an array of cytokines. Pretreatment with a PP2Ac inhibitor, LB100, prevented the PA-induced elevation of vascular endothelial growth factor (VEGF), fibroblast growth factor 1 (FGF1), hepatocyte growth factor (HGF), and dipeptidyl peptidase IV (DPPIV or CD26). Our results disclose a mechanism of lipid metabolism in tanycytes that involves the activation of PP2Ac and highlight the physiological significance of PP2Ac in hypothalamic tanycytes in response to overnutrition and efficacious treatment of obesity.
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Affiliation(s)
- Danyang Liu
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
- Nanhu Brain-computer Interface Institute, Hangzhou 311100, China
- Department of Ophthalmology of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Tao Wang
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
| | - Xingqi Zhao
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
| | - Juan Chen
- School of Mental Health, Bengbu Medical College, Bengbu, Anhui, China
| | - Tianqi Yang
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
| | - Yi Shen
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
- Department of Neurobiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Dong Zhou
- Institute of Neuroscience, NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Brain Science and Brain Medicine, Hangzhou, China
- Lingang Laboratory, Shanghai 200031, China
- Department of Ophthalmology of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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Zheng J, He J, Li H. FAM19A5 in vascular aging and osteoporosis: Mechanisms and the "calcification paradox". Ageing Res Rev 2024; 99:102361. [PMID: 38821416 DOI: 10.1016/j.arr.2024.102361] [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: 01/25/2024] [Revised: 05/05/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
Aging induces a progressive decline in the vasculature's structure and function. Vascular aging is a determinant factor for vascular ailments in the elderly. FAM19A5, a recently identified adipokine, has demonstrated involvement in multiple vascular aging-related pathologies, including atherosclerosis, cardio-cerebral vascular diseases and cognitive deficits. This review summarizes the current understanding of FAM19A5' role and explores its putative regulatory mechanisms in various aging-related disorders, including cardiovascular diseases (CVDs), metabolic diseases, neurodegenerative diseases and malignancies. Importantly, we provide novel insights into the underlying therapeutic value of FAM19A5 in osteoporosis. Finally, we outline future perspectives on the diagnostic and therapeutic potential of FAM19A5 in vascular aging-related diseases.
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Affiliation(s)
- Jin Zheng
- Department of Geriatrics, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Jieyu He
- Department of Geriatrics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Huahua Li
- Department of Geriatrics, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China.
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Li J, Wu J, Xie Y, Yu X. Bone marrow adipocytes and lung cancer bone metastasis: unraveling the role of adipokines in the tumor microenvironment. Front Oncol 2024; 14:1360471. [PMID: 38571500 PMCID: PMC10987778 DOI: 10.3389/fonc.2024.1360471] [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: 12/23/2023] [Accepted: 03/08/2024] [Indexed: 04/05/2024] Open
Abstract
Bone is a common site of metastasis for lung cancer. The "seed and soil" hypothesis suggests that the bone marrow microenvironment ("soil") may provide a conducive survival environment for metastasizing tumor cells ("seeds"). The bone marrow microenvironment, comprising a complex array of cells, includes bone marrow adipocytes (BMAs), which constitute about 70% of the adult bone marrow volume and may play a significant role in tumor bone metastasis. BMAs can directly provide energy for tumor cells, promoting their proliferation and migration. Furthermore, BMAs participate in the tumor microenvironment's osteogenesis regulation, osteoclast(OC) regulation, and immune response through the secretion of adipokines, cytokines, and inflammatory factors. However, the precise mechanisms of BMAs in lung cancer bone metastasis remain largely unclear. This review primarily explores the role of BMAs and their secreted adipokines (leptin, adiponectin, Nesfatin-1, Resistin, chemerin, visfatin) in lung cancer bone metastasis, aiming to provide new insights into the mechanisms and clinical treatment of lung cancer bone metastasis.
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Affiliation(s)
- Jian Li
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Endocrinology and Metabolism, Shandong Second Provincial General Hospital, Jinan, China
| | - Jialu Wu
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yanni Xie
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xijie Yu
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
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Chondrogianni ME, Kyrou I, Androutsakos T, Flessa CM, Menenakos E, Chatha KK, Aranan Y, Papavassiliou AG, Kassi E, Randeva HS. Anti-osteoporotic treatments in the era of non-alcoholic fatty liver disease: friend or foe. Front Endocrinol (Lausanne) 2024; 15:1344376. [PMID: 38524631 PMCID: PMC10957571 DOI: 10.3389/fendo.2024.1344376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/05/2024] [Indexed: 03/26/2024] Open
Abstract
Over the last years non-alcoholic fatty liver disease (NAFLD) has grown into the most common chronic liver disease globally, affecting 17-38% of the general population and 50-75% of patients with obesity and/or type 2 diabetes mellitus (T2DM). NAFLD encompasses a spectrum of chronic liver diseases, ranging from simple steatosis (non-alcoholic fatty liver, NAFL) and non-alcoholic steatohepatitis (NASH; or metabolic dysfunction-associated steatohepatitis, MASH) to fibrosis and cirrhosis with liver failure or/and hepatocellular carcinoma. Due to its increasing prevalence and associated morbidity and mortality, the disease-related and broader socioeconomic burden of NAFLD is substantial. Of note, currently there is no globally approved pharmacotherapy for NAFLD. Similar to NAFLD, osteoporosis constitutes also a silent disease, until an osteoporotic fracture occurs, which poses a markedly significant disease and socioeconomic burden. Increasing emerging data have recently highlighted links between NAFLD and osteoporosis, linking the pathogenesis of NAFLD with the process of bone remodeling. However, clinical studies are still limited demonstrating this associative relationship, while more evidence is needed towards discovering potential causative links. Since these two chronic diseases frequently co-exist, there are data suggesting that anti-osteoporosis treatments may affect NAFLD progression by impacting on its pathogenetic mechanisms. In the present review, we present on overview of the current understanding of the liver-bone cross talk and summarize the experimental and clinical evidence correlating NAFLD and osteoporosis, focusing on the possible effects of anti-osteoporotic drugs on NAFLD.
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Affiliation(s)
- Maria Eleni Chondrogianni
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Endocrine Unit, 1st Department of Propaupedic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Kyrou
- Laboratory of Dietetics and Quality of Life, Department of Food Science and Human Nutrition, School of Food and Nutritional Sciences, Agricultural University of Athens, Athens, Greece
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute for Cardiometabolic Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Centre for Health & Life Sciences, Coventry University, Coventry, United Kingdom
- Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
- College of Health, Psychology and Social Care, University of Derby, Derby, United Kingdom
| | - Theodoros Androutsakos
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina-Maria Flessa
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Menenakos
- 5th Surgical Clinic, Department of Surgery, ‘Evgenidion Hospital’, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Kamaljit Kaur Chatha
- Institute for Cardiometabolic Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Department of Biochemistry and Immunology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Yekaterina Aranan
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute for Cardiometabolic Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Athanasios G. Papavassiliou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Endocrine Unit, 1st Department of Propaupedic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Harpal S. Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute for Cardiometabolic Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Centre for Health & Life Sciences, Coventry University, Coventry, United Kingdom
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Sierawska O, Sawczuk M. Interaction between Selected Adipokines and Musculoskeletal and Cardiovascular Systems: A Review of Current Knowledge. Int J Mol Sci 2023; 24:17287. [PMID: 38139115 PMCID: PMC10743430 DOI: 10.3390/ijms242417287] [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: 11/13/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Adipokines are substances secreted by adipose tissue that are receiving increasing attention. The approach to adipose tissue has changed in recent years, and it is no longer looked at as just a storage organ but its secretion and how it influences systems in the human body are also looked at. The role of adipokine seems crucial in developing future therapies for pathologies of selected systems. In this study, we look at selected adipokines, leptin, adiponectin, chemerin, resistin, omentin-1, nesfatin, irisin-1, visfatin, apelin, vaspin, heparin-binding EGF-like growth factor (HB-EGF), and TGF-β2, and how they affect systems in the human body related to physical activity such as the musculoskeletal and cardiovascular systems.
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Affiliation(s)
- Olga Sierawska
- Institute of Physical Culture Sciences, University of Szczecin, 71-065 Szczecin, Poland;
- Doctoral School, University of Szczecin, 70-384 Szczecin, Poland
| | - Marek Sawczuk
- Institute of Physical Culture Sciences, University of Szczecin, 71-065 Szczecin, Poland;
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Cheng L, Wang S. Correlation between bone mineral density and sarcopenia in US adults: a population-based study. J Orthop Surg Res 2023; 18:588. [PMID: 37559054 PMCID: PMC10410911 DOI: 10.1186/s13018-023-04034-7] [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: 06/09/2023] [Accepted: 07/21/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION In the aging process of the body, in addition to changes in fat and muscle content, there is also bone loss, implying the possibility of a strong muscle-bone-lipid link. In this study, we initially investigated the relationship between lumbar BMD and low muscle mass and the relationship between "muscle-bone-lipid." METHODS The datasets from the National Health and Nutrition Examination Survey (NHANES) 2011-2018 were used in a cross-sectional investigation. BMD and appendicular skeletal muscle (ASM) were measured by dual-energy X-ray absorptiometry (DXA), and appendicular skeletal muscle was adjusted by body mass index (BMI) as a marker of sarcopenia. Weighted multivariate regression and logistic regression analysis were used to explore the independent relationship between lumbar BMD and sarcopenia. Fitted smoothing curves and threshold effect analysis were used to describe the nonlinear relationship. RESULT In 8386 participants with ages 20-59 years, there was a negative association between lumbar BMD and sarcopenia. In the fully adjusted model, the risk of developing sarcopenia decreased by 93% for each 1-unit increase in lumbar BMD (OR = 0.07, 95%CI 0.03-0.20). The risk of sarcopenia was 58% lower in participants in the highest quartile of lumbar BMD than in those in the lowest quartile (OR = 0.42, 95%CI 0.27-0.64). This negative association was more pronounced in the population of women with BMI ≥ 25. CONCLUSION Our findings suggest that lumbar BMD is negatively associated with sarcopenia in US adults. The dynamic balance between "muscle-bone-lipid" is likely to be related to the pathogenesis of bone loss.
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Affiliation(s)
- Lulu Cheng
- College of Acupuncture-Moxibustion and Tuina, Anhui University of Chinese Medicine, Hefei, 230012, China.
- Graduate School, Wuhan Sports University, Wuhan, 430079, China.
| | - Siyu Wang
- Graduate School, Wuhan Sports University, Wuhan, 430079, China
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AlShomar A, Abdulmonem WA, Ahmad QS, Alharbi MS, Alkhiari R, Hamad EM, Rasheed Z. Assessment of osteoporosis in patients with type 2 diabetes mellitus: A study from the central region of Saudi Arabia. Saudi Med J 2023; 44:711-716. [PMID: 37463708 PMCID: PMC10370382 DOI: 10.15537/smj.2023.44.7.20230238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES To understand the impact of diabetes on bone mineral density and whether it increases the likelihood of osteoporosis. METHODS This study was performed on 327 Saudis (aged >40 years) who were screened for osteoporosis and diabetes mellitus (DM). The levels of osteoporosis were determined by an estimation of Bone mineral density (BMD) using a DEXA scan examination. The data on BMD from diabetic subjects were compared with healthy nondiabetic controls. RESULTS Out of 327 enrolled subjects, 38 (11.6%) were found to be osteoporotic, whereas 138 (42.2%) had DM. The data showed that the number of patients with osteoporosis in the DM group was 14 (36.8%), significantly lower than in nondiabetic patients, 21 (55.2%) (p=0.0015). Notably, the data showed no significant difference in the mean BMD of the femur in patients with DM (0.926 g/cm2) and non-diabetes (0.936 g/cm2) (p=0.280; T-score p=0.4746). The mean BMD levels in the spine of the DM study group (1.049 g/cm2) were significantly higher when compared with nondiabetic healthy controls (0.990 g/cm2) (p=0.0031). CONCLUSION Patients with diabetes had higher lumbar BMD than nondiabetics, although femoral BMD was similar. Patients with diabetes have a lower osteoporosis risk than nondiabetics.
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Affiliation(s)
- Ahmad AlShomar
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Waleed Al Abdulmonem
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Qazi Shoeb Ahmad
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Mariam S. Alharbi
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Resheed Alkhiari
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Essam M. Hamad
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
| | - Zafar Rasheed
- From the Department of Medicine (AlShomar, Alharbi, Alkhiari), College of Medicine; from the Department of Pathology (Al Abdulmonem, Rasheed), College of Medicine; from the Department of Statistics (Ahmad), Deanship of Educational Services; Department of Food Science and Human Nutrition (Hamad), College of Agriculture and Veterinary Medicine, Qassim University, Buraidah; and from Dr. Sulaiman Al Habib Medical Group (AlShomar, Alkhiari), Qassim, Kingdom of Saudi Arabia.
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