Health News Report

Wednesday, July 25, 2018

Intensive blood pressure control reduces risk of mild cognitive impairment

Significant reductions in the risk of mild cognitive impairment (MCI)*, and the combination of MCI and dementia**, have been shown for the first time through aggressive lowering of systolic blood pressure in new research results from the federally-funded SPRINT MIND Study reported at the Alzheimer's Association International Conference (AAIC) 2018 in Chicago.

"This is the first randomized clinical trial to demonstrate a reduction in new cases of MCI alone and the combined risk of MCI plus all-cause dementia," said Jeff D. Williamson, MD, MHS, Professor of Internal Medicine and Epidemiology and Chief, Section on Gerontology and Geriatric Medicine at Wake Forest School of Medicine. Williamson reported these results at AAIC 2018.

The results of this large-scale, long-term clinical trial provide the strongest evidence to date about reducing risk of MCI and dementia through the treatment of high blood pressure, which is one of the leading causes of cardiovascular disease worldwide.

"This study shows more conclusively than ever before that there are things you can do -- especially regarding cardiovascular disease risk factors -- to reduce your risk of MCI and dementia," said Maria C. Carrillo, PhD, Alzheimer's Association Chief Science Officer. "To reduce new cases of MCI and dementia globally we must do everything we can -- as professionals and individuals -- to reduce blood pressure to the levels indicated in this study, which we know is beneficial to cardiovascular risk."

Carrillo pointed out that these results fit well with recent population data showing reductions in new cases of dementia in developed Western cultures. These lower rates of dementia may be occurring as these societies have begun to improve control of cardiovascular disease risk factors through medication management, reducing smoking, and greater awareness of healthy lifestyle.
"The future of reducing MCI and dementia could be in treating the whole person with a combination of drugs and modifiable risk factor interventions -- as we do now in heart disease," Carrillo suggested. "These new blood pressure findings raise our level of anticipation for the U.S. POINTER Study, which includes managing cardiovascular disease risk factors as part of the multi-component lifestyle intervention."
The Alzheimer's Association U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER) is a two-year clinical trial funded by the Alzheimer's Association to evaluate whether lifestyle interventions can protect cognitive function in older adults at increased risk for cognitive decline. The interventions include physical exercise, nutritional counseling and modification, cognitive and social stimulation, and improved self-management of health status.
Intensive Blood Pressure Control Significantly Reduces New Cases of MCI, and Combined Risk of MCI and Dementia: SPRINT MIND Study
At AAIC 2018, Williamson and colleagues reported preliminary results related to risk of dementia and cognitive decline from the Systolic Blood Pressure Intervention Trial (SPRINT). SPRINT is a randomized clinical trial that compared two strategies for managing high blood pressure (hypertension) in older adults: an intensive strategy with a systolic blood pressure goal of less than 120 mm Hg versus a standard care strategy targeting a systolic blood pressure goal of less than 140 mm Hg. Previously, SPRINT demonstrated that more intensive blood pressure control reduced the risk for cardiovascular morbidity and mortality (NEJM, 11-26-15). SPRINT helped inform the 2017 American Heart Association and American College of Cardiology high blood pressure clinical guidelines.
SPRINT Memory and Cognition IN Decreased Hypertension (SPRINT MIND) examined whether treating to the lower blood pressure target reduces the risk of developing dementia and/or MCI, and reduces the total volume of white matter lesions in the brain as shown by magnetic resonance imaging (MRI).
Study participants were 9,361 hypertensive older adults with increased cardiovascular risk (based on the Framingham risk score) but without diagnosed diabetes, dementia or prior stroke. Participant mean age was 67.9 years (35.6% women) and 8,626 (92.1%) completed at least one follow-up cognitive assessment. In SPRINT MIND, the primary outcome was incident probable dementia. Secondary outcomes included MCI and a composite outcome of MCI and/or probable dementia. Each outcome was adjudicated by an expert panel blinded to who was in each treatment group.
Recruitment for SPRINT began in October 2010. At one year, mean systolic blood pressure was 121.4 mmHg in the intensive-treatment group and 136.2 mmHg in the standard treatment group. Treatment was stopped in August 2015 due to cardiovascular disease (CVD) benefit after a median follow up of 3.26 years, but cognitive assessment continued until June 2018.
Intervention -- According to NEJM, 11-26-15, "All major classes of antihypertensive agents were included in the formulary and were provided at no cost to the participants. SPRINT investigators could also prescribe other antihypertensive medications (not provided by the study). The protocol encouraged, but did not mandate, the use of drug classes with the strongest evidence for reduction in cardiovascular outcomes, including thiazide-type diuretics (encouraged as the first-line agent), loop diuretics (for participants with advanced chronic kidney disease), and beta-adrenergic blockers (for those with coronary artery disease)."
"Participants were seen monthly for the first 3 months and every 3 months thereafter. Medications for participants in the intensive-treatment group were adjusted on a monthly basis to target a systolic blood pressure of less than 120 mm Hg. For participants in the standard-treatment group, medications were adjusted to target a systolic blood pressure of 135 to 139 mm Hg, and the dose was reduced if systolic blood pressure was less than 130 mm Hg on a single visit or less than 135 mm Hg on two consecutive visits. ... Lifestyle modification was encouraged as part of the management strategy."
In SPRINT MIND, the researchers found a statistically significant 19 percent lower rate of new cases of MCI (p=0.01) in the intensive blood pressure treatment group. The combined outcome of MCI plus probable all-cause dementia was 15 percent lower (p=0.02) in the intensive versus standard treatment group. There was a non-significant reduction in probable dementia alone (HR=0.83, p=0.10). Adverse events -- According to NEJM, 11-26-15, "Serious adverse events occurred in 1793 participants in the intensive-treatment group (38.3%) and in 1736 participants in the standard-treatment group (37.1%) (hazard ratio with intensive treatment, 1.04; P=0.25). Serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or acute renal failure, but not injurious falls or bradycardia, occurred more frequently in the intensive-treatment group than in the standard-treatment group. Orthostatic hypotension as assessed during a clinic visit was significantly less common in the intensive-treatment group. A total of 220 participants in the intensive-treatment group (4.7%) and 118 participants in the standard-treatment group (2.5%) had serious adverse events that were classified as possibly or definitely related to the intervention (hazard ratio, 1.88; P<0 .001="" 75="" according="" adverse="" age="" among="" and="" assignment="" but="" by="" cohort.="" did="" differ="" differences="" events="" group="" in="" magnitude="" not="" number="" of="" older="" or="" overall="" p="" participants="" pattern="" saes="" similar="" the="" those="" to="" treatment="" were="" years=""> "These results support the need to maintain well-controlled blood pressure, especially for persons over the age of 50," said Williamson. "A particular strength of SPRINT-MIND is that 30 percent of the participants were African American and 10 percent were Hispanic."
"This is something doctors and the majority of their community-dwelling patients with elevated blood pressure should be doing now to keep their hearts -- and brains -- healthier. These new results for maintaining cognitive health provide another strong rationale for starting and maintaining healthy lifestyle changes in mid-life," Williamson added.
SPRINT MIND MRI Results
In a related abstract reported at AAIC 2018, Ilya Nasrallah, MD, PhD, of the University of Pennsylvania, Philadelphia, reported preliminary results from 673 participants in SPRINT MIND who were recruited for brain magnetic resonance imaging (MRI). Primary outcomes included change in total white matter lesion (WML) volume and total brain volume (TBV). Follow-up MRIs were obtained for 454 (67.4%) participants at a median of 3.98 years post-randomization.
In this sub-study, WML volume increased in both treatment groups, however the increase was significantly less in the intensive treatment group. There was no significant difference in total brain volume change.
In the intensive treatment group, WML volume increased by 0.28 cm3 compared to 0.92 cm3 in the standard treatment group (mean difference=0.64 cm3, p=0.004).
TBV decreased by 27.3 cm3 in the intensive treatment group versus 24.8 cm3 in the standard treatment group (mean difference=2.54 cm3, p=0.16).
White matter lesions are frequently indicative of small vessel disease and linked to higher risk of stroke, dementia and higher mortality. While white matter lesions are thought to increase the risk of vascular dementia, they also may be a risk factor for Alzheimer's disease. People living with dementia may have Alzheimer's disease and white matter lesions at the same time. Research has demonstrated that when people have more than one type of disease-related brain changes, the cognitive consequences are greater.
Genomic Analysis of Phase 2a Alzheimer's Study with ANAVEX®2-73 May Enable a Precision Medicine Approach "Precision medicine involves giving the right therapy to the right patient at the right time, customized to his or her specific biological makeup," says Professor Harald Hampel, MD, PhD, MA, MSc, AXA Research Fund & Sorbonne University Excellence Chair, Department of Neurology, Sorbonne University, Paris.
Precision medicine emphasizes the customization and individualization of healthcare, with treatments and practices tailored to the specific patient's situation and needs, often taking into account genes, environment, and lifestyle. Sometimes called personalized medicine, it is a common approach in cancer and respiratory diseases.
At AAIC 2018, Hampel and colleagues reported results of an innovative attempt to move a step closer to precision medicine in Alzheimer's therapy trials. Anavex Life Sciences (AVXL) conducted a 57-week Phase 2a study with ANAVEX®2-73, a selective sigma-1 receptor agonist, in 32 people with mild to moderate Alzheimer's disease and analyzed the entire genome DNA and RNA of all study participants, resulting in the analysis of 33,311 genes and 860 pathways.
The company identified several genetic variants that impacted response to the drug, including SIGMAR1, which is ANAVEX®2-73's target, and COMT, a gene involved in memory function. They found further that excluding people with these variants (~20% of the study group) -- leaving about 80% of the population -- resulted in improved scores on gold standard tests of cognition (MMSE) and activities of daily living (ADCS-ADL) (p<0 .05="" p=""> Including participants with milder disease (baseline MMSE?20) and excluding those with a SIGMAR1 variant resulted in improvement of 1.7 MMSE and 3.9 ADCS-ADL at week 57. The additional exclusion of the COMT variant resulted in a score improvement of 2.0 MMSE and 4.9 ADCS-ADL at week 57.
"This study represents an exciting step forward, away from the 'magic bullet, one-size-fits-all' drug development in Alzheimer's, following the targeted therapy successes in the field of oncology," Hampel said. "Our vision is that a precision medicine approach will allow us to more precisely treat and prevent key features of the cause and progression of Alzheimer's. We are intrigued that several studies with this novel approach are now planned or underway."
According to the company, these patient selection markers will be implemented in an upcoming Phase 2b/3 study of ANAVEX®2-73.

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The Alzheimer's Association International Conference® (AAIC®)
The Alzheimer's Association International Conference (AAIC) is the world's largest gathering of researchers from around the world focused on Alzheimer's and other dementias. As a part of the Alzheimer's Association's research program, AAIC serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community.
AAIC 2018 home page: alz.org/aaic
AAIC 2018 newsroom: alz.org/aaic/press
About the Alzheimer's Association®
The Alzheimer's Association is the leading voluntary health organization in Alzheimer's care, support and research. Our mission is to eliminate Alzheimer's disease through the advancement of research, to provide and enhance care and support for all affected, and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer's. Visit alz.org or call 800.272.3900.

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

Mediterranean diet associated with lower risk of, severity of psoriasis

In a new study in JAMA Dermatology 35,735 respondents who are part of an ongoing, observational web-based questionnaire study launched in 2009, of whom 3,557 reported they had psoriasis; the condition was severe in 878 cases and 299 news cases were recorded as those arising more than two years after inclusion in the study group.

Patients with severe psoriasis adhered less strongly to the Mediterranean diet, an eating plan filled with fruits and vegetables, legumes, cereals, bread, fish, fruit, nuts and extra-virgin olive oil.

Cognitive and motor training combined may slow dow progress of dementia or even reverse it

'Researchers at York University's Faculty of Health found that just 30 minutes of visually-guided movements per week can slow and even reverse the progress of dementia. Those in the early stages of dementia who were exposed to 30 minutes a week to a game which used rules to make visually-guided movements, were able to slow down the progress of dementia and for some, even reverse their cognitive function to healthy status.

Previous approaches have used cognitive training alone or aerobic exercise training alone. This study published in Dementia and Geriatric Disorders, is the first to investigate the impact of combining both types of approaches on cognitive function in elderly people with various degrees of cognitive defects.

"We found cognitive-motor integration training slows down the progress of dementia, and for those just showing symptoms of dementia, this training can actually revert them back to healthy status, stabilizing them functionally," says lead researcher, Lauren Sergio, professor in the School of Kinesiology and Health Science and Centre for Vision Research at York University.

In the intervention study, a total of 37 elderly people located at senior centres, were divided into four groups based on their level of cognition. They completed a 16-week cognitive-motor training program that consisted of training sessions involving playing a videogame that required goal-directed hand movements on a computer tablet for 30 minutes a week. Before and after the training program, all participants completed a series of tests to establish their level of cognition and visuomotor skills. Sergio's team performed tests to evaluate cognitive function 14 days prior to and after the intervention period, respectively. Her team observed an overall change in all groups and, specifically, a significant improvement in measures of overall cognition in the sub average cognition group and the mild-to-moderate cognitive deficits group. "These results suggest that even in the earliest stages of neurodegeneration, the aging brain has enough neuroplasticity left that if you can train it on this kind of thinking and moving task, it will improve their cognitive skills," says Sergio. "The brain still possesses the functional capacities to form sufficient new synaptic connections to induce relevant changes on a systems level."
Sergio adds the findings suggest that repetitive cognitive-motor integration training may in fact strengthen the involved neural networks and improve cognitive and functional abilities. Researchers believe the frontal lobe is 'talking' to the motor control areas and this is what is paving the way for success.
The study further found that those in the severe cognitive deficits group who did 30 minutes of this eye-hand task did not decline in their cognitive deficits as expected, but instead stayed the same.
"Generally, you expect someone with severe dementia to have their cognitive function decline over five months, but in our study, they all stabilized."
Sergio says the findings show promise for those who have early-stage dementia because the approach is easy to administer remotely and shows more promise than the basic cognitive training.
York University champions new ways of thinking that drive teaching and research excellence. Our students receive the education they need to create big ideas that make an impact on the world. Meaningful and sometimes unexpected careers result from cross-disciplinary programming, innovative course design and diverse experiential learning opportunities. York students and graduates push limits, achieve goals and find solutions to the world's most pressing social challenges, empowered by a strong community that opens minds. York U is an internationally recognized research university - our 11 faculties and 25 research centres have partnerships with 200+ leading universities worldwide. Located in Toronto, York is the third largest university in Canada, with a strong community of 53,000 students, 7,000 faculty and administrative staff, and more than 300,000 alumni.

Contact sports associated with Lewy body disease, Parkinson's disease symptoms, dementia

There is mounting evidence that repetitive head impacts from contact sports and other exposures are associated with the neurodegenerative disease chronic traumatic encephalopathy (CTE) and dementia. A new study suggests that contact sports athletes may also be at increased risk for Lewy Body Disease, which can cause Parkinson's disease, a brain disorder that leads to problems with movement and thinking.

Since CTE was first described in "punch drunk" boxers in the 1920s, scientists have hypothesized that the motor symptoms that appear in a minority of CTE cases, including tremors, slowness and difficulty walking, were caused by CTE pathology.

But the new study published today suggests that those motor symptoms are instead caused by a separate disease, now also linked to contact sports participation, called Lewy body disease (LBD). LBD, which can lead to Parkinson's disease and Lewy body dementia, is associated with problems with movement, cognition, depression, sleep, and visual hallucinations. This newfound relationship between contact sports and LBD appears to be independent of CTE pathology.

"We found the number of years an individual was exposed to contact sports, including football, ice hockey, and boxing, was associated with the development of neocortical LBD, and LBD, in turn, was associated with parkinsonism and dementia," explained corresponding author Thor Stein, MD, PhD, neuropathologist at VA Boston Healthcare System and assistant professor of pathology and laboratory medicine at Boston University School of Medicine (BUSM).

The research team, from BUSM and the VA Boston Healthcare System, examined 694 brains from three repositories, including the Veteran's Affairs-Boston University-Concussion Legacy Foundation (VA-BU-CLF) Brain Bank, BU Alzheimer's Disease Center, and the Framingham Heart Study.
The total years of contact sports play was linked to an increased risk of having LBD in the cortex of the brain. Those who played more than eight years of contact sports had the greatest risk of LBD, which was six times higher than those who played eight years or less. Clinically, athletes with both CTE and LBD were significantly more likely to have dementia and the symptoms of Parkinson's disease than those with CTE pathology alone.
The researchers have previously shown other brain changes are correlated with the total years of contact sports play. In prior studies, the number of years of tackle football participation was found to predict the severity of tau pathology in the dorsolateral frontal cortex and as well as CTE stage. Additionally, individuals with a history of repetitive head impacts and neuropathological diagnosis of CTE accumulate beta-amyloid (A?) at a younger age and at an accelerated rate compared to controls. The research builds upon previous research from other groups showing an association between concussion/traumatic brain injury and Parkinson's disease.
The new study advances our understanding of the consequences of repetitive head impacts in contact sports on the development of clinical symptoms and the pathology that underlies them. Further work is necessary to better define the risks associated with repetitive head impacts and neurodegeneration. The researchers would like to thank all the families who donated the brain of a loved one to make this study possible.

Sunscreen users receive less than half the sun protection they think

Researchers from King's College London have assessed just how much sun protection people actually receive, based on typical use. It is well known that people don't receive the full ultraviolet radiation blocking benefit of sunscreen, because they are applying it more thinly than manufacturers recommend. The findings are published in journal Acta Dermato-Venereology.

In the first experiment of its kind, the King's team assessed the DNA damage in the skin after lowering sunscreen application thickness below 2mg/cm2 -- the amount manufacturers use to achieve their SPF rating.
Results showed that sunscreen with a sun protection factor (SPF) of 50, applied in a typical way, would at best provide 40% of the expected protection. The findings have prompted the King's team to suggest that consumers use a much higher SPF sunscreen than they think necessary, to ensure they're protected from sun damage.
As part of the research scientists divided a cohort of 16 fair-skinned volunteers into two groups of eight -- (three women and five men in each). One group received a single UVR exposure, to simulate sunlight, to areas treated with high SPF sunscreen of varying thickness, ranging from 0.75mg, through 1.3mg up to 2mg/cm2.
The other group received exposures on five consecutive days -- to mimic continuous holiday exposure. The amount of UVR exposure was varied during the course of the experiment, in order to replicate the conditions in holiday destinations, such as Tenerife, Florida and Brazil.
Biopsies of the UVR exposed areas of skin showed that, for the group that were repeatedly exposed to UVR, considerable DNA damage was found on the areas that received no sun protection, even though the UVR dose was very low.
Damage was reduced when sunscreen was applied at a thickness of 0.75mg/cm2 and considerably reduced when 2mg/cm2 of sunscreen was applied, even with much higher UVR doses.
Five days of exposure to high dose UVR with the sunscreen at 2mg/cm2 showed significantly less damage than just one day's low UVR dose exposure without sunscreen across all samples.
Report author, Professor Antony Young from King's College London said: 'There is no dispute that sunscreen provides important protection against the cancer causing impact of the sun's ultra violet rays. However, what this research shows is that the way sunscreen is applied plays an important role in determining how effective it is.
'Given that most people don't use sunscreens as tested as tested by manufacturers, it's better for people to use a much higher SPF than they think is necessary.
Nina Goad of the British Association of Dermatologists said: 'This research demonstrates why it's so important to choose an SPF of 30 or more. In theory, an SPF of 15 should be sufficient, but we know that in real-world situations, we need the additional protection offered by a higher SPF.
'It also shows why we shouldn't rely on sunscreen alone for sun protection, but we should also use clothing and shade. An extra consideration is that when we apply sunscreen, we are prone to missing patches of skin, as well as applying it too thinly.'

Tuesday, July 24, 2018

Omega-3s help keep kids out of trouble

Something as simple as a dietary supplement could reduce disruptive, even abusive behavior, according to newly released research by a team led by a UMass Lowell criminal justice professor.
Giving children omega-3 fatty acid supplements reduces disruptive behavior, which in turn had a positive effect on their parents, making them less likely to argue with each other and engage in other verbal abuse, according to Jill Portnoy, an assistant professor in UMass Lowell's School of Criminology and Justice Studies.

"This is a promising line of research because omega-3 fatty acids are thought to improve brain health in children and adults. There is more to be learned about the benefits, but if we can improve people's brain health and behavior in the process, that's a really big plus," said Portnoy, noting that a recent research review found that omega-3 supplements do not affect cardiovascular health.

The new research, published in the scholarly journal Aggressive Behavior, is just one example of how Portnoy is studying biological and social factors that can help explain and predict impulsive and risky behavior. The goal is to help determine effective ways to intervene before anti-social behavior escalates into crime.

That work takes Portnoy into the heart of the "nature versus nurture" debate - whether people who commit crimes have something in their physiological makeup that predisposes them to doing so or if social factors like abusive family situations lead them to it.
"Of course, it's both," she said, but exactly how is still to be determined. "Biology and social environment interact in complex ways that we're just beginning to figure out. Before we can design effective interventions, we need to do research to understand what's happening."
Portnoy is exploring such a connection through another research project that is looking at how a low resting heart rate may lead to anti-social behavior.
"My theory is that a low resting heart rate might be an acquired, adaptive trait: If you are subjected to chronic or frequent stress as a child, you adapt by lowering your heart rate. The lower heart rate protects you by blunting your reaction to stressful events, but it can also lead to stimulation-seeking behavior. In other words, a stressful environment may cause physiological changes that lead to an increase in aggressive and impulsive behavior, in addition to causing the behavior directly," she said.
Working with a counterpart at the University of Pennsylvania, where she earned her Ph.D. and taught before coming to UMass Lowell, Portnoy studied hundreds of youths in Pittsburgh, where she grew up. The researchers found that the youths with lower resting heart rates were more likely to act out as a form of sensation-seeking, including anti-social behavior, which can be especially problematic for individuals living where there are few options for positive forms of stimulation.
Portnoy, who now lives in Portsmouth, N.H., will continue her research on this topic this fall with the help of a dozen UMass Lowell undergrads who will intern with her on the Health, Stress and Behavior Study, researching the connection between stress, heart rate and behavior.
Through this study, Portnoy and her team will examine what she describes as a continuum of criminal behavior with the goal of finding new ways to prevent it.
"Many people break the law in small ways; for example, by driving a few miles over the speed limit. I'm interested in people who are behaving aggressively but not yet reaching the level of criminal behavior or maybe they're committing more serious crimes like theft or assault, but haven't been caught. They're still exacting a toll on society. And if we want to design more general social interventions, like teaching people healthier ways to adapt to stress, then we shouldn't just study those who get caught," said Portnoy.

Monday, July 23, 2018

Exercise cuts risk of chronic disease in older adults

New research has shown that older adults who exercise above current recommended levels have a reduced risk of developing chronic disease compared with those who do not exercise.
Researchers at the Westmead Institute for Medical Research interviewed more than 1,500 Australian adults aged over 50 and followed them over a 10-year period.

People who engaged in the highest levels of total physical activity were twice as lively to avoid stroke, heart disease, angina, cancer and diabetes, and be in optimal physical and mental shape 10 years later, experts found.

Lead Researcher Associate Professor Bamini Gopinath from the University of Sydney said the data showed that adults who did more than 5000 metabolic equivalent minutes (MET minutes) each week saw the greatest reduction in the risk of chronic disease.

"Essentially we found that older adults who did the most exercise were twice as likely to be disease-free and fully functional," she said.

"Our study showed that high levels of physical activity increase the likelihood of surviving an extra 10 years free from chronic diseases, mental impairment and disability."

Currently, the World Health Organization recommends at least 600 MET minutes of physical activity each week. That is equivalent to 150 minutes of brisk walking or 75 minutes of running.

"With aging demographics in most countries, a major challenge is how to increase the quality and years of healthy life," Associate Professor Gopinath said.

"Our findings suggest that physical activity levels need to be several times higher than what the World Health Organization currently recommends to significantly reduce the risk of chronic disease.
"Some older adults may not be able to engage in vigorous activity or high levels of physical activity.
"But we encourage older adults who are inactive to do some physical activity, and those who currently only engage in moderate exercise to incorporate more vigorous activity where possible," she concluded.

The research compiled data from the Blue Mountains Eye Study, a benchmark population-based study that started in 1992.

It is one of the world's largest epidemiology studies, measuring diet and lifestyle factors against health outcomes and a range of chronic diseases.

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The full paper is available online at Nature Scientific Reports: https://www.nature.com/articles/s41598-018-28526-3