Cerebral Small Vessel Disease
Cerebral small vessel disease (CSVD) is a common and progressive neurological condition characterized by damage to the small blood vessels deep within the brain. It is a major contributor to cognitive decline, stroke, and other neurological impairments, particularly affecting older adults. Understanding CSVD is crucial for public health due to its widespread impact and the challenges it poses for diagnosis and treatment.
Background and Biological Basis
Section titled “Background and Biological Basis”CSVD encompasses a range of pathological changes to the brain’s small arteries, arterioles, capillaries, and venules. These changes can lead to various observable lesions on brain imaging, including white matter hyperintensities, lacunar infarcts (small deep brain infarcts), cerebral microbleeds, and enlarged perivascular spaces. These lesions disrupt brain function by impairing blood flow, damaging neural tissue, and disconnecting brain regions. Genetic factors are understood to contribute to an individual’s susceptibility to CSVD, with research indicating that “Brain small vessel disease” has an estimated heritability .
A significant constraint was the absence of an independent Korean replication cohort with similarly deep phenotypic data, making it challenging to externally validate the identified genetic associations and phenotype-phenotype networks. While trans-ethnic comparisons with European (UK Biobank) and Japanese (Biobank Japan) populations were performed, these do not fully substitute for replication within the primary ethnic group. The construction of phenotype-phenotype networks from a single sample, without an external validation set, also carries the risk of identifying spurious correlations unrelated to underlying genetic causality. Moreover, Mendelian randomization analyses, intended to infer causal relationships, faced a high dimensionality of significant association pairs and produced some findings that currently lack clear biological rationale, underscoring the need for further experimental and clinical validation.[1]
Population Specificity and Phenotypic Characterization
Section titled “Population Specificity and Phenotypic Characterization”The study’s focus on a homogeneous Korean population, while providing valuable insights into this specific ethnic group, inherently limits the direct generalizability of its findings to other diverse populations. Although trans-national comparisons were conducted, genetic architectures and environmental exposures can vary significantly across ethnicities, meaning that associations identified in this cohort may not be universally reproducible. The recruitment strategy, drawing from individuals attending health check-ups, tends to select for a healthier population profile, which might underrepresent the full spectrum of disease severity and genetic influences on conditions like brain small vessel disease, thereby affecting the observed effect sizes and prevalence of genetic variants.[1]Despite the advantage of leveraging deep phenotyping from health check-up data, which offers greater resolution and reliability than ICD-code based approaches, the unique nature of these phenotypes posed challenges for external validation. The difficulty in finding comparable external cohorts with summary statistics for the wide variety of deep phenotypes, such as specific skeletal muscle mass or detailed pulmonary function measures, means that some of the intricate phenotype-phenotype relationships identified in this study remain unverified. This single-cohort reliance for network construction, even with precisely defined phenotypes, could yield correlations specific to the study population that require further confirmation to establish their broader clinical and biological relevance.[1]
Unaccounted Environmental Factors and Biological Interpretation
Section titled “Unaccounted Environmental Factors and Biological Interpretation”A notable limitation concerns the absence of analyses specifically investigating gene-environment interactions. Complex traits and diseases, including brain small vessel disease, are known to be influenced by a dynamic interplay between genetic predispositions and environmental, lifestyle, and behavioral factors. Without explicitly modeling these interactions, the full genetic and environmental contributions to the observed phenotypes, and the mechanisms underlying susceptibility or resilience, remain partially obscured. Future research incorporating such analyses is crucial for a more complete understanding of disease etiology and for advancing precision medicine.[1] Furthermore, while the study aimed to derive biological meaning from its extensive PheWAS results, certain significant associations identified, particularly within the Mendelian randomization framework, were difficult to explain based on existing epidemiological knowledge. These biologically ambiguous findings highlight remaining knowledge gaps regarding the precise causal pathways and pleiotropic effects of genetic variants. Continued research is necessary to validate these novel associations, elucidate their underlying biological mechanisms, and integrate them into a coherent understanding of complex trait biology. This step is critical to ensure that the detected genetic connections reflect true biological processes rather than spurious correlations.[1]
Variants
Section titled “Variants”The genetic landscape of cerebral small vessel disease (CSVD) involves a complex interplay of various genes and their regulatory elements, with single nucleotide polymorphisms (SNPs) likers117338591 and rs77691192 potentially influencing individual susceptibility. These variants are situated within or near genes such as TMEM178A, CAAP1, and the long intergenic non-coding RNA LINC03106, each contributing to cellular processes that are critical for maintaining vascular health. A large-scale phenome-wide association study (PheWAS) involving a Korean cohort of 10,000 individuals systematically investigated genetic variants across 136 phenotypes, including brain small vessel disease, to identify such associations.[1] This research highlights the broad scope of genetic investigations aimed at understanding the heritable components of various health conditions.[1] The variant rs117338591 is associated with the TMEM178A gene, which encodes a transmembrane protein involved in cellular processes, including immune responses and inflammation. TMEM178A has been implicated in regulating autophagy, a fundamental cellular recycling process crucial for maintaining cell homeostasis and clearing damaged components, including those in endothelial cells lining blood vessels. Disruptions in autophagy pathways can contribute to endothelial dysfunction, a key factor in the development and progression of CSVD.[1] Therefore, variations like rs117338591 that might alter TMEM178Afunction could potentially influence the integrity and health of small cerebral blood vessels, impacting their susceptibility to damage and disease.[1] Another significant variant, rs77691192 , is linked to the CAAP1 gene, or CYP2C9 Associated Apoptosis Promoting 1. While its name suggests an association with cytochrome P450 enzymes and apoptosis, CAAP1 is broadly involved in cellular signaling and potentially in regulating cell adhesion and cytoskeletal organization. Proper cell adhesion and a well-maintained cytoskeleton are vital for the structural integrity and function of vascular endothelial cells, which form the inner lining of blood vessels.[1] Alterations in CAAP1 function due to variants like rs77691192 could compromise these cellular processes, leading to increased vascular fragility, impaired endothelial barrier function, or altered vascular remodeling, all of which are relevant to the pathology of cerebral small vessel disease.[1] Additionally, the long intergenic non-coding RNA LINC03106represents another class of genetic elements that can influence disease risk. LncRNAs likeLINC03106 do not code for proteins but play crucial roles in regulating gene expression, affecting processes such as cell proliferation, differentiation, and apoptosis. Variations within LINC03106 could alter its regulatory capacity, indirectly affecting the expression of genes involved in vascular development, repair, or inflammatory responses, thereby contributing to the complex etiology of CSVD.[1]
Key Variants
Section titled “Key Variants”| RS ID | Gene | Related Traits |
|---|---|---|
| rs117338591 | TMEM178A | cerebral small vessel disease |
| rs77691192 | LINC03106 - CAAP1 | cerebral small vessel disease |
Definition and Measurement Approaches
Section titled “Definition and Measurement Approaches”Cerebral small vessel disease, referred to as “Brain small vessel disease” within this research, is defined as a specific phenotype categorized under the cerebro-cardio-vascular system.[1] This trait was systematically identified and analyzed among a comprehensive set of 136 diverse phenotypes in a phenome-wide association study.[1]The operational definition of cerebral small vessel disease in this context relied on diagnostic imaging modalities. Specifically, its presence was determined through the use of brain Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) as key measurement approaches.[1]
Classification and Categorical Placement
Section titled “Classification and Categorical Placement”Within the study’s structured framework for categorizing health traits, cerebral small vessel disease is classified under the broad “Cerebro-cardio-vascular” biological system.[1]This classification system groups various conditions impacting the brain, heart, and blood vessels, facilitating a systematic analysis of shared genetic underpinnings. The disease is treated as a distinct entity alongside other cerebro-cardio-vascular phenotypes, including heart rate, electrocardiogram (EKG) findings, coronary CT measures, and other specific brain vascular conditions.[1] This categorical approach allows for its comparative analysis with related but separate vascular pathologies within the cohort.[1]
Terminology and Related Concepts
Section titled “Terminology and Related Concepts”The consistent nomenclature utilized throughout this research for the condition is “Brain small vessel disease”.[1] This key term serves as the standardized identifier for analyzing its genetic associations and heritability within the study’s extensive dataset.[1]While distinctly named, the study also investigated other cerebrovascular phenotypes such as “Brain vascular atherosclerosis” and “Brain vascular stenosis” as separate entries.[1] The presence of these discrete terms suggests a deliberate differentiation in the conceptual or diagnostic criteria applied to various forms of brain vascular pathology during the phenotyping process.[1]
Imaging-Based Identification and Characterization
Section titled “Imaging-Based Identification and Characterization”Cerebral small vessel disease (CSVD), referred to as “Brain small vessel disease” in deep phenotyping studies, is primarily identified and characterized through advanced neuroimaging techniques.[1] Specifically, brain MRI/MRA serves as a crucial diagnostic tool, offering objective measures to detect characteristic structural changes within the brain’s small vessels.[1] These imaging findings may include white matter hyperintensities, lacunes, microbleeds, and enlarged perivascular spaces, which represent the pathological hallmarks of the condition. The systematic application of such methods in comprehensive health check-up cohorts ensures high data quality and consistency, providing a robust basis for assessing the prevalence and morphological spectrum of CSVD.[1]
Genetic Contributions and Phenotypic Interconnections
Section titled “Genetic Contributions and Phenotypic Interconnections”The understanding of cerebral small vessel disease is further enhanced by exploring its genetic contributions and interconnections with other health phenotypes.[1]Heritability analysis quantifies the proportion of phenotypic variation in “Brain small vessel disease” attributable to genetic factors, shedding light on its underlying genetic architecture.[1] Phenome-wide association studies (PheWAS) are instrumental in uncovering shared genetic associations and hidden patterns between CSVD and a wide array of other traits, including those from apparently unrelated body systems.[1]This approach provides fundamental information for mapping the detailed landscape of disease underpinnings and is crucial for developing precision medicine strategies that consider individual variability in genes, environment, and lifestyle.[1]
Heterogeneity and Clinical Implications
Section titled “Heterogeneity and Clinical Implications”Cerebral small vessel disease manifests with considerable heterogeneity, influenced by a complex interplay of genetic predispositions, environmental exposures, and individual lifestyle factors.[1]While specific clinical symptoms such as cognitive impairment or motor deficits are not detailed in this context, the objective identification of “Brain small vessel disease” via brain MRI/MRA in health check-up settings holds significant diagnostic value.[1] This systematic detection allows for early identification and risk stratification, potentially serving as a “red flag” for broader cerebrovascular health concerns. The comprehensive phenotyping facilitates the exploration of its clinical correlations and phenotypic diversity across different populations, contributing to a more complete understanding of its varied presentations.[1]
Genetic Predisposition and Polygenicity
Section titled “Genetic Predisposition and Polygenicity”Genetic factors play a significant role in the etiology of cerebral small vessel disease (CSVD). Heritability analysis has estimated the genetic contribution to various phenotypes, including brain small vessel disease, demonstrating that inherited variants influence an individual’s susceptibility. The observed correlation between the impact of genetic loci and heritability further underscores the importance of genetic architecture. This includes polygenic inheritance, where multiple genes, each contributing a small effect, cumulatively influence the development of the trait.[1] Beyond single gene effects, complex genetic mechanisms such as pleiotropy, where a single genetic locus or gene affects multiple distinct phenotypes, contribute to the intricate landscape of CSVD. For instance, genes like CUB and Sushi Multiple Domains 1 Protein (CSMD1), RNA-binding Fox-1 Homolog 1 (RBFOX1), and Protein Tyrosine Phosphatase Receptor Type D (PTPRD) have been identified with high phenotype degrees within gene networks, suggesting broad influences across multiple traits, potentially including those related to vascular health. Such gene-gene interactions within these networks can modulate the overall genetic risk for CSVD.[1]
Lifestyle and Cardiometabolic Risk Factors
Section titled “Lifestyle and Cardiometabolic Risk Factors”Lifestyle choices and cardiometabolic comorbidities are major environmental contributors to cerebral small vessel disease. Mendelian randomization analyses have identified lifestyle factors such as smoking history, alcohol consumption, and exercise amount as causal exposures for various phenotypes, many of which are interconnected with vascular health. For example, alcohol consumption was found to be a significant causal exposure for numerous phenotypes, highlighting its broad impact.[1]Furthermore, prevalent comorbidities like diagnosed hypertension, diabetes, and dyslipidemia are critical contributing factors. Metabolic syndrome, a cluster of metabolic abnormalities including visceral adipose obesity, is strongly associated with an increased risk of cardiovascular disease, which encompasses pathologies affecting cerebral small vessels. These conditions promote systemic inflammation, endothelial dysfunction, and arterial stiffening, thereby accelerating the damage to the brain’s microvasculature.[1]
Systemic Connections and Gene-Environment Dynamics
Section titled “Systemic Connections and Gene-Environment Dynamics”The development of cerebral small vessel disease is also influenced by complex systemic interactions and the dynamic interplay between genes and the environment. Cross-phenotype association studies have revealed significant connections between seemingly disparate physiological systems; for example, red blood cell count has been observed in replicated phenotype-phenotype pairs with brain vascular atherosclerosis across diverse populations. These systemic connections suggest that overall bodily health and specific hematologic parameters can significantly impact cerebral vascular integrity.[1]The concept of gene-environment interactions is paramount in understanding CSVD, as genetic predispositions can modify an individual’s response to environmental triggers. While specific interactions causing CSVD require further detailed analysis, the framework of precision medicine emphasizes considering individual variability in genes, environment, and lifestyle to tailor prevention and treatment strategies. This holistic view acknowledges that genetic susceptibility combined with specific environmental exposures can lead to varying risks and manifestations of cerebral small vessel disease.[1]
Genetic Contributions and Regulatory Mechanisms
Section titled “Genetic Contributions and Regulatory Mechanisms”Cerebral small vessel disease (CSVD), identified as “Brain small vessel disease” in population studies, is recognized to have a genetic component, with heritability estimated for this and numerous other phenotypes.[1]Research indicates that the impact of genetic variants on gene and protein sequences plays a role in disease susceptibility, with a significant correlation observed between the predicted impact of genetic loci (categorized as “modifier low” versus “moderate, high”) and the heritability of traits.[1] This suggests that variations in genes and their regulatory elements can influence an individual’s predisposition to CSVD by altering fundamental cellular functions and biological pathways. While specific genes directly linked to CSVD were not detailed, studies leveraging phenotype-genotype networks highlight the broader genetic landscape, including genes exhibiting pleiotropy, such as CSMD1, RBFOX1, and PTPRD, which are associated with multiple phenotypes and could indirectly influence complex diseases like CSVD.[1]
Pathophysiology of Cerebral Vascular Damage
Section titled “Pathophysiology of Cerebral Vascular Damage”Cerebral small vessel disease involves a range of pathophysiological processes that disrupt the normal function and structure of the brain’s smallest blood vessels. These disruptions can manifest as “Brain unidentified bright object” on imaging, indicative of white matter changes, or more severe conditions like “Brain vascular atherosclerosis” and “Brain vascular stenosis”.[1] The integrity of these vessels is crucial for maintaining brain homeostasis, and their damage can lead to impaired blood flow, oxygen deprivation, and subsequent neurological dysfunction. Diagnostic tools such as brain MRI/MRA are essential for identifying these structural changes and understanding the progression of vascular damage within the brain tissue.[1] The interplay between these specific vascular pathologies contributes to the overall burden and clinical presentation of CSVD.
Systemic Metabolic and Cardiovascular Influences
Section titled “Systemic Metabolic and Cardiovascular Influences”The development and progression of cerebral small vessel disease are profoundly influenced by systemic conditions, particularly those affecting the cardiovascular and metabolic systems. Hypertension, a commonly diagnosed condition, is a critical risk factor that exerts chronic stress on the delicate cerebral vasculature, contributing to vessel damage.[1]Furthermore, metabolic syndrome, a cluster of abnormalities including elevated triglycerides, low HDL cholesterol, high blood glucose, and abdominal obesity, is strongly associated with cardiovascular diseases, including “coronary calcium,” “cardiac ischemia,” and importantly, “brain atherosclerosis”.[1]These metabolic disruptions, mediated by various biomolecules and signaling pathways, create an environment conducive to inflammation, endothelial dysfunction, and vascular remodeling, thereby accelerating the pathology of CSVD. Lifestyle factors such as alcohol consumption, smoking habits, and exercise levels also integrate into this complex network, influencing metabolic health and cardiovascular risk.[1]
Cellular and Molecular Interactions in Disease Progression
Section titled “Cellular and Molecular Interactions in Disease Progression”At a cellular and molecular level, the intricate balance of various biomolecules and cellular functions contributes to the pathogenesis of cerebral small vessel disease. For instance, red blood cell (RBC) count has been observed to have a notable association with “brain vascular atherosclerosis” across diverse populations, suggesting a potential role of hematological parameters in vascular health.[1]While the exact molecular mechanisms are complex, aberrant metabolic processes, such as dyslipidemia (imbalanced HDL and triglycerides) and glucose dysregulation (seen in diabetes), directly impact endothelial cells lining blood vessels.[1] These molecular disturbances can lead to impaired nitric oxide signaling, increased oxidative stress, and activation of inflammatory pathways, all of which compromise the structural integrity and functional capacity of cerebral small vessels. Understanding these cellular and molecular interactions is key to elucidating the underlying mechanisms of CSVD and identifying potential targets for therapeutic intervention.
Diagnostic Utility and Risk Stratification
Section titled “Diagnostic Utility and Risk Stratification”Cerebral small vessel disease (CSVD) is a significant cerebro-cardiovascular phenotype, routinely identified through advanced imaging techniques such as brain MRI/MRA during comprehensive health check-ups.[1] The systematic collection of such deep phenotypic data enhances the diagnostic utility of CSVD in clinical practice by facilitating a more thorough characterization of its presence and severity.[1] This detailed diagnostic approach is crucial for understanding the individual’s cerebrovascular health status.
Insights derived from phenome-wide association studies (PheWAS) and the subsequent construction of phenotype-phenotype networks are pivotal for risk stratification and the implementation of personalized medicine strategies.[1]These networks offer a detailed overview of the interconnections among various phenotypes, encompassing disease states, genetic predispositions, environmental influences, and lifestyle factors.[1] Such an integrated understanding allows clinicians to more effectively identify individuals at high risk for CSVD and related complications, enabling the development of tailored prevention strategies and individualized treatment plans.[1]
Associated Clinical Conditions and Systemic Interconnections
Section titled “Associated Clinical Conditions and Systemic Interconnections”Cerebral small vessel disease is positioned within a broader category of cerebro-cardiovascular phenotypes, which includes conditions like brain vascular atherosclerosis, brain vascular stenosis, brain aneurysm, and brain atrophy.[1] This categorization highlights CSVD’s role in a complex network of systemic vascular health, often alongside other indicators of vascular compromise such as coronary calcium identified via coronary CT.[1] The comprehensive phenotyping approach helps to reveal overlapping pathologies and multi-systemic involvement that contribute to or are associated with CSVD.
The development of phenotype-phenotype networks, based on extensive genetic and clinical data, provides a valuable tool for mapping associations between various conditions, thereby clarifying comorbidities and potential syndromic presentations.[1]For instance, studies have observed shared associations, such as the pairing of red blood cell count and brain vascular atherosclerosis, across diverse populations, illustrating how these networks can uncover systemic links relevant to cerebral vascular health.[1] While direct associations for CSVD with specific comorbidities require further validation, this methodology offers a robust framework for exploring its clinical associations and understanding its broader impact on patient health.[1]
Prognostic Implications and Precision Medicine
Section titled “Prognostic Implications and Precision Medicine”A comprehensive understanding of the genetic and phenotypic landscape surrounding cerebral small vessel disease carries significant prognostic value, aiding in the prediction of disease progression and long-term patient outcomes.[1] By integrating CSVD data into extensive phenotype-phenotype networks, clinicians and researchers can gain deeper insights into its natural history and identify potential biomarkers that might predict future complications or an individual’s response to therapeutic interventions.[1] This proactive approach is crucial for shifting healthcare towards predictive and preventive models rather than solely reactive treatments.
The overarching objective of utilizing deep phenotyping and network analyses for conditions such as CSVD is to advance precision medicine, facilitating the creation of prevention and treatment strategies customized to an individual’s unique genetic makeup, environmental exposures, and lifestyle.[1] Although some findings from large-scale studies necessitate external replication and validation in different cohorts to strengthen clinical confidence, this analytical framework provides a strong foundation for future research aimed at optimizing patient care.[1] The ability to explore intricate phenotype interconnections supports the selection of more targeted therapies and monitoring protocols, ultimately enhancing patient outcomes for CSVD and its related conditions.[1]
Frequently Asked Questions About Cerebral Small Vessel Disease
Section titled “Frequently Asked Questions About Cerebral Small Vessel Disease”These questions address the most important and specific aspects of cerebral small vessel disease based on current genetic research.
1. My parent had memory issues; will I get them too?
Section titled “1. My parent had memory issues; will I get them too?”While not guaranteed, your risk for conditions like cerebral small vessel disease (CSVD) can be influenced by your family history. Genetic factors are known to contribute to susceptibility, meaning inherited predispositions can affect your risk and how the disease progresses. However, many factors beyond genetics also play a role.
2. Is forgetting things just a normal part of getting older?
Section titled “2. Is forgetting things just a normal part of getting older?”While some cognitive changes can occur with age, significant memory problems or slowed thinking are not necessarily normal aging. They can be symptoms of conditions like cerebral small vessel disease, which commonly affects older adults. Genetic factors can make some individuals more susceptible to these age-related brain changes.
3. Why do some people get brain problems, but others don’t?
Section titled “3. Why do some people get brain problems, but others don’t?”There’s a significant genetic component to why some people develop conditions like cerebral small vessel disease and others don’t. Your inherited genes influence your susceptibility and how your brain’s small blood vessels might be affected. However, environmental and lifestyle factors also interact with these genetic predispositions.
4. Can I really prevent brain issues with a healthy lifestyle?
Section titled “4. Can I really prevent brain issues with a healthy lifestyle?”A healthy lifestyle is crucial, even with a genetic predisposition. While genetic factors contribute to your risk for conditions like cerebral small vessel disease, lifestyle and environmental factors also play a dynamic role. Managing general risk factors is key for mitigating the clinical impact and potentially influencing disease progression.
5. Does my ethnic background affect my brain health risk?
Section titled “5. Does my ethnic background affect my brain health risk?”Yes, your ethnic background can influence your risk profile. Genetic architectures and environmental exposures vary significantly across different ethnicities. Research on conditions like cerebral small vessel disease often focuses on specific populations, and findings may not be universally reproducible, highlighting the importance of diverse studies.
6. Will my kids inherit my risk for these brain issues?
Section titled “6. Will my kids inherit my risk for these brain issues?”There’s a possibility your children could inherit some susceptibility. Genetic factors contribute to an individual’s risk for cerebral small vessel disease, meaning inherited predispositions can be passed down. However, having a genetic risk doesn’t guarantee they will develop the condition, as many factors are involved.
7. Is there a way to know if I’m at risk for this disease?
Section titled “7. Is there a way to know if I’m at risk for this disease?”Currently, risk assessment often involves evaluating your clinical symptoms and general health factors. While genetic research is vital for understanding susceptibility to cerebral small vessel disease, its direct application for individual risk prediction is still evolving. Early identification and management of risk factors are key.
8. Why do some people’s brain problems seem to get worse faster?
Section titled “8. Why do some people’s brain problems seem to get worse faster?”The progression of conditions like cerebral small vessel disease can vary significantly between individuals. Genetic factors are understood to influence not only your susceptibility but also the rate at which the disease progresses. This means inherited predispositions can play a role in how quickly symptoms might worsen over time.
9. Does stress or poor sleep make my brain more vulnerable?
Section titled “9. Does stress or poor sleep make my brain more vulnerable?”Complex traits like cerebral small vessel disease are influenced by a dynamic interplay between genetic predispositions and environmental, lifestyle, and behavioral factors. While specific studies on stress or sleep weren’t detailed, these are generally considered important lifestyle factors that could interact with your genetic makeup to affect brain health.
10. Can I still get this even if my family is healthy?
Section titled “10. Can I still get this even if my family is healthy?”Yes, it’s possible. While genetic factors contribute to susceptibility, and family history is a risk indicator, you can still develop conditions like cerebral small vessel disease even without a strong family history. Many factors, including environmental exposures and other health conditions, influence your individual risk.
This FAQ was automatically generated based on current genetic research and may be updated as new information becomes available.
Disclaimer: This information is for educational purposes only and should not be used as a substitute for professional medical advice. Always consult with a healthcare provider for personalized medical guidance.
References
Section titled “References”[1] Choe, E. K. et al. “Leveraging deep phenotyping from health check-up cohort with 10,000 Korean individuals for phenome-wide association study of 136 traits.” Sci Rep, vol. 12, no. 1930, 2022. DOI: 10.1038/s41598-021-04580-2. PMID: 35121771.