Psychiatry Research. 16, I6 176 165 Elsevier

Neuroendocrine and Psychopathological Measures in Anorexia Nervosa: Resemblances to Primary Affective Disorders

Francesca Brambilla, Franc0 Cavagnini, Cecilia Invitti, Franc0 Poterzio, Mario Lampertico, Laura Sali, Maurizio Maggioni, Carlo Candolfi, Albert0 E. Panerai, and Eugenio E. Miiller

Abstract. Clinical and biochemical data suggest a link between anorexia nervosa (AN)andprimaryaffectivedisorders(PAD). In 14femalepatients,aged 15-40years, with 7-month to I l-year histories of AN, we studied circadian cortisol periodicity, response to the dexamethasone suppression test (DST), and plasma levels of /3-endorphin and /3-lipotropin before and after desimipramine therapy. Possible correlations were sought among neuroendocrine impairments, weight loss, and depressive symptomatology. Impaired circadian cortisol periodicity, blunted DST response, and increased P-endorphin plasma levels, observed in a subgroup of patients, could not be related to weight loss, either before oraftertherapy. Instead, a trend toward a relationship between neuroendocrine impairments and depressive symptoms was observed before and after treatment.

Key Words. Anorexia nervosa, primary affective disorders, cortisol secretion, /?-endorphin, /3-lipotropin, desimipramine.

Anorexia nervgsa is a mental disorder that is classified as adistinct nosologicalentity in DSM-III (American Psychiatric Association, 1980). However, depression frequently occurs in anorectic subjects, develops during the followup of some patients after recovery, or is present in their families (Cantwell et al., 1977; Halmi et al., 1979; Gwirtsman and Gerner, 198 1; Eckert et al., 1982). Some biochemical and psychological measures tend to cluster anorexia nervosa (AN) with primary affective disorders (PAD), at least for some subgroups of patients, with the association indicating poor prognosis (Eckert et al., 1982). A number of alterations of the hypothalamo-pituitary- adrenal (H PA) axis are present in both AN and PAD. Examples includeelevatations of plasma, cerebrospinal (CSF), and urinary free cortisol; 24-hour mean plasma cortisol secretion; and cortisol production rate, with blunted response to insulin stimulation (Landonet al., 1966; Carrollet al., 1976; Boyaretal., 1977; Walshetal., 1978;Ettigiand Brown, 1979; Doerr et al., 1981; Fichter et al., 1982; Rubinand Poland, 1982; Pirkeet al., 1982; Garfinkel, 1984). Cortisol circadian rhythms in AN have been reported to be normal (Casper et al., 1979), normal with an elevated set point (Boyar et al., 1977;

Francesca Brambilla, M.D.. is Head, Psychoendocrine Center, Ospedale Psichlatrico Plni. Via lppocrate 45,Milan. Italy. Franc0 Cavagnini, M.D., and Cecilia Invitti. M.D., are in Clinica Medica II, Universitk Milan, Franc0 Poterrio, M.D.. is in Clinica Psichiatrica. UniversitB. Milan. Mario L,ampcrtico, M.D.. is Head. and Laura Sali. M.D.. ia Resident, 2nd Medical Division. Ospedale Generale, Saronno. Mauririo Maggioni, M.D.. is at Villa Zucchi. Carate. Carlo Candolfi, M.D., ia at Centro Analisl, Mowa. Albert0 E. Panerai, M.D.. and Eugenio E. Miiller, M.D., are Professors, lstituto Farmacologia, llniversit& Milan. (Reprint requests to Dr. F. Brambilla.)

0165-1781 85 $03.30 ‘-F) 1085 Elsevier Science Publishers B.V

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Crispin et al., 198 I), or impaired with an increased number and duration of secretory episodes and increased secretion between 6 and 11 p.m., as in PAD (Vigersky, 1977; Doerr et al., 1981; Fichter et al., 1982; Rubin and Poland, 1982; Garfinkel, 1984). Response to the dexamethasone suppression test (DST) is blunted or shows an early escape in patients with AN or PAD (Walsh et al., 1978; Carroll et al., 1981; Doerretal., 1981; Gerner and Gwirtsman, 198 1; Fichter et al., 1982). The blunted DST seems to be correlated with low urinary levels of 3-methoxy-4-hydroxyphenylglycol (MHPG), the major metabolite of brain norepinephrine (NE) (Maas et al., 1968), in both AN and PAD (Cobbin et al., 198 1; Gwirtsman and Gerner, 198 I), although this finding has not always been confirmed (Gerner and Gwirtsman, 1981). In AN, all of these alterations seem to normalize with weight recovery, but occasionally persist in some patients

(Casper et al., 1979). The same impairments noted in AN can occur inuncomplicatedstarvation(Walshet

al., 1978; Fichter et al., 1982; Pirke et al., 1982; Edelstein et al., 1983) and are corrected by weight recovery. Moreover, PAD patients also often lose weight as a result of the disturbed eating behavior that is part of the depressive syndrome. Accordingly, it has been argued that AN and PAD, like starvation, are characterized by a derangement of the HPA axis that is related to weight loss (Berger et al., 1982), though recent data (Targum, 1983; Yerevanian et al., 1984) mitigate against this explanation.

Most reports have focused on the effects of weight loss or weight recovery on HPA function without taking into consideration the impact of the psychopathology typical of AN as a possible cause of the phenomenon. Therefore, we decided to explore the relationships among HPA impairments, weight loss, and psychopathological status of AN patients. As part of this effort, we examined circadiancortisol periodicityand DST response in relation to both depressive symptomatology and weight loss. We then administered desimipramine, a tricyclic antidepressant that acts on the noradrenergic system (Goodwin et al., 1978). Our main goal was to determine whether possible changes in mood would parallel neuroendocrine normalization independently of

weight recovery. We also determined baseline levels of plasma /3-endorphin (/3-EP) and P-lipotropin

(P-LPH) before and after pharmacotherapy because ofthe observationthattheyderive from the same adrenocorticotropic hormone (ACTH) precursor molecule, i.e., pro- opiomelanocortin (Mains et al., 1977). We reasoned that impairments of the HPA axis in PAD and AN might be correlated with simultaneous alterations of circulating opioid titers. It has already been reported that CSF opioid levels are high in a small group of AN patients, but normalize after recovery (Kaye et al., 1982). In PAD patients, plasma and CSF opioid levels have been found to be elevated in some studies (Terenius et al., 1976, 1977;Lindstrometal., 1978;Rimonetal., 1980;Brambillaetal., 198l;Dragoetal., 1982; Risch, 1982) but not in others (Post et al., 1981; Catlin et al., 1981; Naber et al., 1981; Emrich, 1982; Pickar et al., 1982; Alexopoulos et al., 1983).

Methods

Subjects. Fourteen patients with aged 15-40 were studied Table I for the sample’s clinical characteristics). All patients met the major criteria for AN of Feighner et al. (1972). However, we included six patients who had weight losses < 25% of ideal body weight, which has been proposed as a cutoff value for the diagnosis. These patients were steadily losing

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weight and showed all of the psychopathological characteristics ofthedisease-in particular, the anorectic behavior proposed by Feighner et al. (1972)and Halmi et al. (1983) to be the major set pointfordiagnosisofthedisorder. Inaddition,thediagnosisofDSM-IIIPADwasexcludedinall the patients after examination by two psychiatrists. Metropolitan Life Insurance Company of New York standards were used to determine ideal body weight. All the patients were hospitalized during the neuroendocrine tests, before starting therapy, and at the end of therapy. During pharmacotherapy, the patients remained at home. They were allowed free choice of diet throughout the study. ‘The average caloric intake was approximately 800 calories. However, measurement of caloric intake could not be accurate because of the propensity of some patients to hide food or induce postprandial vomiting. Patients had not had any type oftreatmentforat least I month. They had never beenexposed to psychopharmacological therapy before our investiga- tion.

Table 1. Clinical characteristics

% % Below Below

Weight Weight IBW IBW

Patient Duration Duration before after before after

No. Age1 anorexia2 amenorrhea3 Height4 therapy therapy therapy5 therapy5

1 18 2.0 2.0 160 37.0 39.0 29.6

2 29 9.0 8.0 161 46.0 47.0 17.7

3 17 4.0 1.0 160 35.0 34.6 33.0

4 29 13.0 1.6 150 39.8 42.0 12.5

5 19 2.0 2.0 162 41.6 43.9 23.0

6 22 6.0 4.0 160 30.0 30.5 43.9

7 21 3.0 2.9 160 39.0 40.0 27.1

a 15 .0.8 0.7 164 47.5 51.0 12.0

9 29 11.0 11.0 153 40.0 40.5 22.5

10 24 1.2 1.2 170 47.5 49.0 20.5

11 19 1.6 1.0 158 42.0 42.5 17.8

12 35 11.0 11.0 161 35.0 34.0 40.6

13 40 2.6 1.6 160 28.3 54.1

14 20 1.0 0.8 162 40.5 25.8

25.9

15.9

34.2

7.7

1. Age in years. 2. Duration of anorexia in years, months. 3. Duration ofamenorrheain years. months. 4. Height in cm. 5. IBW = ideal body weight.

Endocrine Measures. Cortisol periodicity was studied twice, before and at the end of therapy. Blood cortisol levels were measured at 9:00 a.m., 4:30 p.m., and 1 I:00 p.m. Patients fasted and rested in bed for 12 hours before blood samples weredrawn at 9:00 a.m. At 8:30a.m., a 19-gauge butterfly needle was inserted into a forearm vein and isotonic saline was infused until 9:00 a.m. when 10 ml of heparinized blood was drawnimmediately centrifuged, and the plasma frozen at -20°C until assay. At 4:30 and 1 I:00 p.m., the procedure was repeated. Patients were allowed free eating and normal activity in between. In our laboratory, a rhythm is considered normal when cortisol levels at 4:30 and 1 I:00 p.m. show at least a 50% decrease from the 9:00 a.m. value.

The cortisol response to dexamethasone administration was also measured twice, beforeand after therapy. Patients were given dexamethasone orally, 1 mg, at 1 I:00 p.m. at the end of the study of cortisol periodicity. They fasted and rested in bed for the following 10 hours. At 9:00 a.m., 4:30 p.m., and 1 I:00 p.m. of the following day, blood samples for cortisol assay were drawn as before. Cortisol response to dexamethasone inhibition was considered normal when values the next day were < 5 ng/ml.

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Blood samples for the /3-EP and /3-LPH assay were drawn at 9:00 a.m. during the studies of cortisol periodicity, as well as at the beginning and end of therapy. Blood was treated with EDTA and Trasylol ( IO00 U / ml), immediately centrifuged, and plasma stored at -20” C until assay. /?-EP and P-LPH levels were considered elevated if they exceeded the normal range and were two standard deviations above the mean. As a control, 14 age-and sex-matched healthy subjects were sampled once.

Cortisol was assayed radioimmunologically with commercial kits from Byk-Gulden( Italy). In our laboratory, normal values at 9:00 a.m. are 16.8 * 8 ngi ml, lowered by 50% at I I :00 p.m., and intermediate at 4:30 p.m. After DST, normal suppression at each time should result in values <5 ng/ ml (Carroll et al., 19d 1). /3-EP and P-LPH were assayed by the method of Panerai etal. (1983) using high performance liquid chromatography (HPLC) followed by a radioimmunological assay.

Pharmacotherapy. Desimipramine (DMI) was administered orally to 12 of the 14 patients (2 refused the therapy), 3 times a day for 30 days- 1.5 mg/ kg for I5 days and then 2 mg/ kg for I5 days. Blood DM I levels were assayed before therapy began and every 7 days until the end of therapy to check compliance. DMI levels were assayed by H PLC(Schmidt, 198 I). Psychological status before and after therapy was monitored with the Wechsler Rating Scale (WRS) (Wechsler et al., 1963) for depression and the Zung Self-Rating Scale (ZSRS) (Zung, 1965). The Anorexia Nervosa Inventory -Self-Rating(ANIS) (Fichter and Keeser, 1980) was used toassessanorectic symptomatology.

Statistics. Analysis of variance and Pearson correlation coefficients were used in theanalysis of data.

Results

Therapy wasassociated withamodestweightgain(0.5-3.5 kg)in I 1 of 12cases(Table 1).

DMI blood levels demonstrated compliance and good absorption of the substance. No

marked individual variations were present in serum levels of DMI, which ranged between 39.6 k 9.9 ng/ ml at 7 days and 98.2 + 2 1.8 ng/ ml at 21 days of therapy (plateau levels).

Psychological Data. The WRS and ZSRS (Fig. 1) revealed that before therapy all patients had varying degrees of depressive symptomatology (mean + SEM = 72.2+2for the WRS and 48.1 ? 3.2 for the ZSRS). After therapy, there was a nonsignificant decrease in the meanscores on both scales (WRS z61.6t4.3; ZSRS =42.7+3.4). When each patient was considered individually, WRS scores showed a clear-cut decrease in fivecases(Table 1, nos. 1,3-4, 10-l l),a modest increaseinfive(nos. 5-9),andnochange in two (nos. 2, 12). For the ZSRS, the decrease for each patient was less striking. If we consider the final WRS scores for each patient, five had low depression scores (nos. 1,

4-5, 8, IO), two still had high scores (nos. 2, 12), and the others had intermediate values.

The ANIS results were dubious because the responses before and after therapy seemed rather unreliable. However, a trend toward improvement was also observed with this scale (56.0 * 9.3 vs. 47.6 + 7.2).

If the patients are divided into two groups based on% below ideal body weight (IBW) before therapy, we observe that in the group > 2570 below IBW, two patients had a clear-cut improvement of depression after therapy, two a modest improvement, and one no change. In the group that was< 25% below IBW before therapy, three had aclear-cut improvement of depression after therapy, three a modest improvement, and one no

169

Fig. 1. Total scores for depressive and anorectic symptomatology before and after DMI therapy

131

72

61

48

42

Zung 160

Anis

-9

before after before after before after

Data presented as mean k SEM. Depressive symptomatology measured by the Wechsler-Zung Rating Scales. Anorectic symptomatology measured by the Anorexia Nervosa Inventory-Self-Rating (ANIS 1. DMI = desiml- pramine. Sample comprised 14 female patients with anorexia nervosa.

change. No correlation was observed between weight reduction before therapy and response to therapy.

HPA Axis. The study of cortisol periodicity (Fig. 2) before therapy distinguished two groups of patients, one with normal rhythms (nos. l-2,9-12) and one with abnormal

Fig. 2. Circadian cortisol periodicity before and after DMI therapy

ng/ml before therapy

%!m

I

after therapy

9 16 23 h. 9 16 23 h.

Data presented as mean + SEM. DMI = desimipramlne. Sample comprised 14 female patients with anorexia nervosa. Dashed line = normal rhythm. Solid line = abnormal rhythm.

170

rhythms (nos. 3-8, 13- 14). Patients with a normal rhythm had a mean baseline cortisol levelof 16.3+-2.6ng/mlat9:00a.m., 11.3*2.7at4:30p.m.,and6.1+1.4at ll:OOp.m. Patients withanabnormalrhythmhadmeancortisollevelsof 15.3+ 1.9at9:00a.m., 13.5 f 2.3 at 4:30 p.m., and 13.7 k 1.4 at 1l:OO p.m. Data obtained after therapy show that three patients (nos. 3-4,6) of the five who had abnormal rhythms before therapy still had abnormal rhythms after therapy, while three normalized (nos 5, 7-8); the other two patients with an abnormal rhythm refused therapy. Among the patients who had normal rhythms before therapy, two (nos. 2, 12) developed abnormal rhythms after therapy, and the others did not change.

DST response (Fig. 3) again distinguished two groups of patients-the first with normalsuppression(nos.2,4-5,7-11, 14)(mean~SEM=2.0+0.4at9:00a.m., 1.6+0.3at 4:30 p.m., and 1.5 50.3 at 1l:OO p.m.)andthesecondwithnosuppressionatanypointor with an early escape (nos. 1,3,6, 12-13) (mean f SEM = 8.02 3.6at 9:00a.m., 7.6 k 1 at 4:30 p.m., and 8.7 + 1.2 at 1 I:00 p.m.). In a before-therapy versus after-therapy comparison of the data of the five patients who had abnormal responses at baseline, one was found to have normalized (no. I), three were unchanged (nos. 3,6,12),andonehad dropped out of the study (no. 13). One of the patients who suppressed normally before therapy (no. 9) failed to after therapy.

Of the eight patients who had abnormal rhythms before therapy, three also had blunted responses to dexamethasone(nos. 3,6,13). Aftertherapy, three patients(nos. 3, 6, 12) had both abnormal rhythms and blunted DST responses, and two had only abnormal rhythms (nos. 2,4).

Fig. 3. Cortisol response to dexamethasone suppression before and after DMI therapy

w/ml before therapy

nOnI after therapy

1 I 23 9 16 23 h 23 9 16 23 h

Data presented as mean i SEM. DMI = deslmlpramlne Sample comprised 14 female patients with anorexia nervosa. Dashed line = responders. SolId line = nonresponders.

Age of onset of AN or duration of AN did not correlate with impairments of cortisol periodicityorwithcortisolresponse todexamethasoneinhibition(orwith/3-EPlevels), either before or after therapy. Weight loss was not correlated with depressive sympto- matology before therapy, while after therapy, there was a negative correlation between

171

weight recovery and depressive scores (p < 0.02). Before therapy, there was a positive correlation betweenabsolute weight and cortisol levels at 4:30and 1l:OOp.m. (p<O.Ol)

and between Ye weight reduction and blunted response to dexamethasone @ < 0.05), indicating that HPA impairments cluster in the group with the highest absolute weight or with modest weight reduction. After therapy, there was a negative correlation @< 0.01) between blunted DST response and absolute weight or % weight reduction, indicating that both patients with lower absolute weight or with modest weight reduction can show impaired DST responses. The opposite directions of these two correlations cast doubt on their significance, suggesting the influence of other unknown factors in these relationships. When correlations between the psychopathological and endocrine data were sought, no relationship emerged between the degree of depressive symptomatology before therapy and impairment of either circadian cortisol rhythm or DST response. After therapy, however, those patients whose depression scores remained the highest (nos. 2-3, 12: W RS ~7 l-80) still had an impaired circadian rhythm and a trend toward an abnormal DST response, while those patients who improved psychologically (nos. 1, 5, 7-8: WRS = 39-58) showed a parallel normalization of the endocrine alterations. Analysis of correlation coefficients revealed only a trend toward a negative correlation between ‘$0 decrease of depression scores and blunted DST response (r q -0.47) or impaired circadian rhythms (r = -0.5 1).

Baseline P-EP and P-LPH Levels (Fig. 4). Plasma P-EP levels were high before therapy in seven cases (nos. l-3, 5-6, 10-l 1: 91.4-233.0 fmole/ml) and normal in the others. Mean values of all patients were significantly higher (93.8 * 2 fmole/ ml) than those of controls (38.8 * 6;p < 0.05). After therapy, P-EP levels had increased in three patients who had already had high levels at baseline (nos. 2-3,5: 174.3-291.4 fmole/ ml) and in one case (no. 8) with previously normal levels (10.1 vs. 105.4), while they decreased to normal levels in all the others. Mean values aftertherapy(58.4k26.4) were not statistically different from those before therapy or those of controls.

Plasma P-LPH levels were normal both before and after therapy in nine patients,

elevated before therapy in four cases (nos. 1, 6-7, 10: 52-142 fmole/ ml), and elevated before and after therapy in one patient (no 3: 48.0-69.7). Mean values(+SEM) were not statistically different from those of controls (27.2 f 3.5) and mean values before and after therapy (42.6 f 13.6 vs. 15.3 f 6.7 fmole/ ml) also did not differ. The elevated P-EP values did not correlate with P-LPH values. Nocorrelation was observed betweenp-EP levels and absolute weight or 70 weight reduction from IBW before therapy, or after therapy with absolute weight gain.

All ofthe patients with high/CEP levels before therapy had high or medium-high total depression scores (WRS = 62-99). Two cases (nos. 12-13) had high depression scores (WRS q 83-89) and normal B-EP levels. After therapy, five cases (nos. 1, 5-6, 10-l 1) showed symptomatic improvement (WRS = 15-35% reduction from pretreatment scores) and normalization of /3-EP levels, and one (no. 3) showed symptomatic improvement (WRS = 28% reduction from initial scores) but persistently high ,%EP levels (2 19.4 fmole/ ml). The correlation between psychopathological data and endo- crine data was not statistically significant. Nocorrelations were observed between HPA and P-EP impairments.

172

Fig. 4. Basal P-endorphin and P-lipotropin levels before and after DMI therapy

/~-END~I~P~~IN fmol / ml

The /IGendorphin levels are shown in the upper panel, and the !%llpotropin levels are shown in the lower panel. Data are presented as mean -t SEM. DMI = desimipramlne. Sample comprised 14 female patients wth anorexia nervosa and 15 control subjects.

Discussion

Although our data on this small group of AN patients are clearly preliminary, potentially interesting findings emerged. All the AN patients showed some depressive symptomatology, which improved with DMI therapy. In previous studies,administra- tion of tricyclic antidepressants or lithium to AN patients was associated with reduc- tions in depressive symptomatology and variable degrees of weight restoration (Needleman and Waber, 1976; Barcai, 1977; Moore, 1977; Ossofsky, 1977; Kendler, 1978; Halmi et al., 1982; Stein et al., 1982). The anorectic behavior of our patients was only slightly modified and weight gain, though present in most of the patients, was modest. Thus, we accomplished our goal of substantially improving depressive sympto- matology without greatly altering the starvation state, so that wecould see theeffects of changing levels of psychopathology on neuroendocrine measures.

The endocrine study demonstrated that morningcortisol levels, both beforeand after therapy, were normal. Cortisol levels in PAD patients are often normal at 9:00 a.m.

173

(Carpenter and Gruen, 1982) with elevations only becoming apparent in late

afternoon-evening measurements. This phenomenon was also present in our AN patients. Data related to cortisol circadian periodicity must be cautiously interpreted because only three determinations were made within 24 hours. Nevertheless, our data

reveal that cortisol levels in the mid-afternoon and evening do not show the expected nadir in some patients. The parallel between AN and PAD patients is suggestive. In both disorders, HPA impairments seem to be unrelated to the severity of depressive symptomatology, appearing randomly before therapy. Improvements in depressive symptomatology, however, seem to parallel the normalization of neuroendocrine alterations in most patients. Our data on circadian periodicity and DST response, in agreement with those reported in the literature, reveala subgroup of patients with HPA alterations. No close relationship between impaired circadian rhythm and blunted DST response was observed, but it is possible that more frequent blood samplings would reveal significant correlations.

Weight reduction did not seem to be responsible for the biochemical impairments since there was no correlation between the two phenomena and weight restoration did not correct the endocrine abnormalities. It is true that the weight gains of our patients after therapy were small, but Fichter et al. (1982) reported that a weight gain ofeven 1.5 kg was enough to correct the blunted DST in normal volunteers, and some of our patients gained more than 1.5 kg. It has beensuggested that theendocrineabnormalities noted in AN are more often related to the lack of a specific type of food than to the absolute reduction of caloric intake or weight loss, per se, but this has never been studied in relationship to cortisol alterations. Moreover, our patients’ patterns of food intake were quite constant. Instead, a trend emerged toward a relationship between psycho- pathological symptoms and endocrine abnormalities, both before and after treatment, even though the number of patients in each subgroup, with and without endocrine alterations, was too small to generate statistically significant differences.

In our AN patients, only a subgroup had H PA axis impairments, with a percentage frequency similar to that ofPAD(Carrolletal., 1981). It has beensuggestedthat PADis a heterogeneous disorder that includes patients with different biochemical substrata; it is possible that the same is true for AN.

Our data on plasma fi-EP levels are consistent with the CSF opioid levels reported by Kaye et al. (1982). In our patients, however, there was no relationship betweendegree of weight loss and /3-EP elevations. Moreover, /3-EP levels did not decrease after weight gain, thus excluding any correlation between the two parameters. There was a trend toward a relationship between depressive symptomatology and opioid levels, as we earlier observed in PAD patients (Genazzani et al., 1984). Also, the PAD patients, like the AN patients, showed improvements in mood after DMI therapy and concomitant reductions in P-EP levels. The lack of correlation between P-EP and /3-LPH plasma levels observed in the AN patients was also seen in PAD patients (Genazzani et al., 1984). In individual subjects, plasma opioid and cortisol levels were unrelated, possibly reflecting differential metabolic disposal in the periphery.

In summary, our results do not support a primary role of starvation in inducing HPA axis alterations and, rather, suggest a relationship between mood and neuroendocrine disorders. This relationship reinforces the hypothesis of a possible common denomina- tor in AN and PAD.

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