Cannabis Grow

Interestingly, the mechanisms that give rise to either the protective or the damaging microglial phenotypes are not fully elucidated. Enhancing the microglial-mediated innate immunity in the CNS and/or preventing the harmful effects associated with their chronic activation may offer new therapeutic approaches for the treatment of brain injury and neurodegenerative diseases. One of the most potent stimuli for microglia activation is the bacterial endotoxin LPS, that mimics infection by Gram-negative bacteria. LPS activates intracellular signaling pathways in a complex way leading to secretion of cytokines and to overexpression of several markers of the immune response. Previous studies reported that LPS stimulation induces gene expression of TNFa, IL-1b, IL-6, iNOS and COX-2 as well as the production of NO and PGE2 in primary and BV-2 microglial cell cultures. We reported that CBD reduces the activity of the NF-kB pathway and upregulates the activation of STAT3 transcription factor in LPSstimulated BV-2 cells, and that both CBD and THC decrease the activation of the LPS-induced STAT1 transcription factor, a key player in IFNb-dependent pro-inflammatory processes. Moreover, performing comparative microarray analysis of genome-wide mRNA levels in the BV-2 cells, we reported that CBD, but less so THC, shows a specific gene expression profile associated with oxidative stress and glutathione depletion involving the GCN2/eIF2a/p8/ATF4/Chop-Trib3 pathway. Furthermore, the CBD-stimulated genes were shown to be controlled by nuclear factors known to be involved in regulation of stress response and inflammation, mainly via the -Nrf2/ Atf4 system and the Nrf2/Hmox axis.

We reported that CBD, but less so THC, affects the expression of genes involved in zinc homeostasis,procona valencia buckets suggesting that the regulation of zinc levels could have an important role through which CBD may exert its antioxidant and anti-inflammatory effects. Although the inhibitory functions of cannabinoids on LPSactivated NF-kB and IFN-b/STAT proinflammatory pathways and on the secretion of selected cytokines in BV-2 microglial cells has been studied, a genome-wide search for cannabinoid molecular targets in LPS-activated BV-2 cells has not yet been performed. We have, therefore, performed gene array studies and comparative gene profiling analysis of BV-2 cells treated with LPS, CBD+LPS or THC+LPS. This approach allowed us to analyze the changes induced by CBD and THC on gene expression patterns in LPS-treated BV-2 cells and to explore the genomewide interaction network affected by these treatments. In this regard, a structured network knowledge-based approach to analyze genome-wide transcriptional responses in the context of known functional interactions among proteins, small molecules and phenotypes has been established. We applied this analysis to show the interactions and signaling networks elicited by the cannabinoids in LPS-stimulated BV-2 cells. Our results show that CBD is a potent modulator of microglial activation. Identification of the CBD- and THC-regulated genes and related networks provides a molecular basis for understanding the effects of these cannabinoids on LPS-activated microglia.BV-2 microglial cells were pretreated for 2 h with either THC or CBD followed by the addition of LPS to the incubation medium for another 4 h. The control treatment with cannabinoids alone lasted for 6 h and with LPS alone for 4 h.

The choice of these time points for transcriptional profiling was guided by our previous studies as well as by other reports which investigated the general temporal pattern of microglial activation by LPS. Moreover, according to our previous results, neither THC nor CBD treatments significantly affected the viability of the BV-2 microglial cells during this 6 h period. The RNA prepared from these samples was analyzed for changes in transcriptional levels using the MouseRef- 8 v1.1 Expression BeadChip Illumina Arrays. Each of these arrays has .24,000 mouse targets based on the NCBI mouse Reference Sequence Database, including 16,287 constitutive exons/islands based on the splice variants in the mouse transcriptome and NCBI LocusLink databases. The results of the analyses of the arrays showed that 32% of the transcripts were consistently ‘‘present’’ in the BV-2 RNA samples across all arrays. Moreover, clustering based on inter-array Pearson correlation coefficient indicated no batch effects. Microarray analysis based on a threshold of p# 0.005, revealed that a total of 22% of the Illumina gene set was differentially regulated across treatments. Of these, 1319 gene probe sets were up regulated and 1829 transcripts were down regulated by the LPS treatment ; and from these numbers of genes, 400 transcripts were found to be up regulated and 145 down regulated by LPS by 2-fold or more. When the fold change was set on $3-fold , we found that 226 gene products were up regulated and 33 were down regulated by LPS . The vast majority of the LPS-affected transcripts represented genes that were exclusively responsive to LPS stimulation, and not to treatment with CBD alone or THC alone . the CBD+LPS treatment was analyzed, 1381 gene probe sets were up regulated and 1666 transcripts were down regulated by CBD+LPS . From these numbers of genes, 379 gene products were found to be up regulated and 489 down regulated exclusively as a response to the combination of CBD+LPS and not affected by LPS or CBD alone . When the fold change was set on $2-fold, 502 transcripts were up regulated and 297 gene probe sets were down regulated by the CBD+LPS treatment .

When LPS was applied in the presence of THC, 1216 gene probe sets were up regulated and 1638 transcripts were down regulated; and from these, 424 transcripts were found to be up regulated and 149 down regulated by 2-fold or more . From the 1216 up regulated genes, 157 transcripts were exclusively responsive to THC+LPS treatment alone and from the 1638 down regulated transcripts, 285 gene probes were affected only when THC and LPS were together . When the fold change was set on $3-fold, we found that 230 gene products were up regulated by CBD+LPS and 236 transcripts by THC+LPS whereas 51 gene products were down regulated by CBD+LPS and 31 transcripts by THC+LPS . Our results also reveal that from the 5338 transcripts found to be differentially regulated by the various treatments , 680 gene probe sets were found to be up regulated by CBD alone and 58 gene products by THC alone. CBD had also a much larger effect compared to THC on the number of down regulated genes, 524 gene products were down regulated by CBD and 36 by THC . The groups of LPS-up regulated and down regulated genes that showed a change in expression of $2-fold in either direction were subjected to gene ontology analysis allowing functional annotation using the DAVID Bio-informatics Resources and the KEGG pathways . All major Biological Processes, Cellular Components and Molecular Functions within GO for the LPS-up regulated transcripts, were for the most part, genes associated with the immune and defense responses as well as apoptosis and cell death. KEGG database analysis included genes related to Toll-like receptor pathways and antigen processing as well as to the MAPK pathways. IPA global functional analysis of the LPS-up regulated and down regulated genes confirmed the DAVID representation of genes within IPA specific GO categories . IPA global functional analysis of the LPS-up regulated transcripts show gene products mainly implicated in cell-to-cell signaling, cellular movements, growth and proliferation, as well as cell death,procona buckets immune response and signaling, including genes involved in the NF-kB pathway and in the activation of the liver X receptor/retinoic X receptor . The largest subsets of down regulated transcripts included genes known to be involved in the regulation of macromolecules and nucleotide metabolism, differentiation and development as well as regulation of gene expression and transcription . A list of 183 LPS-up regulated genes are presented in Table S2. This list includes LPS-up regulated genes that were significantly affected by CBD+LPS or by THC+LPS. They appear in the Table according to their categories and specific annotations based on their GO and IPA. The highly up regulated transcripts were related to inflammation, host defense and adaptive response. Inflammatory cytokines and chemokines together with their cognate receptors comprised a large group of more than 20 genes. Interferon related transcripts formed a significant population comprised of 12 genes. Based on GO and relevant literature references, genes were also classified into other functional categories including metabolic enzymes, membrane transport and secretion, kinases, phosphatases as well as transmembrane Gprotein coupled receptors. The remainder of the LPS-up regulated genes was grouped according to their involvement in several other cellular processes such as apoptosis, proliferation and cell cycle progression, transcriptional and translational control as well as stress response. Additionally, we have identified a cluster of genes associated with regulation of extracellular matrix that are known to be involved in molecular recognition between cells, cell adhesion and migration. Genes implicated in cytoskeleton remodeling and control of cell motility and morphogenesis form a separate category.This study addresses the effects of the two major cannabinoids present in cannabis, CBD and THC, on mRNA expression in LPS-stimulated BV-2 microglial cells.

Our results show that pretreatments with CBD or THC differentially affect LPSregulated gene transcription. This result is in line with the more profound effects of CBD on mRNA regulation in surveillant microglial cells, as previously described by our group. Here we show that CBD, more than THC, suppresses the LPSinduction of many proinflammatory genes in selected functional categories including cytokines and chemokines . Moreover, CBD also repressed the basal expression of Ccl2, Ccl7 and Ccl9. Interestingly, Ccl2, Ccl7 and Ccl12 bind to the same receptor , thus, showing binding promiscuity while they activate different signal transduction pathways in different cell populations. From these chemokines, Ccl2 plays a critical role in multiple sclerosis and in its murine model, experimental autoimmune encephalomyelitis . Several reports show that increased expression of Ccl2 in immune cells is closely associated with the clinical activity of EAE . Thus, the CBD down regulation of Ccl2 mRNA is in line with the finding that CBD is ameliorating the EAE disease symptoms. Another hallmark of inflammation is the increased expression of proinflammatory mediators like matrix metalloproteinases . Here, we show that CBD down regulates the expression of the LPS-up regulated matrix metalloproteinase13 . MMP13 level and activity are enhanced in correlation with the degenerative changes in osteoarthritis cartilage and this molecule co-localizes with its specific type II collagen cleavage products. In agreement with this result, Malfait et al., reported that in the murine collagen-induced arthritis CBD treatment blocks the progression of the disease. CD69 antigen is another mediator found to be involved in the CIA model of rheumatoid arthritis. This antigen is highly expressed in the leukocyte infiltrates of various chronic inflammatory diseases. In this regard, CIA disease severity is increased by antibody-induced blockade of the transforming growth factor b in wild type but not in CD69-/- mice, suggesting that CD69 is a negative modulator of autoimmune response and inflammatory reaction. Our current results show that CBD down regulates the mRNA expressions of the LPS-up regulated Cd69 antigen and of Mmp13 suggesting a possible mechanism for the therapeutic activity of CBD in the murine CIA model. The expression of several genes in the inflammatory cytokine functional category was found to be enhanced by CBD . These include the LPS-up regulated expression of Gdf15/MIC-1 and Il-15. From these genes, Gdf15 mRNA expression is up regulated in surveillant/ resting BV-2 cells by CBD but synergistically up regulated by CBD+LPS . Gdf15/ MIC-1 is a member of the TGF-b super family that plays key roles in the regulation of cellular responses to stress signals, inflammation and tissue repair. Gdf15 mRNA expression was found to be up regulated in activated macrophages by secreted proinflammatory cytokines suggesting that Gdf15 may act through an autocrine loop as an inhibitory factor in the late phases of inflammation by suppressing inflammation through the inhibition of macrophage activation. Other genes highly up regulated by CBD are Lcn2 and Aqp9. Lcn2 has been implicated in many cellular processes, such as cell death/survival, cell migration/invasion, cell differentiation, inflammation and iron sequestration, including a role in the acute phase response . With regard to Aqp9, we have previously shown that CBD up regulates Aqp9 mRNA in BV-2 cells . Moreover, CBD synergistically increases the LPS-up regulated Aqp9 . Aqp9 participates in the transport of small solutes and takes part in osmotic swelling induced by apoptotic stimuli.

Informed consent was obtained before starting the behavioral survey, which was administered via hand-held tablet computers. All study procedures were approved by the Institutional Review Board at the University of California, San Francisco. Written consent was obtained from all youths aged 18 years or older and written assent was given by younger participants . Psychosocial exposures measured included PTSD, psychological distress, gender-related discrimination and a parental drinking or drug problem . PTSD symptoms were determined by use of the four-item Primary Care PTSD Screen with a cutoff of three out of four symptoms in the last twelve months . Psychological distress was measured with the 18 item version of the Brief Symptom Inventory , converting the BSI-18 Global Severity Index to Tscores and using a validated clinical cutoff of T > 62 for symptomatic psychological distress in the last seven days . Gender-related discrimination was determined by questions that asked whether participants had ever experienced poor treatment from parents/caregivers, faced difficulties obtaining employment, lost a job/career or educational opportunity, changed schools and/or dropped out of school, or moved away from friends or family as a result of gender identity or gender presentation. Experience of any of the above types of discrimination at any time was defined as having gender-related discrimination in a dichotomous variable for this exposure.

PDAP was determined by a single question based on the DSM-IV criteria for substance abuse,ebb flow tray which asked whether parents or immediate caregivers had ever “had a drinking or drug problem that got in the way of their work and/or relationships” . Socioeconomic status was determined using self-reported household annual income while accounting for the number of individuals dependent on that income using the US Department of Housing and Urban Development’s FY2014 Income Limits for the San Francisco, CA HUD Metro Federal Market Rent Area . HIV status was obtained by rapid HIV testing. Rapid finger prick tests were offered by the research assistants to all participants regardless of self-reported HIV status. Participants were asked to stay for their results but were not required. All participants who tested positive were referred to the San Francisco Department of Public Health Linkage Integration Navigation Comprehensive Services program which provides and coordinates comprehensive HIV care for newly tested positives and known positives who are currently out of care. Other measures such as whether or not participants had been sexually active in the last six months, highest level of education completed, immigration status, and length of time in the San Francisco Bay Area were also collected. Primary outcomes of interest were drug use, defined as any use of marijuana, methamphetamine, crack, cocaine, non-prescribed prescription drugs, ecstasy, GHB, ketamine, heroin or poppers; alcohol use; drug use before or during sex, measured by the question, “how often did you use drugs other than alcohol before or during sex in the last 6 months?”, which was converted into a binary variable to assess presence or absence of any drug use before or during sex; use of multiple drugs; use of multiple light substances and no heavy drugs; and use of multiple heavy drugs, regardless of the use of light substances, in the last six months. “Light” substances included marijuana, poppers and alcohol. “Heavy” drugs included methamphetamine, crack, cocaine, ecstasy, GHB, ketamine and heroin.

These definitions, except for the alcohol use and use of multiple light substances , exclude the use of alcohol and are consistent with prior analyses of poly drug use . We use the term “substances” to refer to both drugs and alcohol, whereas we use the term “drugs” to refer to drugs exclusive of alcohol. Although not a primary outcome, binge drinking was defined as 5 or more drinks on one occasion. In this sample of trans*female youth, we observed a high prevalence of substance use; use of multiple substances was also common. The prevalence of substance use among our sample was greater than that of the general U.S. adolescent population. For example, in the Youth Risk Behavior Surveillance System, 41% of high school adolescents used marijuana, 7% used ecstasy, 18% used non-prescribed prescription drugs, 6% used cocaine, and 3% used methamphetamine, whereas among our sample of trans*female youth, 63% used marijuana, 20% used “club drugs” such as ecstasy, 20% used non-prescribed prescription drugs, 16% used cocaine/crack, and 13% used methamphetamine . Although the elevated prevalences in our sample could be partially explained by differences in sampling methods between the compared studies, they are consistent with other studies of trans*female youth . We also note that the prevalence of substance use among trans*female youth approached levels reported by trans*female adults in San Francisco and studies of other adult transwomen populations, indicating very early onset . Additionally, we found that roughly one in three trans*female youth reported using drugs in conjunction with sexual intercourse. Thus, the association between PTSD, gender-related discrimination, PDAP and drug use before or during sex is of particular importance because situational use of drugs or alcohol before or during sex has been associated with an increased risk of HIV infection and may be part of the explanation for the extremely high prevalence of HIV among transwomen .

Given the acute and long-term consequences associated with substance use in adolescence, including substance use later in life and increased risk for HIV infection, developing targeted interventions to reduce substance use and associated harm among trans*female youth is a pressing public health issue . In this study, trans*female youth also reported high prevalence of PTSD, gender-related discrimination, psychological distress, and PDAP, which were in turn independently and positively associated with drug use in general, as well as use before or during sex. The significant relationship between PTSD and substance use is consistent with prior studies among young people, which have found that PTSD was a significant predictor of substance use . Researchers have postulated that substances may be used by youth to cope with symptoms of post traumatic stress—a process described as the “self medicating” hypothesis . This hypothesis may also explain the association between gender-related discrimination, psychological distress and increased likelihood of substance use. Indeed, discrimination has been implicated as a contributing factor in substance use in general . It is plausible that trans*female youth use substances to cope with stress and transphobia they experience due to their gender identity. Research on racial discrimination, for instance, has found that engaging in substance use to cope with racial discrimination moderated the relationship between discrimination and substance use overtime . Psychological distress related to a young person’s gender identity may similarly influence substance use as a method of coping . These relationships could also be explained by the “minority stress” theory,flood and drain tray which describes how chronic stress—including discrimination and trauma—experienced by minority groups can lead to negative health outcomes and increased risk behaviors . Studies exploring the motivations behind the use of various substances can further elucidate the impact of discrimination and trauma on substance use outcomes. Unfortunately, few studies have explored the role of discrimination and trauma on substance use outcomes among trans*female youth . Future studies should endeavor to examine how psychosocial stressors influence substance use and evaluate the long-term impact of these co-morbidities on the health outcomes of trans*female youth. In the interim, interventions that provide and support alternative coping skills may have some success in reducing substance use as a method of dealing with stressors related to genderbased discrimination . Because trans*female youth are particularly susceptible to the assessed psychosocial risk factors, linkages represent important avenues through which to focus interventions to curb substance use and associated risk behaviors in this population. Structural level interventions aimed at reducing stigma and gender-identity discrimination may be needed to prevent substance use in this uniquely vulnerable group. Similarly, interventions that give parents the skills to prepare their children to recognize and cope with gender-based discrimination may reduce the negative reactions to such stigma and reduce the need for coping, as has been shown in programs and research related to racial and cultural socialization practices of parents . Furthermore, our findings highlight the potential harmful effect of PDAP on trans*female youth. Our findings, though cross-sectional, are consistent with the documented influence of familial substance abuse on substance use among youth in general, which has been observed in many studies .

Researchers posit that the familial influence may be due to youth modeling their behaviors after that of their substance-using parents, as explained by social learning theory . Hence, screening for substance abuse and providing referrals to treatment for substance using parents may translate to reductions in substance use among their offspring. This study has several limitations. First, the cross-sectional design of the study limits our ability to make causal inferences related to the psychosocial risk factors and substance use among our sample. As the on-going cohort progresses, our analysis provides the framework and opportunity to assess the causal relationships between the strong correlations described here and subsequent risk. Second, our sample was limited to the San Francisco Bay Area so is not generalizable to trans*female youth in other geographic regions. In addition, the self-reported data from this study may be subject to social desirability and recall bias. Also, due to the exploratory nature of this analysis, we did not formally adjust for multiple tests of association. Thus, findings with marginal p-values, such as the association between PTSD and use of multiple light substances or psychological distress and the use of multiple heavy drugs , should be interpreted with caution. Although the link between alcohol use and increased sexual risk behavior has been well documented in other populations, we did not assess this association in our sample, a limitation which highlights the importance of this link in future research among trans*female youth . Furthermore, this is a non-probability sample which limits our findings from being generalizable to the broader population of trans*female youth in the San Francisco Bay Area. In particular, the over representation of trans*female youth of color may limit the generalizability of our findings. However, we note that the proportion of participants of color is low relative to a recently conducted population-based study of trans*females in San Francisco, where women of color made up 82% of the sample . Moreover, because trans*females of color are disproportionately affected by HIV in San Francisco, it is important to have a high percentage of youth of color represented in these data . Although our analyses controlled for potential confounding by race/ethnicity and socioeconomic status in order to focus on gender-related discrimination, it is important for future studies to explore the intersectional effects of multiple dimensions of inequality, such as gender, race/ethnicity and socioeconomic status. Regardless of these limitations, this study provides important insights into the prevalence and correlates of substance use among an understudied and marginalized population, which has a practical implications for research and public health programming. Future research should explore the societal, institutional and interpersonal bases of PTSD and gender-related discrimination to better understand how they interact with personal coping and substance use among trans*female youth. The illumination of these pathways has the potential to inform the development of policies and programs aiming to mitigate the rampant health disparities facing trans*female adults. Additionally, the potential link between parental drinking or drug problems and substance use among trans*female youth merits further investigation and draws attention to the potential value of inter-generational and familial interventions. Individuals with psychotic disorders were for many decades not considered appropriate candidates for psychotherapy. The first case reports detailing the use of cognitive behavioral techniques to treat psychosis were published in the 1980s , while the first randomized controlled trial of cognitive‐behavioral therapy for psychosis originated in the United Kingdom in the 1990s . Presently, CBT is listed as a preferred treatment for psychosis by the Schizophrenia Patient Outcome Research Team in the United States, a set of strictly evidenced‐based treatment guidelines . A combination of antipsychotics and structured therapy has been shown to improve both positive and negative symptoms and result in global functional improvement . The CBT focus on cognitive restructuring, normalizing, behavioral self‐monitoring, and activity scheduling promotes social engagement . In one community‐based study, CBT improved positive symptoms, general mental health problems, and depression, as well as reduced admission rates following treatment . The PORT guidelines also recommend social skills training , which targets social cognitive processes, psycho‐education,life management skills , and relapse prevention skills .

Regardless, our analyses demonstrate some measure of construct validity in that higher scores on both measures were linked to reporting mental health conditions in our study. Our measure of sexual orientation “outness” was only asked for gay-identified participants, and a general measure should be included in future studies. A nurse-administered structured interview was used to assess mental health diagnoses and current treatments to ensure these questions were more accurately understood and answered. Given the potential impact of social desirability and reporting bias , we used CASI to collect data regarding illicit substance use. However, we did not use drug testing to confirm or correct self-report data and likely underestimated the true prevalence of substances used . Despite these shortcomings, one of the strengths of our study is the use of RDS to overcome previous sampling shortfalls with GBM and produce a more accurate representation of the population parameters of these variables of interest for the GBM population of Metro Vancouver. Our study also adds new data regarding the detailed prevalence of substance use and mental health conditions among GBM populations in Canada filling a gap in currently available published literature. Finally, our work goes further to examine explicitly the relationship between substance use and mental health conditions among GBM identifying important relationships that have implications for counseling and public health services, interventions, and policy. The greater burden of mental health conditions and higher prevalence of substance use in GBM populations highlight the need for a more explicit focus on these issues in research and service provision.

Mental health specialists should be aware of the relationships with sexuality and substance use when working with GBM clients,rolling bench particularly issues regarding identity disclosure, number of sexual partners, and higher background community prevalence of substance use . Future research should seek to validate current measures and to confirm the relationship between substance use and mental health conditions, which has been demonstrated to produce a syndemic including suicidal ideation among GBM and HIV acquisition . Our study was based in a major metropolitan area, which may limit generalizability to GBM in rural or remote regions, whom are a population with distinct needs and challenges that should be further examined. In order to evaluate generalizability, additional research is needed to explore these issues among GBM populations in other urban and non-urban centers across Canada, particularly if these studies employ RDS or other more representative sampling methods. Given the role of social factors in mental well-being, future research should directly examine experiences of homophobia or heterosexism as possible precursors to substance use and/or mental health issues, along with potential mediators and protective factors. Examining demographic factors independent of one another may not reflect the diversity of experiences that exists among GBM. Using an intersectional approach, which looks at how multiple identities such as race, sexual orientation, and class, interact with one another to shape experiences , may also explain the distribution and experiences of mental health and substance use within diverse communities of GBM. In spite of experiences of marginalization and discrimination, many GBM do not go on to develop mental health conditions or engage in harmful substance use. Shilo, Antebi, and Mor found that factors such as support of family and friends, meaningful connections with the LGBT community, and having a steady partner, protect against developing poorer mental health in lesbian, gay, bisexual, queer, and questioning adults.

Thus, more focus on factors such as these that promote resiliency in GBM would be beneficial to include in future research on mental health and substance use in these populations. Compared with the Canadian population, GBM living in Metro Vancouver have increased levels of substance use and mental health conditions. The strong link between substance use and mental health among GBM has important implications for public health promotion programming and care service provision. A number of social determinants increase the likelihood of mental health diagnosis among GBM, including disclosure of sexuality, low income, and race/ethnicity. GBM living with HIV were significantly more likely to have a lifetime doctor-substance use disorder compared with HIVnegative GBM. Greater attention to these issues is needed across all health and social services given their disproportionate effect on GBM populations. Health promotion and interventions should address issues of substance use, mental health, and sexuality in unison and future research can help direct these efforts by examining possible precursors of these issues, which may be the result of discrimination, prejudice, and stigma.Tobacco use in the general population has declined substantially in the past three decades, but rates remain high in certain populations. The prevalence of tobacco use in the homeless population is 3 to 4 times that of the general population.Among homeless adults, tobacco-related chronic diseases including heart disease, cancer and chronic obstructive pulmonary disease are common and contribute significantly to the increased morbidity and mortality in this population.Among a clinic-based sample of homeless adults aged 50 and older, tobacco-attributable deaths accounted for 26% of the overall mortality and 54% of substance-related mortality.The health consequences of smoking occur disproportionately among older individuals because of the cumulative effects of long term smoking.Among older adults, tobacco-related chronic diseases, particularly chronic obstructive pulmonary disease and coronary heart disease, are among the most common reasons for emergency health care services and preventable hospitalizations.

Current tobacco use contributes significantly to all-cause mortality among older adults, suggesting that tobacco cessation at any age is likely to significantly reduce tobacco-related morbidity and mortality.In a nationally representative sample, older adults were less likely to quit smoking than younger adults because of reduced interest in quitting smoking, higher nicotine dependence, and lower support for smoke-free norms.This highlights the need for tobacco cessation interventions that address tobacco-related beliefs and practices among older adults. Over the past 2 decades, the median age of homeless adults increased from 37 years in 1990 to almost 50 years in 2010.Despite increased tobacco-related morbidity and mortality among older homeless adults, little is known about tobacco use and cessation behaviors in this population. Prior research on tobacco use in the homeless population has focused on younger adults, where the average age of study participants in previous studies was less than 44 years.The high prevalence of tobacco use and the increased burden of tobacco-related chronic diseases with aging underscore a need for studies that characterize tobacco use and cessation behaviors among older homeless adults in order to develop tobacco control interventions that address the unique needs of this population. We conducted a study of a cohort of homeless individuals aged 50 and older sampled from the community to examine rates of and factors associated with tobacco cessation. We hypothesized a priori that current smoking would be associated with symptoms of depression, substance use disorders, history of incarceration, and history of staying in shelters.We also hypothesized that persons who reported smoking heavily or having symptoms of depression at enrollment would be less likely to make a quit attempt at follow-up.The HOPE HOME Study is a longitudinal study of life course events, geriatric conditions, and their associations with health-related outcomes among older homeless adults. From July 2013 to June 2014, we enrolled a population-based sample of 350 homeless adults aged 50 years and older from homeless encampments, recycling centers,grow table overnight homeless shelters, and free and low-cost meal centers serving at least three meals a week in Oakland, California. Participants were eligible if they were English-speaking, aged 50 years and older, defined as homeless as outlined in the Homeless Emergency Assistance and Rapid Transition to Housing Act, and able to provide informed consent, as determined by a teach-back method.The University of California, San Francisco Institutional Review Board reviewed and approved all study protocols.The study included an enrollment visit and a follow-up visit at 6 months. Study interviews took place at a community-based site. After determining eligibility, study staff administered an in-depth structured enrollment interview and collected extensive contact information from participants. We asked participants to check in with study staff in person or by telephone each month. If participants missed two or more check-in visits, study staff reached out to participants using their contact information. From January 2014 to January 2015, we conducted 6-month follow-up visits with each of the participants who completed an enrollment interview. We gave participants gift cards to a major retailer for their participation: $5 for the screening interview, $20 for the enrollment interview, $5 for each month check-in, and $15 for the follow-up interview.We used previously validated questions on tobacco use at the enrollment and 6-month follow-up interviews. We asked participants whether they had ever smoked 100 cigarettes in their lifetime, and classified those who did as ever-smokers. We classified ever-smokers who reported smoking “every day or some days” as current smokers, and those who reported “not smoking at all” as former smokers. We asked current daily smokers to report the number of cigarettes smoked daily. For current non-daily smokers, we estimated average daily cigarette consumption based on self-reported numbers of cigarettes smoked on smoking days in the past 30 days. Participants reported how soon they had smoked their first cigarette after waking, which we dichotomized as greater or less than 30 minutes.

We asked current smokers about their intentions to quit smoking . We asked current smokers to report whether they had stopped smoking for 1 day or longer in the past 6 months because they were trying to quit smoking. We asked participants who responded affirmatively to making a quit attempt to report the length of their last quit attempt. We defined reporting a quit attempt in the past 6-months at the follow-up visit as the primary outcome variable. We determined the proportion of participants who were abstinent for 30 days and 90 days at the 6-month study visit using self-reported information on the length of the last quit attempt. At the 6-month follow-up visit, we obtained additional information from participants on their quitting behaviors.If participants reported having made a quit attempt during the past 6 months, we asked them to report the medications, strategies, and support system they had used during their last quit attempt. Participants reported whether they had used nicotine replacement therapy and/ or any of the US Food and Drug Administration -approved medications for smoking cessation during their last quit attempt. Participants reported whether they had used other strategies to quit smoking including gradually cutting back on cigarettes, switching to smokeless tobacco, other combustible tobacco , or electronic cigarettes, or giving up cigarettes all at once. Participants self-reported their use of a telephone quit line, group or one-on-one smoking cessation counseling, hypnosis or acupuncture, and other internet or family-based support for smoking cessation. Participants also reported whether they had received advice to quit cigarette smoking from their health care provider in the past 6 months, and whether they had acted on the advice to quit smoking.Participants self-reported age, gender and race/ethnicity at the enrollment visit. At the enrollment and follow-up interviews, participants reported whether they had spent any time in jail or prison in the past 6 months. At both visits, we gathered residential history of every place that the individual had stayed, by using a 6-month follow-back residential calendar.We categorized participants as having stayed in shelters if they reported staying in a homeless shelter for single adults or families during the past 6 months.We used questions derived from the World Health Organization’s Alcohol, Smoking, and Substance Involvement Screening Test to assess use of cannabis, cocaine, amphetamines, and opioids. We administered the WHO’s Alcohol Use Disorders Identification Test with a shortened time frame of the previous 6 months to assess risk and severity of alcohol use disorders. We categorized AUDIT scores of 8 or more as indicative of hazardous and harmful alcohol use or an alcohol disorder.To assess the prevalence of depressive symptomatology or significant distress, we administered the Center for Epidemiologic Studies Depression Scale .We used a standard threshold score of 16 or more to categorize depressive symptomatology or significant distress.In this cohort of older homeless adults, the prevalence of current smoking was at least 3 times higher than similarly aged members of the general population. The quit attempt and 30-day and 90-day abstinence rates were similar to that observed among older adults from a nationally representative sample of the general population.However the quit ratio , an indicator of successful quitting, was at least three times lower than the national average.Findings from our study confirm previous research that homeless adults are interested in quitting smoking,but are less successful compared to those who are not homeless.

VCAM-1 and ICAM-1 are released in response to inflammation and facilitate the adhesion and migration of immune and viral factors into and across the vascular endothelium . While VCAM-1 is exclusively expressed on endothelial cells, ICAM-1 is also expressed on leukocytes, astrocytes, and microglial cells . uPAR is a glycoprotein expressed on endothelial cells, in addition to immune and neuronal cells, that facilitates increased vascular permeability, immune cell trafficking, and mitogenic activity, leading to endothelial dysfunction. Blood levels of soluble uPAR are increased in untreated PWH , reduced upon ART initiation , and almost normalized with sustained ART . The associations between the vascular biomarker composite and neurocognitive T-scores were stronger than those of individual biomarkers alone suggesting that each may contribute uniquely to impairment. However, of the three vascular biomarkers, VCAM-1 was the only individual vascular biomarker to emerge as a significant predictor of all three neurocognitive domains when controlling for vascular risk factors and other relevant covariates. It was also the only vascular biomarker that was significantly elevated in our sample of virally suppressed PWH relative to PWoH. This is consistent with studies that have found persistent elevation in VCAM-1 but not ICAM-1 levels following ART and viral suppression .

Given its sensitivity to viral replication and potential for persistent elevations following prolonged ART,indoor weed growing accessories VCAM-1 may be a useful prognostic marker for CVD risk and related neurocognitive sequelae in both treated and untreated PWH. Collectively these findings support the presence of persistent lowgrade inflammation in PWH but highlight endothelial dysfunction as a key mechanism underlying NCI in treated PWH. In our study, inflammation was elevated in PWH relative to PWoH though only weakly associated, and regardless of HIV status, with worse performance in the motor skills domain. Other studies conducted in PWH have also failed to find associations between persistent inflammation and NCI in the context of treated and well-controlled HIV . Persistent immune activation and inflammation in PWH, while present, may not be a primary or direct contributor to NCI in the context of treated and well-controlled HIV disease. One exception may be the selective impact of persistent inflammation on motor deficits, a domain that historically has been most impacted among PWH with chronic disease and/or a history of immunosuppression . This inflammation-motor link replicates another study in virally suppressed PWH that was conducted in a different sample by investigators from our group . Specifically, they found that inflammation, as indexed by a composite burden score that included levels of IL-6, CCL2/MCP-1, sCD14, TNF-a and d-dimer, was associated with poorer performance within the motor skills domain but not other domains. Our weaker results with regard to inflammation may be due differences in individual biomarkers or our approach to constructing composites . Regardless, persistent inflammation may continue to impact NCI in other domains indirectly via its adverse effects on the vascular system and non-HIV-associated complications. This study is among the first to directly compare systemic vascular and inflammatory biomarkers in relation to empirically-derived profiles of neurocognition in a well-characterized cohort of virally-suppressed PWH. However, we acknowledge several limitations.

The crosssectional nature of our data limits our ability to identify temporal patterns regarding the development of inflammation, endothelial dysfunction, and neurocognitive deficits in the context of chronic HIV disease and treatment. Thus, a future analysis that leverages longitudinal data can help address whether subsequent reductions in vascular biomarkers track with improvements in neurocognition among PWH. The current study also did not have access to data for medications that treat cardiovascular conditions, including statin use. Although vascular biomarkers can still show elevations with statin use , prior work has shown that PWH with untreated cardiovascular risk performed worse than those with treated cardiovascular risk on multiple neurocognitive domains, including processing speed, learning/memory, and executive functioning . It is compelling to hypothesize that the elevated vascular biomarker levels in the Dysexecutive/Slow group reflect particular vulnerabilities in fronto-striatal and fronto-parietal networks, possibly in white matter tracts sensitive to neurovascular dysfunction and HIV disease, yet our data do not include direct measurements of structural or functional integrity of specific brain regions . Although similar numbers of clusters/classes and patterns of NC domain impairment have been observed across clinical and non-clinical samples and statistical methods , it is possible that cluster analyses in larger independent HIV samples may reveal other clinically relevant neurocognitive profiles. Last, the PWoH comparison group cannot be interpreted as absolute ‘controls’ given their medical and neuropsychiatric backgrounds – however, these background factors more closely resemble the PWH group, which strengthens our observations of HIV-specific relationships between vascular biomarkers and neurocognition.

The identification of plasma biomarkers that sensitively track with particular neurocognitive deficits and medical profiles will inform efforts to improve neuroHIV clinical care through scalable assessments and tailored interventions. In the present study, our findings support the growing recognition for a vascular subtype of HIV-associated NCI that exhibits a profile of deficits in executive functions and speed-dependent tasks, similar to the classic presentation of vascular cognitive impairment. Our data also highlight endothelial dysfunction as a potential direct mechanism driving this deficit profile, which underscores the importance of neurovascular pathology in the context of viral suppression. Taken together, this vascular NCI subgroup of PWH may benefit the most from interventions that target the neurovascular unit directly and indirectly , which will improve early detection and treatment of NCI, as well as preventing further decline, particularly as the HIV population grows older. Recent years have seen an advent in population-based studies that examine the prevalence, etiology, and developmental trajectories of diverse sub-clinical psychopathological symptoms that pose a risk for the later development of severe mental illnesses. It is increasingly recognized that most categorically defined psychiatric disorders occur on a spectrum or continuum that is not necessarily normally distributed , show high heterogeneity and symptom overlap, and share genetic and environmental risk factors . Therefore, population-based studies of psychopathology in youth assess a broad spectrum of symptoms as well as genetic risk, cognitive and general functioning, socioeconomic, and environmental factors to yield a more complete understanding of symptom etiology and development. Pediatric population-based studies with longitudinal study designs may be helpful for defining normative growth charts of diverse disease dimensions that in turn may aid in developing individual risk predictions . Here, we review different aspects of population-based studies with regard to the psychosis spectrum; we discuss neurodevelopmental underpinnings of psychosis spectrum symptoms, brain morphometric and functional alterations in individuals experiencing psychotic symptoms in the general population, and the role of genetic liability for psychosis. Given the overwhelming evidence offered by this body of recent work that even sub-clinical psychotic symptoms pose a risk for severe mental illnesses,rolling benches we highlight promising strategies that facilitate access to mental health services for adolescents, a group highly vulnerable to mental health problems. Even though further research is needed, in particular to understand risk and resilience factors for longitudinal symptom progression, policy making should take available data into account to further reduce mental health stigma and to invest in prevention and early intervention programs.Despite the longstanding conceptualization of a continuum of psychotic symptoms , this is not reflected in current diagnostic manuals . Recent findings in both help-seeking individuals experiencing PS, and studies on PS in the general population have further emphasized this notion . Presumably, the psychosis continuum is characterized by qualitatively similar PS that vary in levels of conviction and duration, ranging from sub-clinical schizotypal symptoms to severe psychosis spectrum disorders such as schizophrenia. PS, as typically studied in population-based cohorts, include positive symptoms such as hallucinations and delusions. Sometimes negative symptoms such as flat affect are also considered when establishing sub-clinical psychosis categories for detailed discussion on psychometric issues.

The concept of a psychosis continuum has further facilitated the adoption of a clinical staging model . Symptoms typically observed in the general population refer to stage 1a, nonspecific general psychopathologies such as depressive and anxiety symptoms alongside subthreshold PS, and stage 1b with more specific PS, i.e., commonly termed clinical- or ultra-high risk state . Stage 0 in this model is defined by a genetic risk through a positive family history of severe mental illness and other states are characterized by above-threshold PS , persistence of symptoms , and severe, non-remitted psychotic disorders . Importantly, individuals do not necessarily change stages with time but may remain in their initially assigned stage. Similarly, studies on clinical high-risk cohorts specifically examining conversion to full-blown psychosis, i.e., changes of clinical stages, find low transition rates of approximately 20-35% over 2 years . Furthermore, the clinical staging model is primarily based on retrospective studies and requires further prospective validation. The fact that the majority of individuals with a first episode of psychosis have not sought help before their ‘psychotic break’ highlights the necessity to broaden the target symptoms and audience of early intervention strategies for psychosis spectrum disorders. Populationbased studies have become an important strategy to validate the concept of a psychosis continuum, and may be helpful to tailor future primary prevention strategies to the general population by examining longitudinal trajectories of PS development across childhood and adolescence to detect early predictors . Studies on PS in the general population can further be viewed as an alternative to the CHR approach, an enrichment sampling focused on help-seeking individuals fulfilling certain diagnostic criteria . Given that clinical ascertainment is required, CHR cohorts may not reflect the broader population experiencing PS, which may at least partially explain higher pluripotentiality of PS observed in population-based studies relative to CHR samples . Similar to overt psychotic disorders, PS in the general population ) are often accompanied by cognitive impairments , reduced quality of life , higher rates of substance use, functional disability, suicidality , and alterations in brain structure and function , rendering PS an important public health issue. In accordance with a clinical staging model, PS pose an elevated risk for the later development of overt mental illness; not only severe psychosis spectrum disorders but also depression, anxiety disorder, and bipolar disorder , amplifying the significance as a public health concern. However, recent epidemiological and genetic findings highlight the complex relationship between PS and severe mental illnesses : overt psychotic disorders may exhibit diverse psychopathological precursors and similarly, PS in childhood and adolescence do not always foreshadow persistent psychosis and/or schizophrenia later in life. For example, in the Philadelphia Neurodevelopmental Cohort a positive predictive value of 0.51 was reported for initial screening of PS , but in a small Irish youth sample childhood PS had a positive predictive value of >0.59 for adolescent externalizing and internalizing problems . Population-based longitudinal studies on subclinical/ subthreshold PS in children and adolescents offer promise for identifying disease biomarkers that predict progression to overt mental illness . Ultimately, these efforts aim at improving early identification of at-risk youth in order to improve long-term functional outcomes. Risk factors for subthreshold PS and overt psychotic disorders, include genetic risk, both family history and high impact copy number variations such as 22q11.2 deletion syndrome , exposure to drugs as well as childhood adversities/trauma, obstetric complications, and socioeconomic difficulties, including ethnic minority and immigrant status . Importantly, all forms of prevention, i.e., universal, selective, and indicated , can be tailored to these risk factors . For example, universal prevention targets the general population and could involve destigmatization and anti-bullying campaigns to improve mental well-being overall. Selective preventions for people with increased risk for developing psychiatric disorders could be implemented in clinics by providing services for families of patients with severe mental illnesses, and indicated prevention is aimed at improving outcome in CHR individuals . Overall, general population studies allow for larger and unbiased samples, without typical confounders in clinical populations such as medication and illness duration. Such studies can therefore inform and shape policy making for preventive measures of severe mental illnesses. Table 1 provides an overview of population-based studies cited in this review. A pressing question, requiring longitudinal study, is whether sub-clinical PS in youth in the general population are in fact associated with the onset of overt psychosis later in life. One such study is the Dunedin Multidisciplinary Health and Development study, a birth cohort study out of New Zealand that followed the initial cohort over 38 years.

The patient bent down on his right knee and grabbed the dog with his left arm as he held himself up with his right hand, which was in the puddle. He reported a ‘‘buzzing feeling” traveling up his right arm. After bringing his dog to safety, the patient returned to the site, got down on both knees, put both hands in the puddle, felt a ‘‘humming” sensation travel up both arms and felt ‘‘stuck” in that position for 2–3 s . Immediately after the shock, the patient sustained burn marks and experienced short-term memory loss and fatigue. Three dayslater, the patient saw an internist and reported upper right quadrant pain, headaches, numbness, weakness, fatigue, insomnia, and minimal, first degree burn marks on his right underarm and on the dorsal aspect of both forearms. The surface area was 1.1% for each forearm, and an additional 1.1% for the right underarm, for a total affected area of 3.3%. One week later, the patient received MRIs of the lumbosacral spine, cervical spine and brain which all reported no abnormalities. One month later, the patient visited a psychologist regarding anxiety, insomnia, and depression, and was diagnosed with post-traumatic stress disorder and retrograde amnesia. Three months after the electrical injury, the patient saw an ophthalmologist regarding pain behind his right orbital and ‘‘drooping” of the right side of his face; he was diagnosed with Bell’s palsy. Two years after the incident, the patient had an orthopedic evaluation for right side body pain, loss of right hand motor control, right hand tremors,how to cure cannabis pain behind the right orbital and headaches with no orthopedic abnormalities found. The following day, the patient visited a neurologist and a different ophthalmologist regarding the same symptoms, with no abnormalities found.

Three years after the electrical injury, the patient visited a neurologist regarding hypesthesia in the right side of the face and to pinpricks to the right hand, severe pain in the right arm and hand, moderate pain in the left arm and hand, and was diagnosed with electrocution neuropathy. Five months later, the same neurologist noted improvement of the pain in the right arm and hand area. During the same year, the patient visited a therapist and was diagnosed with PTSD, severe anxiety, and situational depression and was prescribed psychotherapy as treatment. Six years after the injury, additional documentation of the damage sustained from the electrical injury was needed to provide objective evidence as part of a lawsuit against the electric company responsible for the exposed wires. The patient visited our laboratory for an MRI DTI and quantitative volumetric analysis, and a clinical neuropsychologist for an exam. At the time of the neuropsychological exam, the patient was taking Bupropion XL, Clobex, Hydrocodone/Acetaminophen, melatonin, Klonopin , Namenda , Neurontin , and medical marijuana. On the Diller-Weinberg Test, the patient missed 39/47 stimuli, and his visual encoding/processing speed on specific Wechsler Adult Intelligence Scale subtests was between the 1st and 5th percentile. On the dominant finger tapping test, the patient scored in the 5th percentile. His performance on a timed task of fine motor dexterity was impaired between 2 – 3 standard deviations below the mean, and his motor and processing speed index was in the 2nd percentile, which is typical residual of electrical injury. The patient scored 20 less points on his Performance intelligent quotient than his Verbal IQ , which is statistically significant and notably unusual. He scored as severely depressed on his Beck, and has had severe chronic pain and PTSD symptoms in the clinical range. The patient’s past medical history was significant for meningitis at age 10, and arthritis and hypertension as an early adolescent. The patient underwent several unrelated orthopedic surgeries from sports related injuries, with the last surgery being sixteen years before the electrical injury.

According to his ex-fiancé, the patient was very social and outgoing before the electrical shock, while he became withdrawn and isolated afterwards. The patient enjoyed activities such as surfing, swimming, hiking, basketball, and skateboarding, all of which he was unable to do, or did differently, after the injury. At the time of the incident, he was in good health and working as a physical trainer.Most electrical injuries happen in the workplace, while some occur in household settings. In dense cities that experience heavy snow during the winter, like Boston or New York City, residents are at a higher risk of electrocution through stray voltage when the snow starts to melt. Stray voltage is the unintended occurrence of an electrical potential between two objects due to a fault in an electrical system and is defined to be less than 10 volts by the U.S. Department of Agriculture. These circumstances, coupled with the increased conductance caused by high-salinity snowmelt, can charge normally non-threatening metal objects, or puddles with ample amounts of stray voltage. Electrical injury occurs when a person has at least two points of contact with two sources of different voltage, one of which may be the earth ground. The extent of electrical injury is dependent on the voltage, amperage, path of and type of the current /direct current, duration of contact, and premorbid state of the patient. In the presence of an external electric field, cell membrane permeabilization occurs as the lipids in the lipid bilayer undergo reorganization in a process known as electroporation. In turn, cell contents such as ions are able to move freely in and out of cells. Through the phenomenon of electroporation, current is able to travel through and leave the body through the second contact point to a grounding source. Clearly these aspects of EI are quite mechanistic, however, one of its enigmas include the remote neuropsychological deterioration of the patient regardless of the trajectory of the current .

EI has been known to cause a spectrum of neuropsychological and psychiatric disorders. Duff compiled a review of twenty eight studies of EI and lightning injury patients, logging 2738 victims reporting a total of 4441 signs or symptoms. These signs/ symptoms were ‘‘categorized into nine different domains of sequelae, which included disturbance of consciousness, attention/concentration deficits, speech/language deficits, sensory deficits, memory deficits, other cognitive deficits, psychiatric complaints, somatic complaints, and neurological complaints”. Another study of the long-term sequelae of low-voltage electrical injury done by Singerman reported numbness, weakness, and memory problems as the most frequent neurological problems and anxiety, nightmares, insomnia, and flashbacks of the event as the most frequent psychological problems. Since the literature suggests EI causes neuropsychological sequelae, it is worth using MRI imaging techniques to examine any structural abnormalities and cerebral lesions. Irregularities observed on MRI scans are generally unique to each EI case, however white matter hyperintensities found on fluid-attenuated inversion recovery image sequences are a common factor. The latter three of the case studies cited all report WMH specifically in the cerebral corticospinal tract. EI has also been known to cause hypoxia, which is characterized by cytotoxic edema in the cortex of the central region and the basal ganglia.The average lamppost in a densely populated city, such as New York City, works on a single-phase 120 V/240 V 60 Hz, AC received from a nearby three-phase generator . The patient received an electrical shock after submerging his hands in a puddle on a sidewalk charged with stray voltage from a nearby lamppost. Workers from the electrical company in the area testified that exposed ends of an electrical cable of a lamppost were causing 8 V of stray voltage. Using the information we know about wet skin resistance,indoor grow methods we can also assume that the patient’s hand had a resistance of 1000 X, while the patient’s internal body had a resistance of 300 X . Rearranging Eq. , we calculate the current passing through the patient’s hand to be approximately 8 mA, while the current passing through the internal body is approximately 26 mA. However since salt water is more conductive than pure water, this would have potentially lowered the resistivity of the patient’s hand, causing the current passing through his hands to be comparatively higher and thus accounting for the no-let-go phenomenon he experienced. To examine the validity of this approximation, we consider the patient’s dog that went into seizure upon stepping in the charged puddle.

A study done by Woodbury investigated the stimulus parameters needed to induce electroshock seizures on rats, and found that at 60 Hz AC, the current needed to promote seizures was 17.7 mA. This is extremely similar to the current needed, 16 mA, to induce the no-let-go phenomenon in the average male. Thus we can assume with substantial confidence that the current passing through the patient’s hand was roughly around 16 mA AC.At age 10, the patient was treated for meningitis. One week after the electrical injury, the 37-year-old patient received a brain MRI that reported no abnormalities. Six years after the injury, the patient had another brain MRI, which was sent to our laboratory. Since the cavitation of his right lateral ventricle is prominent on T1 multi-planar reconstruction and T2 FLAIR MRI sequences , it is highly probable that this particular abnormality was not derived from the patient’s childhood meningitis, otherwise it would have been observed by his former radiologist. MRI DTI analysis done on adult meningitis reports increased FA values in cortical regions, while analysis done on neonatal meningitis reports increased FA values in leptomeningeal regions and decreased FA values in periventricular white matter regions. However, to date, there are no studies that report white matter abnormalities found in adults with childhood meningitis, or studies that have assessed high diffusion anisotropy sequelae in patients with a history of meningitis.At the time of the neuropsychological exam, the patient was taking multiple medications that could have potentially affected cognitive performance. An investigation of these potential effects was conducted. Depressed patients treated with Bupropion scored similarly to normal, healthy controls on neuropsychiatric tests that assessed verbal memory, visual memory, finger tapping, and symbol digital coding. On the dominant finger-tapping test, our patient scored in 5th percentile, while on the coding subtest, he scored in the 10th percentile. The patient’s visual and verbal memory scores were average. In a study that assessed the neuropsychiatric effects of Hydrocodone, subjects that had taken hydrocodone performed 10% worse than the mean on the motor performance test, while no variance was found on simple and complex reaction time tests. Our patient scored in the 2nd percentile on the motor and processing speed index. In a study done on 38 patients taking Clonazepam, 8 patients experienced behavioral side effects while 30 patients did not . The mean absolute discrepancy between VIQ and PIQ of the 8 patients was 17.5 points, while the discrepancy between VIQ and PIQ of the 30 patients who did not experience behavioral side effects was 6.5 points. Our patient’s VIQ and PIQ difference was 20 points. No study has been done on the effects of memantine on cognitive behavior for patients without Alzheimer’s disease , but for patients with AD, memantine improved language and memory scores in comparison to a placebo group. Gonzalez measured the effects of cannabis on cognitive performance by determining overall indexes of neuropsychological performance and running individual neuropsychological tests . Habitual cannabis users performed 1/5th a standard deviation worse than controls in overall index scores, and had performed significantly worse on memory tests. No effects of melatonin on neurocognitive performance were found. No effects of gabapentin on neurocognitive performance were found.Advances in digital technologies and data analytics have created unprecedented opportunities to assess and enhance health behavior and to accelerate the ability of science to understand and contribute to improved health behavior and health outcomes. Over 5 billion people in the world have access to mobile phone services . And access to these technologies is not confined to high income populations or countries but is also increasingly evident in many low and middle income countries and traditionally underserved populations . Digital health refers to the use of digital technologies and data analytics to understand people’s health-related behavior and provide personalized health care resources . Given the widespread access to technology worldwide, digital health offers great promise to enable widespread reach and scalability of evidence-based treatments to promote health behavior and collectively lead to transformations in the delivery of science-based health care.

HCV-infected women were older than HIV-monoinfected women, and both groups were older than women with neither infection. More than half of all women were African American, with the largest proportion among the HCV-infected group. Compared with HIV-infected women and those with neither infection, HCV-infected women were more likely to report being in menopause, having a history of injection drug use, and smoking currently and also more likely to have diabetes and to have a higher homeostasis model assessment–estimated insulin resistance value but a lower low-density lipoprotein level. HIV-infected women had lower high-density lipoprotein levels and higher triglyceride levels than HIV-uninfected women. Compared with HIV-monoinfected women, HIV/HCV-coinfected women had slightly lower CD4 counts and higher current HIV viral loads.To our knowledge, our study is the first to examine liver fibrosis using ultrasound-based TE measurement of liver stiffness in a geographically and ethnically diverse cohort of US women with well-characterized metabolic parameters. We found that HIV/HCV-coinfected women but not HIV-monoinfected women had higher liver stiffness values than those with neither infection. Greater waist circumference, a marker of central obesity, was associated with liver stiffness in HCV-infected women, but not HIV-monoinfected women. Among HIV-infected women , a history of AIDS was associated with greater liver stiffness. Our finding that HIV-monoinfected women did not seem to have higher liver stiffness values than uninfected women was unexpected.

HIV infection per se has been shown to infect hepatic stellate cells ,metal greenhouse benches which in turn can lead to hepatic injury. The authors of that study suggested that HSC activation would be required in order to infect HSCs and stimulate expression of collagen and proinflammatory cytokines that promote fibrosis. In our study, >50% of our women had undetectable HIV RNA levels. Furthermore, in analyzing HIV-moninfected women only, we observed an association of liver stiffness with higher HIV RNA levels and a history of clinical AIDS . There are 2 possible reasons for the difference between our finding of a lack of association between HIV monoinfection and liver fibrosis and findings of other studies directly comparing HIV-monoinfected adults with adults with neither HIV nor HCV infection. First, Price et al studied HIVmonoinfected men not receiving highly active ART, and Blackard et al studied HIV-monoinfected women seen in the HERS cohort from 1993 to 2000. These studies therefore included patients that were more likely to have uncontrolled viral replication and lower CD4 counts and to be receiving antiretroviral agents associated with hepatic steatosis or liver injury, such as stavudine, didanosine, and zidovudine. In both studies, when the analysis was limited to those with HIV monoinfection only, greater immunosuppression was associated with greater fibrosis. Second, those studies used indirect serum markers of fibrosis APRI and FIB-4, which are derived from clinical laboratory values that might be altered by HIV infection itself. Vermehren et al found that whereas 37% of HIV-monoinfected patients had significant liver fibrosis or cirrhosis, as indicated by the serum fibrosis marker Fibrotest , only 21% had significant fibrosis as predicted by TE.

That study concluded that Fibrotest estimated much higher levels of fibrosis than TE in HIV-monoinfected patients. Examination of the association of HIV and HCV status with indirect serum markers of fibrosis and direct serum markers relative to TE measured liver stiffness are currently underway. It is noteworthy that waist circumference was associated with liver stiffness in our HCV-infected patients but not in HIVmonoinfected patients. Studies in HCV-monoinfected persons have shown that central obesity is a strong predictor of fibrosis, a stronger predictor than BMI, consistent with our findings. In HIV-monoinfected patients, DallaPiazza et al did not find an association of obesity with liver fibrosis estimated by the APRI. That study did not examine the association of waist circumference with liver fibrosis. Taken together, our findings and others suggest that central obesity further worsens underlying HCV-associated liver injury. By contrast, in the setting of little injury to the liver, the adverse effects of obesity may be less apparent. One question that needs study is whether hepatic steatosis, thought to be a consequence of excess visceral adipose tissue, is a mechanism by which rapid fibrosis progression occurs in the setting of HCV infection. In our study we found that daily marijuana use was associated with less liver fibrosis, with associations reaching statistical significance in HIV-monoinfected and control participants. By contrast, previous studies in HCV-monoinfected patients found daily marijuana use to be a strong risk factor for fibrosis progression. This discrepancy may be partly explained by the fact that our study included few women with significant fibrosis, and marijuana use was more common in women without HCV infection.

Findings of prior studies have suggested that cannabis may have little or no influence on the initiation of fibrosis but may only be an important cofactor in fibrosis progression when fibrosis is already present. Although we also found that Hispanic race was associated with greater liver stiffness in HIV-monoinfected women, the number of women of Hispanic race in our cohort was low, and therefore our findings should be interpreted with caution. Nevertheless, studies in the general population have shown that, compared with African Americans and whites, Hispanics have a greater prevalence of hepatic steatosis and are at greater risk of nonalcoholic fatty liver disease–associated cirrhosis. Our study has some important limitations. First, the cross sectional design limits our study to evaluation of exposures and disease status at one point in time. It is theoretically possible that liver fibrosis preceded our studied exposures; this is especially true of metabolic markers. Second, the proportion of patients with significant fibrosis in our HIV-monoinfected patients was small and limits our statistical power for identifying potential risk factors. However, the advantage of TE in providing a continuous measure of liver stiffness allows for broader study of fibrosis progression, producing a more robust evaluation of the factors associated with liver disease progression. Finally, the use of TE in our cohort has some limitations, including the exclusion of women that were more often obese. The exclusion of women with a BMI >35 kg/m2 may also have limited our ability to detect an effect of central obesity with fi- brosis in the HIV-monoinfected and control women. A detailed analysis comparing serum biomarkers of fibrosis with TE in the same study population is underway. Using TE to estimate fibrosis in a large cohort of women with HIV monoinfection, HIV/HCV coinfection, HCV monoinfection, and neither infection, we conclude that HCV but not HIV infection is associated with increased liver fibrosis. Central obesity further worsens liver fibrosis in HCV-infected women, but its effect in the absence of HCV-associated liver injury seems to be lessened. The mechanisms by which central obesity may worsen liver fibrosis in the setting of underlying HCVassociated liver injury need further investigation, including study of the contribution of hepatic steatosis and inflammation to liver fibrosis.

Neurocognitive dysfunction is a hallmark feature of schizophrenia and, to a lesser extent, of other psychoses; a conceptualization originating roughly 100 years ago with Kraepelin and Bleuler. There is ample evidence of significant but milder impairments during the premorbid phase,rolling greenhouse tables greater deficits during the prodromal or clinical high risk period,culminating in relatively severe deficits in the first episode and chronic phases. This suggests an evolution of neurocognitive dysfunction in individuals developing psychosis, especially schizophrenia. The CHR20 period is of considerable interest because it offers a temporal window into the changes occurring during the “near-psychotic” state, before confounders such as chronicity and long-term medication use cloud the picture. A substantial body of neurocognitive research in CHR populations has been summarized in a number of meta-analyses. “Small-to-medium effect size impairments across most neurocognitive domains studied and small-to-large ESs in those who convert to psychosis ” have been reported14 . Verbal memory and processing speed have emerged as relatively strong predictors of psychosis. However, small samples, different measures, and variable reporting of sample characteristics limit the reliability of these findings. In this second phase of the North American Prodrome Longitudinal Study , we assessed the largest CHR sample to date. First, we sought to identify the key neurocognitive functions impaired in the CHR stage, especially in those who later convert to psychosis. Descriptions of schizophrenia place considerable emphasis on the centrality of dysfunctions in attention and working memory. Evidence of severe deficits in declarative memory has more recently emerged in first episode  and CHR14, samples. Olfactory identification deficits have also been touted as a possible risk factor32,33 and processing speed and general cognitive ability have been shown to be robustly impaired in persons who later develop schizophrenia.We chose to provide extensive coverage of neurocognitive dimensions thought a priori to mark the evolution into frank psychosis. Second, we investigated if the neurocognitive profiles were characterized by a general deficit syndrome or specific impairments. This is of particular relevance for those individuals who transition to psychotic disorders as it provides critical information about the nature of neurocognition in the earliest phase of psychosis36. We hypothesized that the CHR+C group would be characterized by especially salient deficits against a background of general impairments. Third, we examined differences between medicated and unmedicated CHR individuals. Many of these young people take a range of medications including antipsychotics.Such medications could improve or impair cognition idiosyncratically. Prior CHR neurocognitive studies have not systematically addressed medication status.

The large sample in NAPLS-2 enabled an investigation of a sizeable subgroup of CHR+C individuals who have never been medicated, and thus help to identify an unadulterated picture of neurocognitive function. Finally, we explored the potential usefulness of neurocognition for predicting transition to psychosis. While it is unlikely that neurocognitive measures will be highly predictive by themselves of conversion to psychosis, in part because they are impaired in many neuropsychiatric disorders, knowing their relative sensitivities in combination with clinical features may help in the real-world prediction of psychosis or disability . NAPLS-2 is a consortium of eight programs studying the psychosis prodrome in North America, as in NAPLS-1. The methodology and clinical features of the NAPLS-2 study are detailed elsewhere. From a sample of 764 CHR participants and 279 healthy controls ranging in age from 12–35, 689 CHR and 264 HC participants provided baseline neurocognitive data. The study protocols and informed consents were approved by the ethical review boards of all sites, and all procedures comply with the ethical standards of the relevant committees on human experimentation and with the Helsinki Declaration, as revised in 2008. The CHR sample met the Criteria of Prodromal Syndromes 20, based on the Structured Interview for Psychosis Risk Syndromes 20, or if under age 19, criteria for schizotypal personality disorder or COPS. Participants were excluded if they had a lifetime Axis I psychotic disorder, estimated IQ’s < 70 on both measures of IQ, a central nervous system disorder, or DSM-IV substance dependence in the past 6 months. Other nonpsychotic DSM-IV disorders were not exclusionary unless they clearly caused or better accounted for prodromal symptoms. Antipsychotic medications were allowed, provided there was clear evidence that psychotic symptoms were not present when the medication was started. HCs could not meet criteria for any prodromal syndrome, current or past psychotic or Cluster A personality disorder, or have first-degree relatives with a history of psychotic disorder or psychotic symptoms. For some analyses, we used a rescaled sum of unusual thought content/ delusional ideas and suspiciousness/persecutory ideas items from the SIPS positive symptoms. Transition to psychosis was determined by meeting SIPS Presence of Psychotic Symptoms criteria. Assessments were at baseline, 12 and 24 months. Current alcohol and marijuana use was assessed with the Alcohol and Drug Use Scale . The Calgary Depression Scale for Schizophrenia was used to assess depression. The neuropsychological battery was designed to cover a range of functions using well established clinical neuropsychological tests, as well as experimental measures of sensory, perceptual, or cognitive functions hypothesized to be important indicators of CHR status or conversion to psychosis. These included the MATRICS battery, the Wechsler Abbreviated Scale of Intelligence for general intellectual ability and the Wide Range Achievement Test-4 reading task to estimate premorbid ability. Experimental measures included the Babble test , the University of Pennsylvania Smell Identification Test for olfactory identification, a visual and verbal paired associate memory test , and three auditory attention & working memory continuous performance tests .

The changes in A-type potassium channel gating caused by 2-AG include a shift of the voltage-dependent activation of IA in the depolarizing direction, acceleration of the inactivation kinetics, and reduction of the maximal current for large depolarizations. The IA–inhibiting effect of 2-AG likely results from a direct action on the channel through a membrane lipid interaction; specifically, binding of 2-AG may modify the interaction of the voltage-sensing S4-S5 region of the channel with the S6 region that controls channel opening and closing. It is thus suggested that by modulating IA, 2-AG and related lipid signaling molecules can directly tune neuronal excitability in a cellautonomous manner. 2) Delayed rectifiers: Besides exerting inhibitory effects on fast–inactivating potassium channels as described above, endocannabinoids also modulate the activity of classical delayed rectifier-type potassium channels. Classical delayed rectifiers like Kv1.2 , Kv2.1, and Kv3.1 do not show inactivation in the millisecond time scale; functionally, delayed rectifiers terminate action potentials, restore the dominant potassium permeability of the resting membrane potential, and shape the action potential. AEA has been shown to inhibit Shaker-related Kv1.2 channels; specifically, via accelerating the inactivation rate of Kv1.2, externally applied AEA concentration-dependently reduces Kv1.2 channel currents recorded at whole-cell and outside-out patch modes in fibroblasts stably transfected with Kv1.2 cDNA, whereas intracellularly dialyzed AEA is without effect. This inhibitory effect of AEA on Kv1.2 channels does not require activation of CB1 receptors or G protein signaling since neither CB1 receptor antagonists nor pertussis toxin could prevent the effect.

Moreover,rolling grow table externally applied Δ9 -THC, the major psychotropic constituent of cannabis, is capable of mimicking the inhibitory action of AEA on the Kv1.2 channel. Poling et al. thus propose that an acceptor site on the extracellular side of the Kv1.2 channel recognizes AEA and other cannabinoid-like molecules. In vascular smooth muscle cells, modulation of potassium channel activity plays an essential role in regulating membrane potential, which in turn influences the open probability of vascular CaV channels, the contractile tone of vascular smooth muscle, and blood flow . External application of AEA has been reported to concentration dependently reduce the delayed rectifier K+ current acquired in the whole-cell mode from freshly dissociated rat aortic smooth muscle cells in a CB1 receptor-independent manner. In addition, methAEA and WIN 55,212–2 elicit similar inhibition of delayed rectifier K+ current, and these effects are also CB receptor independent. Van den Bossche and Vanheel thus concluded that cannabinoids likely bind to an external site on or near the delayed rectifier Kv channel of the aortic vascular smooth muscle cells to modulate the channel activity. Intriguingly, it appears that AEA may inhibit delayed rectifiers in different tissues via a similar mechanism, i.e., acting from the extracellular side of the membrane . It has been demonstrated that in both primary cultured rat cortical astrocytes and astroglial cells in cortical slices, low micromolar concentrations of AEA promote a strong reduction of the delayed rectifier outward K+ current. Pharmacological blockade experiments further uncovered the AEA-induced inhibition is independent of CB1 receptor activation, AEA metabolism, and Ca2+ signaling. The delayed rectifier-inhibiting effect of AEA in astrocytes is mediated by its interaction with the extracellular leaflet of the plasma membrane based on the observation that only extracellularly, but not intracellularly, applied bovine serum albumin recovers the delayed rectifier K+ current suppressed by AEA.

Moreover, the inhibitory effect of AEA on astrocyte delayed rectifier potassium channels does not involve an interaction of AEA with lipid rafts and/or caveolae as cholesterol-extracting agents fail to abrogate the AEA effect. Collectively, the findings made by Vignali et al. suggest that AEA may stabilize the closed state of the delayed rectifier potassium channel by binding to hydrophobic determinants of the protein complex. Their findings support that endocannabinoids may effectuate their modulation of CNS function through regulating potassium channel-mediated homeostatic function of the astroglial syncytium, which might explain some non-neuronal effects of the endocannabinoid system . In the pancreas, Kv channels contribute to the regulation of insulin secretion by controlling the repolarization of pancreatic β-cell action potential. The delayed rectifier is thought to be the dominant Kv current of β-cells, and hence has received much attention as potential therapeutic targets for type 2 diabetes. It is noteworthy that delayed rectifier Kv channels in β-cells are also modulated by endocannabinoids. Spivak et al. reported that 2-AG concentration dependently inhibits the whole-cell current of delayed rectifier potassium channels in the mouse insulinoma cell line R7T1, with an IC50 of 20 μM; moreover, the inhibitory effect of 2-AG on β–cell delayed rectifier K+ current is CB receptor independent. The predominant delayed rectifier potassium channel in murine β-cells is the Kv2.1 type; moreover, delayed rectifiers from Kv1 , Kv2, and Kv3 subfamilies are also present in murine β-cells. In addition, Kv1.5 is detected in human insulinoma cells and is highly expressed in human islets. It is possible that multiple distinct Kv channels comprise the delayed rectifier current of the human ß- cell . In the human heart, Kv1.5 channels underlie the ultra-rapidly activating delayed rectifier K+ current that is critical for determining the height and duration of the human atrial action potential and a potential target for treating atrial arrhythmias. It has been demonstrated by Barana et al. that both AEA and 2-AG exhibit a high potency to inhibit human Kv1.5 current acquired in stably transfected mouse fibroblasts, an inhibitory effect that is independent of CB receptor activation and changes in the order and microviscosity of the membrane; in other words, the potencies of blockade are not related to the liposolubility of the compounds.

Endocannabinoidinduced block of human cardiac Kv1.5 channels appears exclusively when endocannabinoids are applied at the external surface of the cell membrane; furthermore, the blockade by AEA or 2-AG is reduced by mutation of R487 located in the external vestibule-entryway, a residue that determines Kv1.5 sensitivity to external tetraethylammonium . AEA also inhibits atrial end pulse sustained K+ current in human atrial myocytes which is mainly carried by Kv1.5 channels, and it significantly prolongs the duration of action potentials recorded in mouse left atria. These findings thus support that endocannabinoids block human cardiac Kv1.5 channels via specific interaction at the extracellular TEA binding site of the channel, a mechanism by which the endocannabinoids regulate the shape of atrial action potentials. Moreno-Galindo et al. examined AEA modulation of cloned Kv1.5 channels expressed in transfected HEK293 cells and showed that AEA exerts high-potency block of Kv1.5 channel currents in a CB receptor independent manner from the cytoplasmic membrane surface,cannabis grow equipment consistent with open-channel block. The postulated binding site for AEA in the study by Moreno-Galindo et al. is located on the S6 domain that lines the channel vestibule, which, however, is distinct from the extracellularly located interaction site suggested by Barana et al.. Specifically, Moreno-Galindo et al. identified Val505 and Ile508 within the S6 domain of Kv1.5 , two residues facing toward the central cavity and constituting a motif that forms a hydrophobic ring around the ion conduction pathway, as AEA interacting sites. Moreno-Galindo et al. thus suggest that the hydrophobic ring motif may be a critical determinant of CB receptor-independent AEA modulation in other K+ channel families. Studies reviewed above support that the endocannabinoid AEA may directly interact with delayed rectifier Kv channels and thereby modulate the channel function in a CB1/CB2 receptor independent manner. Interestingly, observations made on cloned Kv channels expressed in Xenopus oocytes have revealed that membrane lipids such as PIP2, by removing fast inactivation, can convert A-type potassium channels into delayed rectifiers, whereas AEA and arachidonic acid, by introducing fast inactivation, can convert non-inactivating delayed rectifiers into rapidly inactivating A-type potassium channels. These findings thus imply that AEA may control the coding properties of neurons and synapses beyond the characteristics set by the expression profile of Kv channel protein subunits.In addition to BK and Kv channels, endocannabinoids also modulate two-pore domain potassium channels. TWIK-related acid-sensitive potassium channel 1 , a member in the K2P channel subfamily, encodes an acid- and anesthetic-sensitive background K+ current, which sets the resting membrane potential of both cerebellar granule neurons and somatic motoneurons, and may contribute to anesthetic induced immobilization.

It has been demonstrated by Maingret et al. that, unlike other K2P channels, TASK-1 expressed in COS-7, CHO or HEK293 cells is directly blocked by submicromolar concentrations of AEA, an effect independent of both CB1 and CB2 receptors and G proteins. The inhibition of TASK-1 by AEA is specific, not mimicked by 2-AG, another endocannabinoid, or by Δ9 -THC, the major psychoactive compound in cannabis; additionally, AEA hydrolysis is not involved, as the non-hydrolysable analogue methAEA is similarly effective. These findings suggest that TASK-1 constitutes a novel, sensitive molecular target of AEA. It is recognized that cannabinoids including AEA profoundly affect locomotion, exerting a dose-related biphasic effect ; direct modulation of TASK-1 by low doses of AEA might thus account for some of the biphasic, CB1 receptor-independent effects observed with AEA on locomotion.The role played by CB receptors in regulating energy balance is well established. Endocannabinoid lipids are known to exert orexigenic effects via activation of central cannabinoid CB1 and CB2 receptors; in addition, the peripherally produced endocannabinoids also act as local regulators of insulin secretion through pancreatic β-cell CB receptor-mediated elevation in Ca2+ levels. Beyond a physiological role in regulating energy balance, the cannabinoid transduction cascade may have a pathophysiological function to stimulate insulin-dependent lipid deposition through enhanced insulin output in response to increased levels of peripheral 2-AG, as seen in obesity, which implies that a dysregulated endocannabinoid system in the adipocytes and β- cells likely contributes to hyperlipidemia, hypoadiponectinemia, and hyperinsulinemia in obesity. The ATP-sensitive potassium channel, a member in the inwardly rectifying potassium channel subfamily, functions as a high fidelity metabolic sensor that couples intracellular metabolic state to membrane excitability, serving a homeostatic role ranging from blood glucose regulation to cardioprotection. KATP channels in pancreatic β-cells regulate insulin secretion in response to plasma glucose levels, via regulating membrane potential and thereby the activity of CaV channels, intracellular Ca2+ levels, and Ca2+-dependent exocytosis of insulin. Interestingly, β-cell KATP channels have been shown to be modulated by endocannabinoids. Spivak et al. reported that single-channel KATP currents acquired at 2 mM glucose in the inside-out patch configuration in R7T1 cells, a mouse insulinoma β-cell line, are concentration dependently inhibited by 2-AG applied from the cytosolic side . CB1 receptors are expressed in murine β-cells; however, the CB1 receptor antagonist AM251 does not affect 2-AG’s inhibitory action on KATP channel current, indicating that CB1 receptors do not mediate the effect. The direct blockade of the KATP channel by 2-AG at low glucose concentrations would depolarize the β-cell and results in stimulation of insulin secretion; it is suggested that 2-AG may increase insulin secretion in a manner similar to that of the sulphonylureas by directly interacting with the KATP channel. However, a role of AEA on the function of pancreatic β-cell KATP channels has yet to be explored. Endogenous KATP channels in follicle-enclosed oocytes from Xenopus laevis are subject to modulation by gonadotropins and may play important roles in oocyte maturation and hormonal regulation of oocyte development. The effect of endocannabinoids on cromakalim -activated KATP currents has been examined in follicular oocytes using two-electrode voltage-clamp recordings. AEA inhibits cromakalim-activated KATP currents in a noncompetitive manner, with an IC50 of 8.1 μM; the inhibitory effect of AEA on cromakalim-induced KATP currents is independent of CB receptors and of Gi/o-coupled receptors, as manifested by the ineffectiveness of CB receptor antagonists and pertussis toxin, respectively, to prevent AEA-induced block. Furthermore, inhibitors for AEA’s degradative enzymes amidohydrolase and cyclooxygenase fail to affect the blockade of cromakalim-induced KATP currents caused by AEA, indicating that the effect of AEA is not mediated by its metabolic products. Evidence provide by Oz et al. thus suggests that AEA may modulate the hormonal maturation process in Xenopus oocytes by modulating KATP channel activity. AEA is involved in the regulation of cardiovascular function. In addition to Kv channels in ventricular myocytes and vascular smooth muscle cells , myocardial KATP channels are also functionally modulated by AEA. Contrary to the observations made in pancreatic β–cells and follicle-enclosed oocytes where endocannabinoids suppress native KATP channel function, Li et al. reported that in isolated rat ventricular myocytes, AEA increases whole-cell KATP currents induced by dinitrophenol, a mitochondrial uncoupler, in a concentration dependent manner. Furthermore, the stimulatory effect of AEA on ventricular KATP currents is reduced by pretreatment of cells with the CB2 receptor antagonist AM630, whereas the CB1 receptor antagonist AM251 has no effect.

One debate in the HIV literature is the extent to which HIV disease is associated with accelerated aging as opposed to other comorbid conditions or other lifestyle factors associated with HIV. However, it is difficult to differentiate the effect of HIV itself versus the downstream effects of HIV or lifestyle factors associated with risk of contracting HIV . For example, many studies have documented higher risk of vascular risk factors including hyperlipidemia, type II diabetes, hypertension, and abdominal obesity in PWH likely due to the cardiometabolic side effects of ART, chronic immune activation, comorbid conditions that are more common in PWH , and increased risk of chronic stressors . Cysique & Brew propose that vascular cognitive impairment is implicated in the pathogenesis of neurocognitive impairment in PWH, particularly older PWH, given that cardiovascular and cerebrovascular conditions can cause alterations in the blood-brain barrier, altered vascular reactivity, and brain changes, particularly in white matter. A recent meta analysis by McIntosh et al., found that cardiovascular disease, particularly type II diabetes, hyperlipidemia, and current smoking, are associated with an increased risk of cognitive impairment in PWH. CVD has been associated with brain changes in PWH, but the majority find an association with abnormal white matter , which was not examined in the current study. Several vascular risk factors were examined as covariates and were not found to be significantly associated with cognitive outcomes; although it is important to note that this group is limited in that participants with more significant vascular comorbidities such as stroke or myocardial infarction were excluded for these analyses.

Nevertheless,commercial racks further exploration of vascular risk factors and how they are associated with cognition and brain aging in this cohort and PWH more broadly is of course warranted to further understand the effects of HIV versus the effects of comorbid conditions associated with HIV. Comparing the results of the current study to the middle-aging literature is difficult. First, while brain changes due to AD pathology can begin in mid-life, it is still several years from midlife to when one would develop late-onset aMCI/AD; thus decades-long studies are needed to better understand brain changes in mid-life and how they relate to late-life AD. Therefore, the literature is sparse and generally relies on AD risk to examine memory and neuroimaging in mid-life. Second, many studies with an aging focus examine a memory composite and thus it is difficult to discern the association between delayed recall versus recognition and brain integrity from these studies. Even older-adult studies often do not specifically examine recognition memory as again they either examine aMCI diagnosis, which in the older adult literature does not necessarily imply recognition impairment, or a memory domain. Third, given the AD focus of middle-aging studies, many middle-aging studies focus on the medial temporal lobe and do not explore other regions such as the basal ganglia or the prefrontal cortex. From the sparse middle-aging research that examines both memory and neuroimaging, there is some indication that memory is associated with several neuroimaging correlates, most notably the medial temporal lobe. For example, the Wisconsin Registry for Alzheimer’s Prevention study, which focuses on adults aged 40-65 and is enriched with a family history of AD, has reported memory and neuroimaging associations. For example, in a study of 261 WRAP participants, those with subjective memory complaints had significant cortical thinning in the entorhinal, fusiform, posterior cingulate, and inferior parietal cortices and reduced amygdala volume compared to participants without subjective memory complaints.

In 109 participants in the WRAP study, participants that were Aβ+, determined via PET imaging, exhibited significantly thinner entorhinal cortex, accelerated age-associated thinning of the parahippocampal gyrus, and performed worse across cognitive measures, although not significantly worse, compared with the Aβ− group . Approximately 65% of WRAP participants were female and approximately 95% of participants were non-Hispanic white. In a study of 210 adults aged 40-59 by Ritchie et al. , worse spatial recall and visual recognition as well as greater dementia risk were associated with lower brain and hippocampal volume. Overall, the middle-aging literature is quite limited, so it is difficult to discern if episodic memory, regardless of the type of memory , reliably associates with the medial temporal lobe in middle age. While it is significant that these studies do find associations between memory, AD risk, and the medial temporal lobe as well as other brain structures, these studies do not report prefrontal involvement like that observed in the current study. Of note, the study participants in these two studies markedly differ from the CHARTER cohort; the CHARTER cohort was not enriched for family history of AD, is predominantly male , and this sub-sample is 50.5% African American/Black and 38.4% non-Hispanic White. However, Jak et al., , which examined men in their 50s , also found that MCI diagnosis was associated with smaller hippo campal volume, although only the hippocampus was examined in this study. One curious finding was that the post hoc analyses examining a sub-sample of participants showed that better delayed recall was associated with a thinner entorhinal cortex. The aim of these analyses were to examine and confirm that prior findings are applicable to participants that were ideally treated for HIV disease and did not have any current substance use that could confound results. Although it should be noted that full sample is already a group that somewhat differs from the general population of PWH in that this group excludes PWH with severe comorbid conditions, they have little to no current substance use, and are relatively well treated for HIV as compared to the general population . Nevertheless, this finding is opposite of what was hypothesized based on the literature.

While thicker cortex has been associated with cognitive dysfunction in some settings, suggesting that it is the deviation from normal cortical thickness that is meaningful , within the HIV and AD literature this has not been observed. In HAND and AD , atrophy is consistently related to worse cognitive functioning. Therefore, it is likely that this is a spurious finding. Given that this is a relatively small sub-sample and may not be generalizable, and thus this finding should not be over interpreted. To further validate the specificity of memory and medial temporal lobe relationships and show that memory is not just related to overall brain integrity, processing speed and psychomotor skills were also examined in aim 1c. It was hypothesized that these two domains would be more associated with fronto-striatal structures implicated in HAND. In the entire sample, processing speed and psychomotor skills were not significantly associated with the medial temporal lobe as hypothesized. However, they were not significantly associated with prefrontal or basal ganglia structures either. Overall, these findings were not in line with the hypotheses, and given that episodic memory was not associated with medial temporal lobes,greenhouse rolling benches these findings do not help to demonstrate that associations with the medial temporal lobe are specific to memory and not cognitive functioning in general. In post hoc analyses, a thinner pars orbitalis was significantly associated with worse psychomotor functioning, which was somewhat in line with the hypotheses; however, the literature would suggest that we may expect psychomotor function to be more related to basal ganglia structures, particularly the putamen . When examining covariates for this aim of the study, AIDS status and APOE e4 status were associated with worse delayed recall. Regarding AIDS status, nadir CD4 count has repeatedly been associated with riskof HAND both within the CHARTER cohort and in other cohorts around the world . While nadir CD4 count was examined as a potential covariate and was not found to be associated with delayed recall, AIDS status is of course associated with nadir CD4 given that an AIDS diagnosis is defined by either an opportunistic infection or if CD4 cell count drops below 200 cells per milliliter of blood at any point in one’s life . It is thought that greater immunosuppression is associated with CNS injury and those neurologic consequences may persist even after treatment with ART and immune recovery ; this highlights the importance of HIV identification and initiation of ART to avoid immunosuppression. Based on the estimated duration of HIV, most of these participants contracted HIV either before ART was available or in the era in which ART was not recommended to be initiated until after immunosuppression. This cohort on average is characterized by a history of immunosupression with immune recovery given that there is high rates of AIDS with evidence of immune recovery as evidenced by a median CD4 count of almost 500 and high rates of current ART use.

Given that ART policies have changed and it is now recommended that ART is initiated immediately after diagnosis , continued research on aging with HIV will be needed to understand different cohort effects . Nadir CD4 has been associated with thinner cortex and smaller brain volumes throughout the brain, particularly in the parietal, temporal, and frontal lobes, and the hippocampus . Therefore, it is important to reiterate that episodic memory and prefrontal regions were significantly associated with one another even when accounting for AIDS status. Interestingly, one study found that low nadir CD4 was associated with reduced functional connectivity in the memory networks in APOE e4 carriers not but non-carriers . Regarding APOE status, several studies have examined the association between memory and APOE status in middle age, finding that APOE e4 carriers have similar memory and cognitive performance to non-carriers until the mid-to-late 50s when differences start to appear . Interestingly, the association between APOE e4 status and worse memory, specifically delayed recall but not recognition, was found within this group of PWH whose mean age was in the early 50s. However, other early markers associated with preclinical AD, such as the association between memory and medial temporal lobe structures were not, although APOE by medial temporal lobe interactions were not explored. Previous HIV studies have shown mixed results when examining the association between APOE status and cognition within PWH. Within the larger CHARTER cohort, Morgan et al. found that APOE e4 status was not associated with a greater risk of HAND; however, this study was from an earlier time point in which participants were, on average, 44.1 years old. Moreover, in another CHARTER study by Cooley et al. in a sub-sample of CHARTER participants aged 50 and over, APOE e4 status was not associated with volumetric differences on MRI or MR spectroscopy metabolite analyses. However, these structural analyses may not have had the specificity to detect more minute differences in specific regions of the brain such as the medial temporal lobe. Nevertheless, the HIV literature is mixed as a review found that some HIV studies do find worse cognitive and brain integrity in PWH who are APOE e4 carriers whereas others do not . Several HIV studies, particularly in PWH over the age of 50, have found that APOE e4 status is associated with worse brain integrity in several regions including cerebral white matter, the thalamus, and temporal, parietal, and frontal regions. Additionally, one study comparing PWH to HIV-negative controls found APOE e4 carrier status to be beneficial in younger age, consistent with the well-documented antagonistic pleiotropy effect of APOE across the lifespan, but found that the negative effect of APOE e4 status in persons over the age of 50 was stronger in PWH compared to HIV-negative participants . Despite this one study, few studies have examined if there is a synergistic effect between APOE status and HIV status on cognition and brain integrity, although animal models do suggest possible mechanisms of a synergistic interaction between HIV and APOE status . Notably missing from the HIV literature is an examination of differential associations by sex or race/ethnicity and APOE’s association with cognition and brain integrity. In a meta analysis of aging research studies, APOE e4 women were found to be at greater risk of AD compared to APOE e4 men but only between the ages of 65 and 75 . Additionally, there are known differential effects of APOE status on AD risk by race. The effect of APOE status on AD risk is significantly attenuated in African Americans/Black people compared to non-Hispanic white people . Therefore, future examination of the relationship between sex, race/ethnicity, APOE status, and other genetic markers of AD risk within PWH is certainly warranted.