While the timeframe for the current study was 55 weeks and the proportion of subjects reporting ARBs during this interval approached 50% in females, ARBs occur over many years and longer term follow ups are needed. In addition, the short time frame of reporting for the prior month for each assessment resulted in relatively low numbers of ARBs per individual per evaluation. Additional caveats are worth noting. All information about ethnic identity and blackouts involved self-reports, which may underestimate ARBs because heavy drinking can interfere with accurate recognition of whether an ARB occurred. It is also important to recognize that while the SRE has proven to be a robust predictor of future heavy drinking and alcohol problems, the present analyses did not control for years of drinking, the type of beverage consumed or other covariates. However, prior studies demonstrated that the relationship of SRE scores to heavy drinking and related consequences remained robust even after controlling for sex, weight, marijuana use or smoking histories and operated similarly in 12- year-old subjects with recent drinking onsets and in young adults . Finally, there are important subgroups among EA, Asian and Hispanic populations, which, reflecting our sample size, could not be evaluated,vertical farming equipment suppliers and additional risk factors associated with ARBs were not included in analyses. These caveats aside, the present findings indicate that the propensity toward ARBs goes beyond the amount of alcohol consumed and is related to interrelationships among ethnicities, sex, and the sensitivity to alcohol. There are important differences among subgroups of students regarding how characteristics contribute to the ARB risk.

Understanding how these interrelationships operate can be important in identifying who carries the highest risk and in creating focused and efficient prevention programs. Universal HIV testing is a cornerstone in efforts to achieve epidemic control as HIV-infected and unaware people are associated with the majority of HIV transmission events. In particular, during acute and early HIV infection , people who are unaware of their HIV status represent a subgroup with a disproportionate risk of HIV transmission due to high HIV viral loads, ongoing sexual risk behaviors and greater per-contact infectivity. The CDC recommends provision of confidential partner services to provide HIV risk reduction education and HIV testing to the recent sex or needle-sharing partners of newly HIV diagnosed people. By linking recentlyexposed persons to testing and treatment, this public health intervention has been used to limit the spread of sexually transmitted infections , such as syphilis and gonorrhea, since the early 20th century. In the setting of HIV, however, partner services has had its limitations. In 2006, Katz et al. estimated that fewer than half of newly HIV-diagnosed persons received partner services at public health departments across the United States. Reasons include that partner services is not mandated by law for HIV infection and more importantly that HIV remains a highly stigmatizing condition with significant implications for direct or indirect disclosure. Not only is partner services underutilized, but it can be limited in finding HIV unawares in the setting of newly diagnosed chronic HIV infection in which persons are often required to recall partners from several years prior.

In 2007, the Task Force on Community Preventive Services, in reviewing the efficacy of partner services, showed that 20% of all referred partners were newly diagnosed with HIV. Persons with AEH likely represent a group particularly appropriate for partner services, as recall of recent sexual or needle-sharing partners may be more likely to identify putative transmission partners . Studies of partner services in the setting of recent HIV infection are limited, but demonstrate a greater yield of new HIV diagnoses in the setting of newly diagnosed acute HIV infection as compared with partner services provided to chronically HIV-infected persons. We examined the yield of HIV partner services provided to persons newly diagnosed with AEH in San Diego for identification of HIV-unaware persons, individuals with AEH, genetically linked partners and HIV-uninfected individuals at high risk for acquiring HIV infection.Adults and adolescents were offered confidential and free-of-charge screening for acute, early and established HIV infection at multiple community-based sites in San Diego as part of the San Diego Primary Infection Resource Consortium from 1996 to 2014. Before 2007, a quantitative HIV RNA was performed in HIVantibody–negative persons presenting with signs or symptoms of AEH and behavioral risks for HIV infection . Beginning in 2007, HIV nucleic acid testing was provided to all HIV antibody–negative persons regardless of symptoms and exposures. AHI was defined by a negative or indeterminate HIVantibody test in the presence of detectable HIV-1 RNA, corresponding to Fiebig stages I–II. Early HIV infection was characterized by using one of the available assays to estimate recency [Vironostika HIV-1 enzyme immunoassay ; Durham, North Carolina, USA , Less-Sensitive or Detuned Vitros anti-HIV 1þ2 assay and limiting antigen and defined as HIV antibodyþ/detuned HIV antibody consistent with infection less than 170 days.

Consenting antiretroviral -naive individuals with AEH were offered enrollment and longitudinal follow-up in the observational SD PIRC study.Routine clinical laboratories and HIV drug resistance testing were performed at baseline; demographic and behavioral risk data were collected for all individuals. Longitudinal follow-up included visits at weeks 2, 4, 8, 12 and every 24 weeks thereafter. HIV partner services were offered to all AEH clients and included education and counseling to elicit information about recent sex or needle-sharing partners. Index cases were offered ‘self-disclosure’ , ‘dual-disclosure’ and ‘third-party notification’ for recruiting their recent sex or needle-sharing contacts. Study staff providing partner services received structured partner services training by the California Department of Public Health or Centers for Disease Control and Prevention. These structured trainings were repeated by our study staff every 5 years. The trainings included how to elicit partners from index cases, including prompts and reinterviews, and delivering exposure notifications to partners. Privacy concerns were taken very seriously, in particular when an index case chose third-party notification . Partners successfully contacted were offered free-of-charge HIV testing and counseling through SD PIRC or a testing facility of their choice and linkage to prevention and treatment services. Those with positive HIV test results who reported unknown or negative HIV serostatus before HIV testing were defined as newly HIV diagnosed, whereas those who reported positive serostatus or found to have been diagnosed previously were defined as previously diagnosed. All recruited partners who underwent HIV testing and counseling with the SD PIRC provided behavioral risk information, and recruited partners identified with AEH were also offered enrollment into SD PIRC as index clients . Partnerships were characterized as genetically linked if the HIV population sequence from an index case and their recruited partner were less than or equal to 1.5% genetically different using the Tamura-Nei model. The study focused on sex or needle sharing partners recruited within 6 months of diagnosis of the index case. Statistical analysis was performed using SPSS version 22 and SAS 9.3 . The efficacy of partner services provided to AEH clients was assessed by the number of index cases needed to interview to identify recruited partners: for HIV/STI testing, newly diagnosed with HIV infection,grow light shelves AEH infection and genetically linked index and recruited partners. We compared demographic and behavioral characteristics between HIV-infected and HIV uninfected recruited partners by using two-tailed t tests and two-tailed x2 analyses. Because both index and recruited partners were occasionally represented in multiple different partnerships, mixed-effects logistic modeling was performed for genetic linkage and new HIV diagnoses. The UCSD Human Research Protections Program approved the study protocol, consent and all study related procedures. All study participants provided voluntary, written informed consent before any study procedures were undertaken.We found that partner services for persons with AEH represents an effective tool to find HIV-unaware persons, particularly when partner services is performed within 30 days of diagnosis. Importantly, more than a third of the newly HIV-diagnosed recruited partners were still in the acute and early phases of HIV infection, that is the phase with the greatest risk of HIV transmission. Partner services also identified putative transmission partners, with genetically linked partners representing 61% of the seroconcordant partnerships. Finally, partner services identified a high-risk HIV-uninfected cohort, whose risk behaviors did not differ from those newly diagnosed with HIV infection. The HIV epidemic is propagated by HIV unawares, particularly during the phase of AEH. We demonstrated that HIV screening within the sexual contact network of persons diagnosed with AEH is an effective strategy to identify HIV unawares in early stages of HIV infection. In this study, one out of three recruited partners was newly diagnosed with HIV infection and one out of seven with AEH. This was 12 times higher than the overall yield of voluntary community-based HIV screening of MSM with the SD PIRC , the HIV-screening program used to identify the index participants in this study. Also, the recruited partners identified in this study represented a more high-yield cohort than previously documented. In two prior studies of partner services in AHI, 7–10% of all recruited partners identified were newly diagnosed with HIV, as compared with 33% in this study.

Partner services might contribute to broader public health goals to end the epidemic. Although we found a decrease over time in the number of recruited partners , which may be explained in part by the success of anonymous, internet-based sexual networks, partner services continued to be high yield in terms of identifying HIV-positive individuals . Another key finding was that the immediacy of partner services was essential. Partners identified in the first 30 days of a new AEH diagnosis were more likely to yield a new HIV diagnosis and a putative transmission link to the index case . In addition, 29% of genetic linkages occurred in partnerships in which the recruited partner also had AEH, showing that partner services coupled with phylogenetic analysis could potentially be an effective tool in identifying and targeting real-time transmission outbreaks among AEH persons. The HIV-uninfected recruited partners in this study reported behavioral risks that were comparable with AEH-infected index cases. Because they belonged to the sexual network of an individual with high infectivity, and because their risk behaviors did not differ from HIV-infected recruited partners, this group may represent ideal candidates for focused HIV-prevention services, including pre-exposure prophylaxis . Limitations of this study included the observational study design and the convenience sampling used to identify the study cohort. Further, this study was performed among MSM and in San Diego, among whom the HIV epidemic may differ from other areas of the world. Despite the fact that new HIV diagnoses within this studies were based on laboratory findings, self-report , and also checked against local HIV clinical and research databases, we can’t rule out that a proportion of recruited partners classified as newly diagnosed may, in fact, have been diagnosed with HIV before. Also, our study participants identified fewer recruited partners when compared with two prior studies of partner services . This is most likely because field-services were not provided in this study, as compared with the two prior studies in which partner services was performed by the local public health departments. In conclusion, our study indicates that provision of partner services to persons with AEH within the first 30 days of diagnosis represents an effective tool for finding HIV-unaware persons, including those with AEH who are at greatest risk of HIV transmission. In addition, partner services in this setting identifies HIV-uninfected partners who may greatly benefit from targeted prevention services, such as PrEP. These findings may suggest that in settings in which time and funding are too limited to perform partner services in all new HIV diagnoses, partner services should be focused on individuals diagnosed with AEH and performed within 30 days of diagnosis. Increased focus of partner services on individuals with AEH in these settings may potentially improve partner services delivery by clinicians and public health departments, identification of HIV-unawares and persons during AEH and identification of a high-risk HIV-uninfected cohort appropriate for prioritized prevention services and PrEP. Taken together, these could translate into a larger impact on HIV epidemic control than partner services has had to date. Modeling studies evaluating the downstream effects of targeted partner services, that is the effects of combined identification and treatment of high-transmission risk persons, PrEP in those found to be HIV-uninfected and also real-time identification of AEH outbreaks are needed. These studies would further elucidate the impact of partner services in persons with AEH on epidemic control.

During the recent economic recession, General Fund revenue in current dollars decreased over two consecutive fiscal years. Since the low point of the 2009–2010 when the General Fund fell to $6.4 billion, this number has increased by an average of $0.65 billion over the past four years.A March 2015 estimate projected that General Fund revenue was on track to grow by nearly nine percent in the current fiscal year, but contraction in oil and gas industry-related activity is projected to slow revenue gains. The projected General Fund amounts for the fiscal years beginning in 2014 and 2015 are $9.6 billion and $10.3 billion, respectively. One novel aspect of this year’s budget debate is that economic gains are substantial enough that lawmakers will have to consider tax refunds under TABOR. According to TABOR, which voters ratified in the state constitution in 1992, the state must issue tax refunds if revenues exceed the prior year’s spending after accounting for inflation and population growth. TABOR refunds have not been possible for at least a decade. The governor’s budget includes a rebate forecast in the amount of $167.2 million.Legislators may ask voters to forego refunds in lieu of providing spending in a number of areas. The governor’s budget letter outlines several contingency plans where additional legislation or voter approval may be necessary to enact the spending items it includes. The governor’s 2015–2016 budget proposed increasing appropriations from the General Fund for most state departments. Table 1 provides summary data comparing the proposed budget with spending levels from the prior year.

The first items discussed in the governor’s budget letter concern education,4×8 botanicare tray which is among the governor’s highest priorities. Since Governor Hickenlooper previously campaigned for passage of Amendment 66—a tax increase to fund K-12 education— it is not surprising to see his budget propose increases in education funding in the aftermath of its defeat. Put to voters on the 2013 ballot, Amendment 66 proposed an approximate 10 percent increase in the tax rate on income up to $75,000 and a 25 percent increase on income beyond $75,000. According to the state, the amendment would have raised taxes by $950 million in the first year following adoption. Despite the fact that supporters of the amendment raised in excess of $10 million to promote the measure, Colorado voters overwhelmingly rejected the tax increase with 64 percent of the electorate voting against it. Following this resounding defeat, the governor’s proposed budget seeks to increase education funding. The defeat of the tax increase to fund education could make more modest increases in education spending more acceptable to Republican legislators. Many Democratic lawmakers who supported the tax increase view the governor’s increase in K-12 spending as all the more necessary. Accordingly, the budget for the upcoming fiscal year increases total spending on K-12 education by 8.1 percent , an increase in per pupil funding of nearly $475 that brings total per pupil funding to about $7,500. Spending on higher education will increase by over $100 million after agreement was reached in 2014 on legislation limiting undergraduate tuition increases to no more than six percent in exchange for greater direct support from the state budget.4 General Fund increases for public institutions of higher education was set at about $75 million. This amount allocated to the governing boards of higher education institutions reflects an increase of 12.5 percent in General Fund spending.

An additional $30 million would be allocated to a new Colorado Opportunity Scholarship Initiative, which would go toward student scholarships funded jointly by public and private sources. The budget from the previous year included about $60 million from the General Fund to institutional support with $40 million designated for student financial aid. After education, the second largest increase in spending is proposed to go to the Department of Health Care Policy and Financing where, as in previous years, caseload increases have necessitated greater funding. Accordingly, the budget includes an increase of $82 million from the General Fund. An additional $154.7 million in General Fund spending is pegged for future casework and modernization related to Medicaid, children’s health plans, and other health programs. Another notable increase in health care spending is a proposed increase of $11.4 million for 1.0 percent raises in provider and targeted service rates. Nearly $7 million of a $25 million General Fund increase in Department of Human Services spending is proposed to allow counties to hire 130 additional child welfare caseworkers, and mental health and juvenile correctional institutions are scheduled to hire more than 100 new full-time employees.Interest in directing greater funds to this area grew after the murder of Department of Corrections Director Tom Clements in 2013. The new director, Rick Raemisch, has championed meaningful prison reform. After increasing General Fund spending for the department by more than six percent last year, the 2015–2016 budget proposes a more modest increase of 4.0 percent, or nearly $30 million. The department estimates a small increase in the number of offenders housed in its facilities, and greater funding will allow the department to improve operations and facilities, including the addition of 330 beds.

The state expects to hire more than 20 full-time employees to better assist people in the criminal justice system with mental health issues. A 1.0 percent provider rate increase is also included in the budget. The only departments with proposed reductions in General Fund spending were Public Health and Environment, Public Safety, and Revenue. Funding requested for the Department of Public Safety is 8.5 percent lower due to the absence of nearly $10 million in funding allocated to purchase aircraft and equipment for an aerial firefighting fleet. These funds made it into the prior year’s budget after the state experienced one of the most devastating wildfire seasons in its history. Partially filling this void is a proposed additional $2.7 million in funding to go toward two new Colorado Bureau of Investigation forensic labs and a 1.0 percent increase for state community corrections program providers. Funding proposed for the Department of Public Health and Environment is 28 percent lower largely due to the absence of appropriations made last year to help communities recover from widespread flooding that occurred in September 2013. General Fund spending for the Department of Revenue is slated for reduction with the loss of a one-time appropriation of $6.2 million in the prior year’s budget to help the department modernize its operations. These anomalies explain most of the larger cuts in General Fund spending. The budget preserves the status quo in most areas with a few targeted increases. The marijuana tax revenue makes spending increases more palatable to legislators. In 2012, when nearly 55 percent of Colorado voters cast ballots in favor of legalizing recreational marijuana use by adults over the age of 21 the state’s counties were nearly evenly divided on the issue. Thirty-three of the 64 counties had a majority voting in favor of legalization, while 31 counties were had more no voters. One of many reasons for the ultimate success of the measure was that localities were given the option to prohibit marijuana business.”A year-end analysis in The Denver Post noted that 23 Colorado counties currently permit marijuana cultivation, sales, or both . Within these counties, 53 cities or towns permit recreational marijuana sale. As of March 2015,grow glide racks the state had licensed a total of 341 retail stores to sell marijuana. Including those authorized to sell medicinal marijuana, the number of outlets is over 500 .6 A study by the Marijuana Policy Group found that the demand for marijuana in the state likely far exceeds prior estimates, although the total amount of tax revenue generated by the first year of legal recreational sales fell short of expectations . Using survey data, the study estimates about 13 percent of Colorado’s population used marijuana at least once in 2010 or 2011. Approximately nine percent of adults reported consuming cannabis in some form at least once a month. Based on a survey about frequency of use, Light et al. estimate that the total marijuana demand in the state is 121.4 metric tons annually.

According to their methodology, individuals that consume cannabis daily constitute about one-fifth of marijuana users, but about two-thirds of total demand. Results from this study, when considered in conjunction with tax data, present a paradox. If the demand for marijuana was previously underestimated, why have tax revenues associated with the new marketplace fallen short of expectations? One of many possible explanations is that many individuals continue to take advantage of the black or medical markets to avoid the taxes associated with higher-priced retail marijuana. Given the novelty of recreational marijuana legalization, substantial uncertainty existed regarding the economic benefits that would ensue. Taxes on recreational marijuana include a base sales tax of 2.9 percent, an additional 10 percent sales tax, and a 15 percent excise tax. By the end of 2014, recreational and medicinal marijuana sales totaled nearly $700 million , with about 45 percent of the total from retail sales. During the first month of recreational sales, few retail outlets were operational, and sales of medical marijuana were more than double the nearly $15 million in recreational marijuana sales. Recreational marijuana sales increased every month through August by an average of $2.8 million. August was the first month that recreational sales exceeded medicinal sales. Recreational sales decreased for the first time in September and held steady at about $31 million over the next few months. December brought another increase as recreational sales passed $35 million for the first time. Recreational sales in January 2015 came in at nearly $36.5 million, so it remains yet to be seen at what point sales will plateau . Tax revenue associated with the sales has been well below most prior projections. Figure 1 provides monthly tax, licensing, and fee revenue data for both recreational and medical marijuana in 2014. All data are from the Colorado Department of Revenue. As seen in the figure, revenue from medicinal sales remained relatively constant in 2014, ranging from a low of $1.41 million to a high of $1.87 million. Some expected the number of medicinal marijuana patients to decrease with the roll out of recreational marijuana, but the number of residents with a valid red card actually increased by over 4,000 to reach a total of 115,467 . Governor Hicken looper originally estimated the state would receive $134 million in marijuana tax revenue in the 2014–2015 fiscal year. This figure was revised in April to approximately $114 million . When the final tax revenues from 2014 were tabulated, the state had collected $76 million, $63.4 million in taxes and the remaining revenue from licensing and other fees. The state of Washington collected approximately $22.7 million in tax revenues and fees for marijuana sales that began in July . Under the tax structure approved by voters, the first $40 million in marijuana excise tax revenue is mandated to go toward school construction. Revenue beyond this amount is not designated for particular purposes. In 2014, excise tax revenue totaled $13.3 million, which fell below expectations. January 2015 showed signs of greater optimism as $36.4 million in recreational marijuana was sold, resulting in over $2.35 million in excise tax revenue for schools. This is the first month excise tax revenue exceeded $2 million. In January 2014, excise tax revenue totaled just $200,000 . In sum, revenue from legal recreational and medicinal marijuana continues to grow steadily, despite the fact that revenue levels have not approached what many originally projected. For numerous reasons, the continued unfolding of the recreational marijuana market merits watching. Stricter packaging rules for edible marijuana products were recently adopted. In March 2015, the state had to defend legalized marijuana in federal court for the first time in response to a lawsuit filed by Nebraska and Oklahoma officials. One aspect of the state’s marijuana industry in a nascent phase is marijuana tourism. A recent study estimated that “out-of-state visitors currently represent about 44 percent of metro area retail sales and about 90 percent of retail sales in heavily visited mountain communities. Visitor demand is most prevalent in the state’s mountain counties, where combined medical and retail marijuana sales more than doubled after retail sales were legalized in January, 2014” . In some areas, much of the revenue generated through marijuana sales comes from out-of-state visitors. Regulations initially imposed differentiated sales limits whereby state residents could purchase four times the amount of marijuana per day than an out-of-state visitor.

Effective translation of research findings into clinical practice using Predictive Analytics will not only require the combination of expert domain-knowledge and data integration technology as outlined above. Effective translation will also need to address more general issues regarding the organization and structure of the emerging field. This will require joint efforts from all stakeholders including researchers, clinicians, patients, funding bodies, and policymakers. One such example is the Patient Centered Outcomes Research Network and its associated psychiatric networks, the Mood Network, the Interactive Autism Network, and the Community and Patient Partnered Centers of Excellence which focuses on behavior disorders in under served communities. 50 Given the often sensitive nature of the data needed to build predictive models – which might for example include electronic health records – an adequate level of security must be maintained at all times. Whether this speaks for decentralized infrastructure or outsourcing to specialized institutions is likely to remain a matter of intensive debate. As an example, PCORnet uses a federated datamart with a common data model infrastructure for multiple health care systems across the US that includes over 90 million people. Similar discussions will probably arise with regard to the predictive models themselves. Whereas only easy access to validated, pre-trained models will make them widespread, useful tools in the clinic, predictive models might also enable the prediction of sensitive personal data from the combination of seemingly harmless information an individual might readily provide. Thus,2 tier grow rack it is in the interest of all stakeholders to reach a public consensus regarding the regulation of access to pre-trained models before practically applicable models become available.

While some level of regulation is likely beneficial with regard to industry use, it will be essential for efficient model construction to encourage model sharing for research purposes. Especially for multi-modal models, sharing modality-specific, pretrained models will save substantial amounts of time and money. Finally, we need experts to consider the legal implications of deploying models which predict health-related information which potentially guides medical decisions. From a more applied perspective, we believe that technology will continue to simplify data acquisition and improve data quality in the years to come, thus bringing predictive Mobile Health applications within reach. While holding great promise, especially mHealth applications raise the question of whether it is generally better to rely on mechanistic predictors or instead on a pragmatic approach.23, 51 While we firmly believe that the identification of causal relationships provides the most robust and scientifically satisfying features for prediction, we expect a pragmatic approach to prevail in the years ahead for two reasons. First, while causal predictors might be most effective, they will often be inefficient. For example, measuring variables of brain metabolism causally linked to a disorder might enable the construction of highly accurate predictive models. If however, we can use cheaper and more readily obtainable measures not causal to the disorder with comparable or even slightly lower predictive power, those would probably be more efficient and thus more useful to clinicians in practice. Secondly, as decades of research have only begun to uncover causal links on single levels of observation, we think it highly unlikely that unified theoretical models across levels of observation will be established even in the mid-term. To promote the endeavor of creating individualized predictive models to improve patient care and maximize cost efficiency in psychiatry, concrete steps can to be taken by institutions, researchers and practitioners. For example, we have recently seen numerous educational efforts such as organizing workshops and seminars on the various technical topics.

Conferences such as the European College of Neuropsychopharmacology Congress or the Resting-State Conference and many others will continue to host sessions and satellite symposia dedicated to predictive analytics. Common in the field of machine learning, but currently scarce in psychiatry, predictive analytics competitions in which teams compete for the best predictive model performance bring together clinicians, researchers, and machine learners and may accelerate the availability of pre-trained, validated models in the midterm as well as make this research more visible to the public. Although patients, clinicians, and researchers share a common interest in improving mental health outcomes, there will need to be a thoughtful balancing of issues related to privacy, data security, and ethics in relation to the contrasting priorities and roles of various stakeholders. Currently, research and curation of shared data bases arise primarily from publicly funded, academic research groups, where data sharing is viewed as a common good to support greater utilization of large datasets to enhance predictive accuracy. A private business, on the other hand, could have the different role of using predictions to make decisions about reimbursing health care options or to advise on hiring practices or to identify potential customers for advertisements. Although these contrasting goals could lead to some tensions about the use of predictive analyses, there are examples where a public-private hybrid could be advantageous. For example, because intervention research is costly and complex, it tends to have limited numbers of subjects and relatively short durations . Public-private partnerships could take advantage of the ongoing administration of treatments to very large numbers of subjects over extended time periods. In summary, we believe that unimodal feature-engineering and model integration across levels of observation will be the key to highly accurate and efficient Predictive Analytics Models in mental health.

Successful Predictive Analytics projects will thus require 1) substantial domain knowledge to enable optimal feature-engineering for the often massively multivariate datasets obtained on each level of observation and 2) profound machine learning expertise with a focus on model integration techniques. With technology rapidly simplifying data acquisition and model construction, we urge all stakeholders including researchers, clinicians, patients, funding bodies, and policymakers to initiate an open discussion regarding key-issues such as data-sharing and model access-regulations to enable Predictive Analytics technology to close the gap between bench and bedside. Neuroimaging in patients with major depression has revealed abnormal activation patterns in multiple brain networks, including the default mode , cognitive control, and affective networks. The DMN, anchored in the medial prefrontal cortex and posterior cingulate cortex , is suppressed in healthy adults during tasks that demand external attention, but does not show the typical pattern of task-induced deactivation in adults and adolescents with MDD . The cognitive control network, including dorsal lateral prefrontal cortex , which is typically activated during cognitively demanding tasks, has shown decreased activations in adults with MDD . The affective network includes the amygdala and other limbic-region structures , and most saliently for MDD, the sub-genual anterior cingulate cortex , which is considered a core region in the functional and structural pathophysiology of MDD . The affective network exhibits abnormal activation patterns during emotion processing in adults with MDD . These abnormal activations in distributed networks may account for corticolimbic dysregulation in MDD .Mirroring these brain activation abnormalities, patients of different ages with MDD have shown abnormal intrinsic functional connectivity of the brain measured via resting-state fMRI . First,commercial grow set up increased resting-state connectivity within the DMN and between the DMN and sgACC has been reported in adults and adolescents with MDD. Hyper connectivity of sgACC correlated with duration of current depressive episodes in adults and with emotional dysregulation in pediatric depression . These results support the possibility that DMN-sgACC hyperconnectivity might underlie depressive rumination . Second, several studies reported decreased resting-state connectivity within the cognitive control network in adult patients with MDD . In line with this evidence, MDD has been conceptualized as an imbalance between the DMN and the cognitive control network . Third, atypical connectivity between the amygdala and cortical structures has been found in adults and children with MDD and is thought to reflect deficits in emotion regulation. Despite evidence of abnormal functional connectivity across distributed brain networks in patients with MDD, it is unclear whether these differences reflect the state of current depression versus neurobiological traits that predispose individuals to be at risk for MDD. One approach to distinguishing between current state and predisposing traits is the study of unaffected individuals at heightened risk for MDD, such as unaffected children at familial risk for MDD by virtue of having a parent with MDD. Such familial history increases the risk of MDD in offspring by three to five fold , and increases the risk of a broader spectrum of mood and anxiety disorders . Understanding whether rs-fMRI findings represent trait or state markers of MDD in the young can lead to the identification of informative neural biomarkers of risk for mood and anxiety disorders and help develop early intervention strategies to mitigate this risk. Rs-fMRI also possesses significant translational strengths in its short duration of scanning, and the lack of task performance demands that can complicate interpretation of activations. In the present study, we examined rs fMRI in unaffected children at familial risk for MDD and other mood and anxiety disorders by virtue of being offspring of parents with MDD and compared them with age matched children who were offspring of parents with no lifetime history of any mood disorder . Two previous studies examining at-risk children and adolescents found decreased connectivity between amygdala and frontal-parietal network in unaffected children of depressed mother and in children with early onset depression , and decreased connectivity within the frontal-parietal cognitive control network in unaffected adolescent girls with parental depression .

Based on previous functional connectivity results in patients with MDD, we focused on functional connectivity differences between at-risk and control children in the DMN, the cognitive control network, and the affective network, using a seed-based functional connectivity approach. We examined connectivity differences from the two midline anchor regions of the DMN , which are associated with self-referential processing and self-focused rumination in MDD , and from seed regions in left and right DLPFC and amygdala. We tested: 1) whether unaffected at-risk children exhibit patterns of abnormal functional connectivity similar to those reported in patients with MDD, and 2) whether connectivity of DMN-sgACC is related to symptom scores in at-risk children. To further test whether resting-state connectivity can be a useful neural biomarker for risk for MDD, we built classification models based on resting-state d ata to discriminate at-risk versus control children.Data were acquired on a 3T TrioTim Siemens scanner using a 32-channel head coil. T1- weighted whole brain anatomical images were acquired. After the anatomical scan, participants underwent a resting fMRI scan in which participants were instructed to keep their eyes open and the screen was blanked. Resting scan images were obtained in 67 2-mm thick transverse slices, covering the entire brain . The resting scan lasted 6.2 min .Two dummy scans were included at the start of the sequence. Functional connectivity analysis Rs-fMRI data were first preprocessed in SPM8, using standard spatial preprocessing steps. Images were slice-time corrected, realigned to the first image of the resting scan, resampled such that they matched the first image of the resting scan voxel-for-voxel, normalized in MNI space, and smoothed with a 6-mm kernel . Functional connectivity analysis was performed using a seed-driven approach with in-house, custom software “CONN” . We performed seed-voxel correlations by estimating maps showing temporal correlations between the BOLD signal from our a priori regions of interest and that at every brain voxel. We performed resting-state connectivity analysis from the DMN seeds , cognitive control network seeds , and bilateral amygdala seeds . The DMN and DLPFC seeds were defined as 6-mm spheres around peak coordinates from . The amygdala seeds were defined from the WFU Pick Atlas . Physiological and other spurious sources of noise were estimated and regressed out using the anatomical CompCor method . Global signal regression , a widely used preprocessing method was not used because it artificially creates negative correlations which prevents the interpretation of anticorrelation and can contribute to spurious group differences in positive correlations . Instead, aCompCor allows for interpretation of anticorrelations and yields higher specificity and sensitivity compared to GSR . See Supplementary Information for details on the aCompCor. A temporal band-pass filter of0.008 Hz to 0.083 Hz was applied simultaneously to all regressors in the model. Residual head motion parameters were regressed out. Artifact/outlier scans were also regressed out. Head displacement across the resting scan did not differ significantly between the two groups for either frame-to-frame translations in x, y, z directions or frame-to-frame rotations . The number of outliers also did not differ significantly between the groups .

Nuclei and cytoplasmic extractions were carried out as follows. 2g of tissue was ground in liquid nitrogen and mixed with 1xNIB buffer with DTT; the mixture was filtered through microcloth and the filtrate centrifuged at 1260g at 4°C for 10 minutes. The supernatant was decanted and reserved as the cytoplasmic fraction. The pellet was resuspended in 2ml 1xNIB buffer with 10ul of 10% triton x-100 and protease inhibitors before centrifuging at 1200g at 4°C for 10 minutes. The supernatant was discarded and the pellet resuspended in 0.5ml of JAJ-Extraction Buffer . This suspension was sonicated and centrifuged at 3000g at 4°C for 10 minutes – the resulting supernatant was reserved as the nuclear fraction. Nuclear and cytoplasmic fractions were then run on an acrylamide gel and a western blot was carried out using the purified GP16 serum. A ~90kDa band was observed in the WT cytoplasmic fraction which is the correct size for full length FUN protein, and a ~37kDa band was observed in the fun cytoplasmic fraction. Both WT and fun nuclear fractions displayed a ~70kDa and ~37kDa band . Western blots were then attempted using crude, nuclear and cytoplasmic fractions of protein extracted from fun-2 plants, but none of these gels showed any bands despite confirmation of protein presence in sample by probing with KN1 antibody . Other extraction procedures were carried out using triton, SDS, dodecyl maltosidase and IGEPAL detergents, but none of these westerns showed any bands . In order to further purify the serum,horticulture products primers AV242 and AV243 were designed to a highly antigenic region of the protein predicted by antigen prediction software . This 96bp product was cloned into pENTR and recombined into pDEST15 using C3040 cells, which greatly improved transformation efficiency.

pDEST15-3500 was cloned into Rosetta cells to purify protein and create a column as described above. This column was used to purify GP15 serum; the purified serum was found to react weakly to FUN-recombinant protein in a dot plot, but none of the controls . 15 western blots were attempted using this purified serum, but none showed bands, or had high background such that any bands present would be obscured . Solubilising the 3500-GST construct before creating a column may help – a dot plot based on extractions solubilised with DDT showed that solubilisation greatly improved 3500-GST construct recovery from culture .In summary, we can say that FUN is a conserved, universally expressed, disordered protein that localises to the nucleus. Cytoskeletal binding has been implied by both bio-informatic prediction programs and Y2H, as has involvement in nucleotide binding, especially RNA and GTPases. The highly conserved nature of FUN across the grasses, and significant conservation across the Plant Kingdom, along with the mutant study presented in Chapter 1, make a compelling case for the importance of this protein in general plant growth and development. The nuclear localisation of FUN, along with its synergistic interaction with the transcription factor WAB1 , and its interactions with various hormone mutants suggest that FUN is involved at some stage in a signal transduction pathway between the hormones and downstream gene expression. The universal expression of FUN makes it unlikely that FUN can be considered a signalling molecule per se; instead it strengthens the hypothesis that FUN is involved in the transduction of these signals. On the other hand, there is evidence of variance in transcript levels so there could be some merit to the idea that FUN is a real signal. Using Gene Ontology term analysis, it has been shown that disordered proteins are heavily biased toward signalling, regulation and control110, strengthening the signalling network hypothesis.

The disorder of FUN may also have contributed to the difficulty in creating a specific antibody. Many disordered proteins are thought to undergo conformational changes in order to transduce signals110 and the high concentration of serines that could be phosphorylated , as well as a serine repeat chain in FUN , could allow these conformational change. Despite the fact that the antibody was shown to be non-specific, and the same immunoblot pattern was produced in both normal and fun tassels , the pattern of expression in the normal tassel fits the feminised tassel phenotype. Additionally, the expression pattern agrees with the nuclear localisation shown by YFP-fusion and bioinformatic prediction . Thus the expression pattern could indeed be real. Since both GO term analysis by FFPred agrees with the Y2H that tubulin interacts with FUN, and that nucleotide binding is likely for FUN, these avenues should not be ignored. While it is difficult to imagine how cytoskeletal binding could be important to the FUN protein’s function in a signal transduction pathway, the importance of nucleotide binding in signalling needs no explanation. Intriguingly, one of the Y2H predictions is ricin, a protein that binds to ribosomes, which are of course rich in RNA. Though ricin is a deadly poison to animals, its presence in low levels in plant cells could indicate that it works as a regulator of ribosome function in plants, and has been co-opted by the infamous Ricinus communis that accumulates it in high concentrations in its beans, presumably as a defence mechanism. Among school-aged children, ADHD is one of the most common psychiatric disorders. Estimates have placed the prevalence of ADHD as high as 3-7% of all children in the United States, with as many as 37- 85% of these cases persisting into adulthood1 . Pharmacotherapeutic treatment of ADHD typically begins when a patient is 9.8 to 10.6 years old, with a duration of 33.8 to 42 months. Treatment is most commonly prescribed to individuals that are 10-14 years old and is usually made available to the individual or to the parents of the individual until graduation from high school or college. The most-prescribed stimulant for ADHD is methylphenidate ; however, amphetamines account for about one-third of all ADHD treatment prescriptions. Biologically, methylphenidate interacts with the dopamine transporter to block dopamine reuptake, thus increasing dopamine in the synaptic cleft. Amphetamines also interact with the dopamine transporter but via an efflux mechanism, reversing the direction that the transporter conducts dopamine.

Both methyphenidate and amphetamine increase the amount of dopamine in the synaptic cleft of the mesocorticolimbic system, resulting in an increased level of attentiveness that is beneficial to those with ADD or ADHD. In terms of treatment of ADHD, stimulant treatment such as methyphenidate and methamphetamine is considered to be the first line of defense in ADHD therapy. This type of treatment is frequently attempted before other methods of intervention, such as counseling or non-stimulant medication, and in the short term, stimulant treatment of ADHD has proven effective,plant grow trays with 73% of cases reporting treatment to be “favorable and effective” and only 22% reporting minor side effects. In combination, prescription of amphetamines has increased greatly during the past 20 years, especially among young children and those over 14.Prescription of amphetamines to two-to-four year olds increased 380% between 1990 and 1997, while prescription to those older than 14 increased 817%. Given the young age of treatment onset and the duration for which the drug is made available to ADHD patients, along with the prevalence of its clinical use, some critics have raised concern in scientific literature over excessive stimulant use and the long-term effects of stimulants on children. Such concern is bolstered by the strong correlation between ADHD and Substance Use Disorder , the repeated abuse or dependence on a substance that alters the central nervous system for the purpose of obtaining its mind-altering effects or avoiding a withdrawal. For instance, adolescent tobacco use has been shown to be significantly higher amongst those with ADHD9 . Alcohol abuse is associated with as many as 17% to 45% of ADHD adults, while drug abuse is seen in 9 to 30%, suggesting that ADHD patients are at a significantly higher risk than the general population. Specifically, adolescents with ADHD have been calculated to be more than three times as likely to use marijuana when compared to the general population, and a striking 39.1% of ADHD patients older than 13 responded in a survey that they had abused nonprescription stimulants—mostly cocaine and methamphetamine. Moreover, amphetamines are reinforcing. Following use of an amphetamine, an individual will be more likely to use the drug again if given the opportunity. This property can lead to abuse and drug-seeking behavior. It follows that amphetamine treatment may contribute to general drug-seeking behavior and substance abuse in ADHD individuals and may especially raise the risk of non-medical stimulant abuse. However, other studies have also implied that stimulant treatment, including treatment with amphetamines, may lower the likelihood of an individual with ADHD to “self-medicate,” thus lowering the potential for drug abuse in adolescence and adulthood16. Based on these few population-level studies and meta-analyses, a portion of the medical community has come to the conclusion that treatment of ADD or ADHD with amphetamine is beneficial for the majority of patients. However, these studies have a number of weaknesses that will be addressed in this review.Animal studies have shown that amphetamine treatment of ADHD may increase susceptibility to substance abuse, demonstrating the abuse potential that amphetamines pose. For instance, several animal studies have demonstrated that amphetamine exposure induces drug cravings in rats. One such study illustrated that rats treated with amphetamine tended to have higher levels of self-administration of cocaine, suggesting that prescription of amphetamines may raise susceptibility to non-prescription stimulant drug abuse in human patients. A similar study concluded that self-administration of amphetamine led to sensitization of its rewarding effect, as well as to the rewarding effects of both cocaine and morphine. Since sensitization of reward may play a major role in the development of drug-craving and dependence, amphetamines, therefore, seem likely to increase a patient’s sensitization to his or her own prescription. This may then lead patients to illicit nonprescription drugs to fill the void of reward that their treatment once occupied. Thus, a patient’s prescription would increase the likelihood of abuse of both amphetamines and almost any other drug with reinforcing properties.

In particular, drugs with similar stimulant properties that activate the mesocorticolimbic dopaminergic system, such as nicotine, cocaine, and methamphetamine, are strong candidates for abuse following amphetamine treatment. Moreover, abuse of non-medical stimulants may stem directly from dependence on ADHD medication. Studies of ADHD patients found that 15%-25% reported having abused their medication recently, via crushing and snorting the pills or taking a higher-than-prescription dose for recreational purposes. One group discovered that the most important factor in the development of abuse of prescription amphetamines was the abuse of other substances, implying that substance abuse may lead to abuse of medication. However, the data in this study can be interpreted to imply reverse causation; given the sensitizing and reinforcing nature of amphetamines, patients may become dependent on their medication and turn to other substances after their medication no longer gives them satisfaction. Furthermore, the abuse of ADHD treatment seems to be much higher for amphetamines when compared to methylphenidate. Researchers have found that the most-abused medications used to treat ADHD were mixed amphetamine salts, constituting 40% of all abused ADHD medication, while long-acting amphetamines constituted an additional 12% of abused medication. Therefore, amphetamine abuse alone constituted 52% of prescription medication abuse. Since only one-third of stimulant medication prescribed for ADHD treatment is amphetamine-based, it is apparent that amphetamines have a higher potential for abuse than other ADHD treatments. Thus, the animal and population studies detailed above both found an increase in stimulant abuse amongst ADHD patients treated with stimulants. Lastly, population studies also found that increased drug abuse following amphetamine prescription was specific to stimulant abuse. In a study that followed 21 untreated and 98 treated ADHD patients into adulthood, a significant increase in cocaine use was found amongst those treated with stimulants. Other studies found that both nicotine and cocaine use were increased amongst ADHD patients that were treated with stimulants. However, it was also found that depressants such as marijuana and alcohol showed no increase in abuse potential, supporting the hypothesis that amphetamine and/or stimulant prescription specifically raises the risk of non-medical stimulant abuse via sensitization. It has been hypothesized that stimulant treatment is increasingly protective against drug abuse in adult life the earlier the medication is prescribed in childhood.

The auricles are two wedge-shaped structures that develop on either side of the midrib, expanding in the proximal-distal plane as they approach the margins. Auricles are derived from both epidermal and mesophyll tissue and their structural function is likely to allow the blade to bend outwards to maximise light capture. Together, the mature ligule and auricle represent the position of the blade/sheath boundary , but their position is defined by this boundary, not the other way round. The BSB is visible before ligule and auricle development and the anastomosis of intermediate veins, which also characterises the BSB, is visible in leaf mutants liguleless1and lg2 that lack the ligule. As such, it is clear that the BSB is a fundamental component of the leaf upon which the ligule and auricle are elaborations. The lg1 mutant is a classical mutant that lacks both ligule and auricle and possesses a diffuse BSB. The lg2 mutant is similar to lg1, but upper leaves have partial recovery of ligule and auricle at the margins, while lg1 does not display this partial recovery but has a slightly better defined boundary. lg1 leaves are slightly narrower than normal siblings. Tassel branch number is reduced in both lg1 and lg2 and the transition to the reproductive phase is delayed in lg2 mutants, such that they produce more leaves than normal siblings.The accumulation of LG2 mRNA precedes that of LG1 – it is observed in the meristem,grow racks with lights while LG1 mRNA is only observed at the BSB. On the other hand, LG2 mRNA is observed in the lg1 background and LG1 mRNA is observed in the lg2 background at the leaf margins, so there does not seem to be a direct “switching on” of LG1 by LG2 nor vice versa.

LG1 encodes a nuclear localised protein that contains a domain with significant similarity to SQUAMOSA PROMOTER-BINDING1 and SBP2 proteins from Antirrhinum majus. In contrast to LG2, LG1 functions cell-autonomously. Wavy auricle in Blade1is a dominant mutation that results in ectopic expression of the WAB1 protein in the leaf. WAB1 functions in the tassel to turn on LG1, which in turn promotes branch initiation. When WAB1 is ectopically expressed in the leaf, the resulting activation of LG1 causes the distinctive over proliferation of the auricle at the ligule boundary as well asectopic auricle and sheath in the leaf blade. At the blade sheath boundary the blade width of Wab1 is similar to normal siblings, but distal to this, the blade quickly narrows such that Wab1 has a very narrow blade further up the leaf. This narrowing is due to a deletion of the lateral domain of blade, as shown by analysis of the triple mutant ns1;ns2;Wab1, where both the marginal domain and lateral domains are lost. A reduction in the number of lateral veins in the Wab1 blade support the hypothesis that narrowing in the Wab1 blade is due to deletion of domains rather than loss of cell expansion59. The disruption of the BSB in lg1 and lg2 made them obvious candidates for crossing to fun. As Wab1 displays hypertrophy of the auricle, and fun displays complete loss of the auricle, we made a double mutant population to ask if FUN is required for ectopic auricle growth in the Wab1 background.Families segregating for Wab1, lg2, lg1 and fun were made according to the genealogy shown in Figure 3-1. Leaf width measurements were taken at blade mid point and/or 5cm above the blade/sheath boundary. Sheath lengths were measured from the base of the leaf to the MLK at the midrib and/or the auricle at the margin closest to the base of the leaf.

Plants were identified by their distinctive phenotypes with double mutant phenotypes from previous generations informing identification of plants as more mutations were introduced into the family. In families AV814-7, genotypes of double and triple mutants were also deduced from the presence of single mutant plants in the family.In families AV182, AV545 and AV814-7, Wab1;fun plants were observed . Wab1 plants had slightly shorter blades than fun or normal siblings, while all three had similar sheath lengths. When Wab1 and fun were combined, blade lengths were reduced and sheath length was increased , suggesting a change in the position of the blade/sheath boundary . The increase in sheath length did not make up for the loss of blade, resulting in a leaf that was shorter overall in the double mutant. The plants had extremely narrow leaves at the midpoint – narrower than either Wab1 or fun alone . Wab1;fun double mutant plants have a disrupted BSB with both auricle and ligule displaying deviations from normal plants. While both Wab1 and fun have normal ligules, in the double mutant, the ligule is patchy, disrupted and displaced over a large region . Although disruption of the BSB in the Wab1;fun double mutant is extensive, the ligule at the intersection of the BSB and the midrib is consistently present and this point is also marked on the abaxial side of the leaf as a lighter coloured area which forms a raised bump along the midrib . I have termed this point the “midrib ligular knot” . In normal plants, the MLK is slightly proximal to the stem, compared to the marginal auricle, while in Wab1 plants the MLK and marginal auricle are about equidistant. In fun, the MLK is displaced distally compared to normal siblings while in the Wab1;fun double, the MLK is much more proximal to the base of the leaf than the marginal auricle .

Wab1;fun double mutants form points of ectopic ligule in the blade, reminiscent of the ectopic auricle in Wab1 single mutants, interestingly, there is very little, if any, ligule associated with the ectopic auricle in Wab1, while the double shows clear ectopic ligule . The Wab1;fun double mutant often retains some auricle at the margins of the leaf, and this is associated with “wings” of marginal tissue that extend a relatively short distance along the blade . The tassel of Wab1;fun plants resembles a fun tassel . Combining the Wab1 mutant with lg1 resulted in total loss of both the marginal auricle and MLK, though the boundary was still detectable by the commencement of the midrib . When Wab1 was combined with lg2, the MLK was lost but the marginal auricle was increased as in a Wab1 plant . In family AV545, the blade width at the midpoint was slightly reduced in lg2 plants but there was no evidence of an additive effect of narrowing in the Wab1;lg2 double mutant plants in family AV364 . A Wilcoxon t-test detected a reduction in width at the base of the leaf in Wab1;lg2 plants,rolling benches for growing though reference to the scatter plot reveals that the data are so scattered that the Wilcoxon t-test is misleading – rather I would argue that there is no difference in the width at the boundary between any of these mutant backgrounds. Tassel branch number is reduced to lg2 levels in the Wab1;lg2 double mutant . The Wab1;lg2;fun triple mutant showed loss of the extended marginal auricle seen in Wab1;lg2 as well as loss of the MLK seen in Wab1;fun .Both Wab1 and fun lead to narrowing of the leaf blade. Since narrowing in the leaf blade of Wab1 is due to a deletion of the lateral domain of the leaf, and narrowing in fun is associated with narrow cells , an additive interaction in the double mutant is not surprising. The lack of narrowing in lg2 and the epistatic narrowing observed in the lg2;fun double mutants implies that lateral expansion of the blade is associated with elaboration of the auricle but not definition of the MLK or the ligule itself. The partial recovery of blade width close to the BSB in the Wab1 mutant where there is extensive auricle supports this hypothesis.Although Wab1 leaf blades are slightly shorter than normal siblings, the extreme shortening of Wab1;fun double mutant blades was surprising since fun blades are of normal length . Furthermore, though Wab1 displays almost no displacement of the MLK and marginal auricle location as compared to normal siblings, and fun displays a slight distal displacement of the MLK, the Wab1;fun double mutant MLK is extremely proximal to the stem as compared to the marginal auricle .

This extensive synergistic interaction is mirrored in the Wab1;lg1 double but not the Wab1;lg2 double mutant. Since Wab1 is known to activate LG1 but not LG2 , these interactions would place FUN downstream of LG1. The additive interaction between lg2 and fun resulting in a loss of ligule at the midrib as well as loss of auricle at the margins shows that these genes function in different zones and pathways to elaborate the BSB. It seems likely that LG2 is responsible for elaborating the boundary at the midrib, while FUN elaborates the auricle at the margins. The different zones of action are underlined by the double mutants with Wab1 – loss of LG2 does not affect the elaboration of marginal auricle in the Wab1;lg2 double mutant , while the Wab1;fun double retains the MLK but loses the marginal auricle. In the Wab1;lg2;fun triple mutant both the marginal auricle is reduced, and the MLK is lost, as would be expected if LG2 and FUN work in different domains. It is possible that LG2 and FUN have a common upstream element and Two characterised mutants that are deffective in the synthesis of brassinosteroids in maize are nana1 and nana2. The maize mutant nana1 was isolated from the F2 of a plant with active Mutator transposons. PCR revealed a 497-bp insertion in a gene homologous to DE-ETIOLATED2in A. thaliana. DET2 is a steroid 5α-reductase known to catalyse a step in the BR synthesis pathway in A. thaliana. The knockout det2 phenotype can be rescued by addition of active brassinolide and is characterised in A. thaliana by extreme dwarfism as well as increased male sterility, dark green leaves, and repression of hypocotyl etiolation in the dark. In the maize na1 plant, levels of the substrate of the DET2 enzyme, -24- methylcholest-4-en-3-one, accumulated to 475% that of normal sibs, while downstream intermediates were reduced. While rescue by addition of brassinolide was not reported, addition of the BR inhibitor propiconazole to wild-type maize plants caused them to phenocopy the nana1 phenotypes of greatly shortened stature and feminised tassels. Since NA1 transcript was shown by in situ to accumulate in developing anthers, the role of BR in development of masculine flowers is supported. Five years after the publication of the causative mutation of the nana1 plant, the classical mutant nana2 was cloned31. Like na1, na2 is of greatly reduced height and has a feminised tassel. Since the na2 phenotype was so similar to na1, it was not surprising that a mutation was found in the maize orthologue of the A. thaliana DWF1 gene31. AtDWF1 is a Δ4-sterol reductase and dwf1 mutants accumulate its substrate 24-methylenecholesterol and have low levels of campestrol indicating a block in the BR pathway. The dwf1 phenotype, like det2, can be rescued by application of brassinolide in A. thaliana. The maize na2 plant was also shown to have low campestrol and later intermediates implying a similar block in the BR biosynthesis pathway. The overall na2 phenotype is similar to na1: short stature, feminised tassel and suppressed tillering. NA2 transcript is expressed in many tissue types including seedlings, mature and growing leaves, and immature ears and tassels with the highest expression detected in developing leaf collars, which is the position of ligule and auricle. Older tissues tend to have lower expression of NA2, supporting a role for BR in expansion and growth. Crosses with GA deficient mutants and application of GA to developing na2 plants has shown an interaction between these two hormone pathways in regulating growth and defining sex in Zea mays. GA and BR are thought to have independent roles in defining the absolute height of a plant, since the na2;d5 double mutant was shorter than either single mutant31. Masculine inflorescence development requires GA and BR to work together – the feminised tassel of na2 is abolished in the double mutant, implying that GA is needed for BR deficiency dependent feminisation. This hierarchy is mirrored in the ear: the anther ear phenotype of d5 is not abolished in the na2;d5 double mutant. Together these results show that BR is not essential for the masculinisation of inflorescences, while GA is essential for emasculation.

Mifepristone , a glucocorticoid receptor antagonist, works on the stress system by regulating the amygdala. Preclinically, both systemic and central amygdala injections of mifepristone were shown to suppress yohimbine stress-induced reinstatement of alcohol seeking, indicating that the central amygdala plays an important role in mifepristone’s effects on ethanol-seeking. Recent preclinical research in primates has shown mixed results, such that mifepristone was shown to decrease chronic voluntary alcohol consumption in rhesus macaques at doses of 30 and 56 mg/kg per day, but had no effect on alcohol-seeking or self-administration in baboons at slightly lower doses of 10–30 mg/kg per day. Of note, in the former study, cessation of mifepristone treatment resulted in a rapid return to baseline intake levels, and mifepristone was not effective in preventing a relapse during early abstinence. In a human laboratory study with 56 alcohol-dependent participants, mifepristone was effective in reducing alcohol craving and consumption relative to placebo, improved liver-function markers, and was overall well tolerated. A two-week Phase 4 RCT examining the effects of mifepristone on cognition in AUD was recently conducted, but recruitment challenges rendered the results inconclusive. Of note,vertical grow rack system in this trial, participants who received mifepristone had higher Beck Depression Inventory scores compared to placebo at 4 weeks post-randomization despite similar scores at baseline between the two groups, indicating a greater severity of depression symptoms caused by the medication. Additional clinical research on mifepristone as a treatment for AUD and its potential side effects is warranted.Ibudilast is an inhibitor of phosphodiesterases -3, -4, -10, and -11 and macrophage migration inhibitory factor.

Ibudilast has been shown to dose-dependently suppress pro-infammatory cytokines, such as interleukins IL-1β, IL-6, and tumor necrosis factor alpha , and to increase the anti-infammatory cytokine IL-10 and neurotrophic factors.As increases in infammation are seen in AUD, the effects of ibudilast in treating AUD are thought to be driven by its anti-infammatory and proneurotrophic qualities. Preclinically, ibudilast was demonstrated to reduce alcohol intake in two rat models, and decreased drinking selectively in alcohol-dependent mice in comparison to nondependent mice. These preclinical findings align with prior rodent studies in which pharmacological inhibition of PDE also reduced alcohol intake. In a 7-day human laboratory crossover trial , ibudilast was well tolerated and decreased tonic craving in comparison to placebo. Additionally, ibudilast improved mood during exposure to alcohol and stress cues, and reduced the mood-altering and stimulant effects of alcohol among participants with more severe depressive symptoms. Another recent 2-week RCT enrolling 52 participants found that ibudilast also significantly decreased the odds of heavy drinking during the trial by 45% compared to placebo and attenuated neural response to alcohol cues in the ventral striatum. Ibudilast appears to be well tolerated, with common adverse side effects including gastrointestinal symptoms , headaches, and depression. In the aforementioned 2-week RCT, no significant differences in side effects were seen between groups. In summary, early findings from clinical studies of ibudilast for AUD treatment appear promising and warrant further clinical investigation.Prazosin and doxazosin are alpha-1 adrenergic receptor antagonists with similar chemical structures that can readily cross the blood-brain barrier and block noradrenergic excitation of the mesolimbic dopaminergic system . Both medications are used for the treatment of hypertension and benign prostatic hyperplasia. While these medications show good safety and tolerability, doxazosin appears to have a better clinical profile, such as improved absorption profile and a longer half-life, leading to less frequent dosing.

Adrenergic receptors regulate sympathetic nervous system activity through activation of the neurotransmitter norepinephrine. Stress physiology is disrupted with chronic alcohol use, particularly during early alcohol abstinence. In early abstinence, individuals with AUD experience more emotional dysregulation, stress, and alcohol cravings, all of which can increase the risk of relapse. Thus, alpha-1 blockers like prazosin and doxazosin may help to normalize these stress system changes seen in AUD. Preclinical work found that prazosin reduced ethanolrelated operant responding in acute withdrawal for dependent, but not non-dependent rodents. In addition, prazosin treatment prevented yohimbine stress-induced reinstatement of ethanol seeking and attenuated ethanol intake during relapse in alcohol-preferring rats. Doxazosin decreased voluntary alcohol intake in alcohol-preferring rats in a dose-dependent manner, and this effect was likely not due to general motor impairment. Further, doxazosin significantly reduced voluntary ethanol intake in a rodent model of AUD and stress exposure. In humans, an early 6-week pilot study with 24 randomized participants with AUD revealed that prazosin treatment was associated with fewer drinking days per week and fewer drinks per week than placebo. More recently, 92 participants with AUD completed a 12-week double-blind study with prazosin and medication management. Results from intent-to-treat analyses showed that prazosin participants had greater reductions in heavy drinking and rates of drinking over time, although these effects were modest. A 10-week RCT comprising 41 individuals with AUD showed no significant effect of doxazosin over placebo on quantity of alcohol consumption. However, further examination of clinical moderators revealed that doxazosin significantly reduced drinks per week and heavy-drinking days among individuals with higher family history of AUD and higher standing diastolic blood pressure. Similarly, moderator analyses from a 12-week RCT of prazosin found that one’s degree of alcohol withdrawal symptoms predicted clinical response, such that participants with high levels of withdrawal symptoms benefited the most from treatment. A small meta-analysis of 6 studies with a total of 319 participants tested the effectiveness of drugs acting on adrenergic receptors for AUD and found a significant treatment effect of prazosin and doxazosin on alcohol consumption but not abstinence.

In summary, prazosin and doxazosin show some early promise as a treatment for AUD and may be particularly beneficial as a harmreduction approach and for individuals with significant alcohol withdrawal symptoms or family history of AUD as well as comorbid post-traumatic stress disorder .Alcohol use has been shown to alter the glutamate system. Chronic and binge drinking inhibit glutamate levels and transmission through blockade of NMDA receptors, subsequently leading to elevated glutamate levels during alcohol withdrawal . N-Acetylcysteine is a cysteine prodrug that works to restore glutamatergic tone in reward circuitry by improving the expression and function of the cysteine-glutamate exchanger and normalizing glial glutamate transporters. Preclinically, NAC has been shown to reduce withdrawal effects , block the development of behavioral sensitization to alcohol, and attenuate biological adaptations induced by alcohol cessation. Additionally, NAC reduced ethanol-seeking and self-administration in rodents. NAC and aspirin co-administration also reduced ethanol intake and relapse binge drinking in ethanol-preferring rats. In a recent meta-analysis of seven RCTs with a total of 245 participants, NAC compared to placebo was shown to reduce craving symptoms across a number of substance use disorders. A secondary analysis of a 12-week, multisite RCT of NAC to treat cannabis use disorder in 277 participants found that NAC increased odds of between-visit abstinence, and reduced alcohol consumption by 30%. However,clone rack a recent 5-day human laboratory study found that NAC did not attenuate alcohol self-administration. Additional clinical trials will also examine the effectiveness of NAC in adolescent and adult samples of AUD . These trials include samples with comorbid psychopathology and will use neuroimaging methods to examine the neural circuitry underlying NAC’s modulation of relevant metabolites and neural reactivity to alcohol cues. Orally-administered NAC appears to be well tolerated, with the most common adverse effects being nausea and diarrhea. Of note, NAC is currently being tested in adolescent AUD, a unique prospect as no other AUD pharmacotherapies are yet approved for adolescents. In summary, NAC represents a promising potential treatment for AUD and merits further exploration. The orexin/hypocretin system is well known for its role in sleep-wake regulation but has more recently been implicated in AUD. Orexins are neuropeptides that are densely localized in the lateral hypothalamus. Orexins A and B bind to the G-protein coupled orexin-1 and orexin-2 receptors. Orexin A has equal affinity for both receptors, whereas orexin B has selectivity for orexin-2 receptors.

The dense orexin projections from the lateral hypothalamus to the ventral tegmental area provide neurobiological support that orexins may influence responses to rewarding stimuli, including alcohol. Animal models demonstrate that orexin-1 receptor antagonists reduce alcohol drinking in alcohol-dependent mice and alcohol-preferring rats. Orexin-2 antagonists also reduce alcohol drinking and reinstatement/relapse in mice and rats. Similarly, dual orexin antagonists reduce alcohol consumption in alcohol-preferring rats. Given the effectiveness of orexin antagonists in reducing alcohol drinking at the preclinical level of analysis, suvorexant has garnered interest as a drug that can be repurposed to treat AUD. While no animal or human laboratory study has directly examined the efficacy of suvorexant on alcohol-related behaviors, two ongoing Phase 2 RCTs will assess suvorexant’s potential as a treatment for AUD and comorbid AUD + insomnia . The sedative effects of suvorexant are of notable concern, particularly if individuals engage in alcohol drinking during treatment. Thus, the level of patient monitoring throughout the treatment phase and finding the optimal time of dosing to negate the additive sedative effects are important factors to consider to fully evaluate its therapeutic potential.The following sections discuss novel agents that have not yet been approved for any use. These medications are early in development and the majority do not yet have available clinical findings on their application toward the treatment of AUD.ABT‐436 is an orally active, highly selective vasopressin type 1B receptor antagonist. V1B antagonists attenuate basal hypothalamic-pituitary-adrenal axis activity and have shown favorable effects in rat models of alcohol dependence, including attenuating reinstatement of alcohol self-administration, and diminishing alcohol intake by alcohol-preferring and alcohol-dependent rats. ABT-436 has been shown to attenuate basal HPA axis activity in humans. A 12-week RCT enrolling 150 participants found ABT-436 to be associated with an increased percentage of days of abstinence compared to placebo, as well as significantly reduced cigarette use. However, no differences were found on heavy-drinking days or alcohol craving. A subgroup analysis also showed that ABT-436 appeared to have greater efficacy among participants with high baseline stress levels. This study was the first Phase 2 clinical trial that tested a V1B receptor antagonist for AUD. The finding that ABT-436 reduced both alcohol drinking and smoking indicate a potential use for V1B antagonists to treat co-use of alcohol and nicotine. ABT-436 is generally well tolerated in humans, with the most common side effect being diarrhea. Furthermore, results indicate that patients with high levels of stress may specifically benefit from medications targeting the vasopressin receptor.N-[ benzyl] 4-methoxybutyramide is a GHB analogue that has shown promising in vitro and in vivo preclinical results as a potential agent for the treatment of AUD. The addition of GET73 to cultures of rat hippocampal neurons rescued negative ethanolinduced effects, reductions in cell viability, and increases in reactive oxygen species production, providing evidence for a neuroprotective role of GET73 as an AUD treatment. In vivo, GET73 treatment at low, non-sedative doses reduced alcohol intake and suppressed relapse in alcohol-preferring rats, as well as exerting anxiolytic effects. These effects are similar to those seen with GHB administration; however, GET73 was shown not to bind to either high- or low-affinity GHB binding sites in rat cortical membranes. Recent studies indicate that GET73 may act as a negative allosteric modulator at the metabotropic glutamate sub-type 5 receptor; however, the complete mechanism of action of GET73 remains unclear. A translational study examining GET73-alcohol interactions found that neither 30 nor 100 mg/kg GET73 administered in rats potentiated alcohol-induced intoxication. Additionally, GET73 administered both in the presence and absence of alcohol was well tolerated in two samples of 14 and 11 participants, with no severe adverse events and no difference in adverse events. A Phase I clinical trial in two samples of 48 and 32 participants found that both single doses and repeated ascending doses of GET-73 were safe and well tolerated. Another inpatient human laboratory study conducted by the same group confirmed the safety and tolerability of GET73 such that no serious or severe adverse events occurred when GET73 was co-administered with alcohol. Co-administration also did not affect the pharmacokinetics of either GET73 or alcohol. However, GET73 also had no effect on alcohol cue-induced craving or self-administration, warranting additional research. A clinical trial of the effects of GET73 on magnetic resonance spectroscopy measures of glutamate and GABA levels in individuals with AUD was recently completed ; however, the results have not yet been posted, and another trial, which includes a free-drinking bar lab component, is ongoing .In comparison to the drawbacks presented by GABAB agonists like baclofen and SMO, positive allosteric modulators at this receptor present a potential alternative.

Since TBI has been linked to increased blood brain barrier permeability, it is possible that mechanisms associated with increased BBB permeability can enhance HIV’s penetration and virulence in HIV+TBI+ individuals . Viral proteins and inflammatory mediators could disrupt BBB regulation, allowing increased leukocyte migration and inducing subsequent neuronal damage and death . Our analyses were based on a study limited to HIV infected people. Therefore, though our results are compatible with a model of additivity, without examining HIV-uninfected groups that have TBI we cannot be certain whether these are additive or interactive effects. Because this was an exploratory study, we did not rigorously control for multiple comparisons, and thus the data must be regarded as preliminary. Furthermore, since our study was retrospective, some details about the TBIs were unavailable. It is possible that the TBI group itself differed in some way that we did not account for. A potential future prospective study could integrate more clinical information about a participant’s head injury such as the location of initial insult, Glasgow Coma Scale rating, or more precision on duration of unconsciousness. Future studies could also utilize functional magnetic resonance imaging information as another means to evaluate neuropsychological performance simultaneously with metabolic imaging. Looking at the number of head injuries that a person experienced could also have been worthwhile , as neuropsychological tests of memory, attention, and motor function have shown worse performance with repeated head injury . For example, HIV– individuals with multiple TBIs,growing rack when compared to those with a single TBI, exhibit significantly poorer memory and executive functioning .

Given that these two neurocognitive domains are the same as those that showed significant deficits in our study, it would be interesting to determine whether there are cumulative effects of multiple TBI on HIV-associated neurocognitive decline. Despite some limitations, our study does indicate that TBI may increase vulnerability to brain dysfunction in HIV-infected individuals. If confirmed, the results indicate that those involved with HIV care need to take head injury into account in their neurological evaluation and clinical management of HIV patients.Self-mutilating injuries are encountered predominantly in male patients in the ED.This pattern of behavior is seen in patients with personality, acute and chronic psychotic, major affective, and gender disorders. Self-harm behavior is primarily encountered in patients with personality disorders, especially in those with borderline personalities.Favazza postulated that this behavioral pattern is an effort to rid oneself of depersonalization, guilt, rejection, hallucinations, sexual involvements and complex emotional states.Self-harm behavior represents a rescue attempt triggered under circumstances in which expression of aggression is inhibited. Our case is a typical example of this behavior, seen frequently among prisoners.3 Authors cite that sexual, physical or emotional abuse and biological causes are important underlying factors in the etiology of self-harm behavior, abuse being the most important.Self-cutting is the most common type of self-injurious behavior. Cutting injuries to the wrists and arms are the most frequently encountered locations due to accessibility, although a myriad of different injury locations have been recorded.A variety of major self-mutilation attempts have been cited in the literature. Erdur et al. reported a 27-year-old patient with schizophrenia who amputated his tongue and penis.Ahsaini et al. published a report of a 40-year-old man who presented in hemodynamic shock after eviscerating both testes with his fingernails.Michopoulos et al reported a 66-year-old man who had been mutilating his fingers for the last six years.

This behavior started as nail biting and continued on to severe finger mutilation, resulting in loss of the terminal phalanges of all fingers in both hands. Koh and Lyeo wrote of a 20-year-old patient with schizophrenia who enucleated his own eye.Our patient was challenging in that he was a prisoner and not very cooperative, which hampered a thorough psychiatric evaluation. A presumptive diagnosis of psychosis was based on the patient’s indifferent attitude, limited cooperation, low-toned speech with short questions and answers, mystic delusions, auditory and sensory delusions – hearing commands and inappropriate affect. Self-harm behavior is seen primarily in patients with borderline and antisocial personality, major affective, and gender disorders and substance abuse. The fact of being imprisoned, along with possible secondary gains such as getting away from prison for admission to hospital due to “illness,” and lighter sentencing penalties, may have led the patient to engage in such behavior. Therefore, further investigation in terms of simulation, personality disorders and substance abuse is necessary. Self-mutilation associated with self-cannibalism is a rare condition. It can be due to a severe mental disorder such as schizophrenia. It could also be the result of a personality disorder or a malingering secondary behavior to get a lesser criminal penalty. Tobacco industry has continuously used product modifications, such as manipulating smoke pH with various chemical additives, to make combustible cigarettes more appealing to novice users. For decades, Philip Morris and other tobacco companies have used ammonia as a relatively innocuous additive for a variety of purposes, including augmenting certain flavors, cutting costs by expanding or “puffing up” the volume of cured tobacco leaves, preparing reconstituted tobacco sheet , denicotinizing tobacco , and even lowering/removing tobacco smoke carcinogens.

In the early 1960s, while evaluating the impact of ammoniated recons used in Marlboro cigarettes, Philip Morris discovered that freebase or unbound nicotine, as opposed to nicotine bound to other molecules , is more volatile and vaporizable, thus being highly bio-available. This led to the development of low-yield cigarettes that still had the nicotine kick necessary to keep customers “satisfied”. The freebased low-yield version of Marlboro cigarettes became the world’s most popular cigarette; Marlboro has remained the top selling cigarette brand in the world since 1972. The commercial success of Marlboro persuaded the rest of the tobacco industry to utilize ammonia to convert nicotine to its freebase form, as part of a new process for manufacturing cigarettes. However, this was achieved only after competitors uncovered Philip Morris’ “secret” of freebasing nicotine in cigarettes by reverse engineering the chemistry of Marlboro cigarettes. More than half a century later, a relatively unknown vape company, Juul Labs Inc., recognized the utility of salt-based nicotine for a novel electronic cigarette device, called JUU. Started in 2017, Juul Inc. is a spin off company from Pax Labs, which was a manufacturer of vaporizing devices for cannabis and loose-leaf tobacco; Pax Labs was preceded by Ploom as the original company for e-cig development. Remarkably, JUUL’s use of salt-based nicotine, which is significantly less aversive than freebase nicotine, made it very quickly popular among naïve users, particularly adolescents and youth. The high content of nicotine in JUUL, which was claimed to be equivalent to nicotine content of a pack of 20 cigarettes, also made JUUL highly appealing to adult smokers, seeking a putatively less-harmful alternative to combustible cigarettes. Shortly after its launch, JUUL became the preeminent vaping product on the market and a dominant player in the vaping industry. In December 2018, Altria, one of the world’s largest cigarette manufacturers and the parent company of Philip Morris USA, acquired a 35% stake in JUUL. This made Altria a major force in both the tobacco and vaping markets. Nearly 1 year later, the US Surgeon General declared “youth vaping” an “epidemic” in the United States [8], and the US Food and Drug Administration called JUUL a particular cause for concern. Not long after, in August 2019, the Centers for Disease Control and Prevention , the FDA, state and local health departments,drain trays for plants and other clinical and public health partners reported a nation-wide outbreak of vaping related severe lung illnesses and deaths, also referred to as “ecig, or vaping, product use-associated lung injury ”. Most EVALI cases reported using e-cig products containing vitamin E acetate and tetrahydrocannabinol , the principal psychoactive component of cannabis. However, the CDC did not rule out the etiologic involvement of other substances present in non-THC containing e-cig products. The EVALI outbreak lasted for several months, but declined considerably by February 2020. Worldwide, there are around 1.1 billion current cigarette smokers aged 15 or older, of whom 942 million are males and 175 million are females. In 2019, there were an estimated 155 million smokers aged between 15 and 24 years – equivalent to 20.1% of young men and 5.0% of young women, globally.

Two-thirds of all current smokers began smoking by age 20, and 89% of smokers began by age 25, highlighting a critical age window during which individuals develop nicotine addiction and transition to become established smokers. Globally, 7.4 trillion cigarette-equivalents of tobacco were consumed in 2019, amounting to 20.3 billion each day. Countries with the highest consumption per person were mostly in Europe. One in three male and one in five female smokers consumed 20 or more cigarette-equivalents per day, worldwide. The 10 countries with the largest number of tobacco smokers, which together comprised nearly two-thirds of the global tobacco smoking population in 2019, were China, India, Indonesia, the United States, Russia, Bangladesh, Japan, Turkey, Vietnam, and the Philippines—one in three current tobacco smokers lived in China. In many countries, progress in reducing the prevalence of smoking did not keep a pace with population growth, resulting in significant rises in the number of young smokers. India, Egypt, and Indonesia had the largest absolute increases in number of young male smokers. Turkey, Jordan, and Zambia had the largest increases in number of young female smokers. Over half of countries, worldwide, showed no progress in reducing smoking among 15–24 years old. Youth vaping is an evolving public health problem in the United States and around the world . Results from the 2020 National Youth Tobacco Survey and Monitoring the Future survey showed that nearly 3.6 million American teens were current users of e-cigs, of whom 80% reported using flavored products, such as fruit, mint, menthol, and candy, desserts, or other sweet-flavored eliquids. Specifically, one in five U.S. high school students and one in ten middle school students reported current use of e-cigs in 2020. The CDC and FDA analysis of the 2021 NYTS, conducted during January 18 – May 21, 2021, showed an estimated 2.06 million U.S. middle and high school students reporting current use of e-cigs. The authors, however, cautioned that because the 2021 NYTS was fully conducted amid the COVID-19 pandemic through mostly online data collection, estimates from this year’s survey should not be compared to previous NYTS survey waves that were primarily conducted on school campuses. Following a same trend, the percentage of college-age youth who vape nicotine, has risen dramatically in recent years. Between 2017 and 2019, the 30-day prevalence of e-cig use increased from 6 to 22% among college students, and from 8 to 18% among 19 to 22 year-olds not in college. Together, these data indicate a continued and dynamic evolution of the global tobacco epidemic and youth vaping epidemic. Tobacco smoking-related diseases, including cardiovascular disease, pulmonary disease, stroke, and cancer in multiple organ sites, such as the lung, mouth , throat, nose and sinuses, esophagus, bladder, kidney, and ureter, pancreas, stomach, liver, cervix and ovary, the bowel , and white blood cells , are the leading causes of preventable death, worldwide. In 2019, smoking was associated with 1.7 million deaths from ischemic heart disease, 1.6 million deaths from chronic obstructive pulmonary disease, 1.3 million deaths from tracheal, bronchus, and lung cancer, and nearly 1 million deaths from stroke. Approximately 87% of deaths attributable to tobacco smoking occurred among current smokers. Only 6% of global deaths attributable to smoking occurred among individuals who had quit smoking for at least 15 years. This underscores the significant health benefits of smoking cessation, especially when achieved earlier in life and soon after the initiation of smoking. Chemical analyses of e-cig vapor have revealed the presence of some of the same toxicants and carcinogens as those found in cigarette smoke, including carbonyl compounds, volatile organic compounds, free radicals, and heavy metals, albeit mostly at substantially lower concentrations.The latter likely arise from the mixing and heating of humectants [e.g., propylene glycol and glycerol ; PG/VG] and flavorings present in e-liquid. Overall, the reduced levels of toxicants and carcinogens in e-cig vapor are consistent with the fact that e-cigs, unlike traditional cigarettes, do not “burn” tobacco to produce inhalable materials. This has led to the perception that e-cig use/vaping is safe or less harmful than tobacco smoking [28, 29]. Whilst the lower levels of toxicants and carcinogens in e-cig vapor may imply mitigated health risk, they cannot, however, equate to no risk . In fact, exposure to many of the same constituents of e-cig vapor, at various concentrations, has been associated with a wide range of cardiovascular-, immune-related , and respiratory diseases, and cancer.

The first primary aim of this study was to confirm known group differences between CHR and UC subjects in experience of childhood trauma, psychosis risk symptoms, and functioning, as well as evaluate groups differences across inflammatory analytes known to be associated with childhood trauma. First, we hypothesized that CHR subjects would demonstrate higher levels of proinflammatory markers known to be associated with experience of childhood trauma as well as the 15-Analyte Index developed by Perkins et al. relative to UC subjects. Interestingly, CHR individuals in this sample demonstrated lower levels of TNF-a as compared to UCs, which is inconsistent with research demonstrating significantly elevated baseline blood plasma levels of TNF-a, CRP, and IL-6 in CHR individuals who endorsed a history of trauma . Significant differences were not revealed for Cortisol, CRP, IL-6 or the 15-Analyte Index between UC and CHR groups. The non-significant findings of differences in the 15-Analyte Index is attributable to the index being derived to discriminate between subjects who progress to psychosis, versus those that do not, and unaffected individuals, thus grouping the CHR subjects together resulted in non-significant differences between CHR and UC groups. Further, TNF-a is a proinflammatory cytokine, and thus, is involved in the initiation and aggravation of inflammatory responses, including cell apotosis. Interestingly, the biology of TNF in the brain allows for it to both protect neurons, as well as initiate their destruction through different protein activation processes . Although we are unable to evaluate this type of process in the current dataset,4×4 grow tray the observed decreased levels of TNF-a between CHR and UC subjects may relate to a meaningful narrative of complex inflammatory activation and suppression processes associated with enduring effects of childhood trauma such as increased stress reactivity in individuals at risk for psychosis .

For example, Jeffries et al. reports that as compared to CHR-NC, CHR subjects who convert to psychosis demonstrate a striking loss of complexity in analyte correlation networks that could be prognostic, indicating that network imbalance in pro-inflammatory suppression and activation processes is an important feature of in understanding progression to psychosis. Second, we hypothesized that CHR subjects would demonstrate significantly higher incidence of childhood trauma, greater severity of psychosis risk symptoms, as well as lower global, social, and role functioning as compared to UC subjects. Consistent with our hypothesis, this sub-sample of CHR participants demonstrated significantly higher overall psychosis risk symptoms severity, as measured by the SOPS, and lower functioning on the GAF, GFS, and GFR as compared to UC subjects. By definition, CHR individuals experience more psychosis risk symptoms and lower functioning as compared to unaffected individuals . Thus, the findings that CHR subjects in this sample demonstrated higher psychosis-risk symptoms and lower functioning is to be expected. More importantly, as compared to UC, CHR subjects in this sample demonstrated significantly higher total unique trauma, as well as higher incidence of trauma on most individual trauma sub-types, including, psychological bullying, physical bullying, emotional neglect, psychological abuse, and physical abuse. Three-fourths of CHR subjects in this sample reported history of childhood trauma, which is consistent with previous reports that prevalence of childhood trauma in individuals at risk for psychosis may be up to 90% ; however, this proportion is higher than larger sample from which this data was derived with approximately 60% of all CHR subjects reporting history of trauma. Thus, results from this study replicate previously demonstrated findings from Addington et al. , that CHR subjects experienced greater total number of unique trauma and bullying than UC subjects; however, this sub-sample of participants also demonstrates significant differences in emotional neglect, psychological abuse, and physical abuse, which was not demonstrated in the larger sample.

Although only CHR subjects demonstrated a history of sexual abuse, the group differences between CHR and UC subjects was not significant. We can hypothesize that since the current sample of CHR subjects is enriched with a higher proportion of individuals who are known to have converted to psychosis , that increased childhood trauma is associated with poorer clinical outcomes in this CHR sample, which was further explored in Aim 4. Finally, we hypothesized that CHR subjects who experienced history of childhood trauma would demonstrate higher levels of proinflammatory markers known to be associated with experience of childhood trauma as well as the 15-Analyte Index developed by Perkins et al , higher levels of baseline psychosis symptom severity, and lower baseline global/social/role functioning relative to CHR subjects with no history of childhood trauma and that these differences would vary by trauma sub-type. Inconsistent with our hypothesis, no differences were observed between CHRTrauma and CHRNoTrauma subjects in levels of the 15-Analyte Index, Cortisol, CRP, TNF-a, or IL-6. However, when analyzing groups by sub-type of trauma, it was revealed that CHR individuals who endorsed psychological bullying, physical abuse, and sexual trauma also demonstrated higher total incidence of trauma as compared to CHR subjects that did not endorse one of those sub-types of trauma. Further, CHRTrauma subjects who endorsed a history of psychological bullying demonstrated significantly lower Cortisol than CHRTrauma individuals with no history of psychological bullying. While blunted morning salivary Cortisol response in has been observed in first episode psychosis subjects who experienced a higher incidence of childhood trauma , the opposite effect has been seen with blood based Cortisol. In this sample, higher levels of blood based markers of Cortisol were associated with conversion to psychosis in this sample and added as one of the 15-analytes in the Perkins et al. index. Further, reported that higher incidence of psychological bullying was associated with poorer global role functioning in CHR subjects. Thus, while we know increased levels of Cortisol are important to predicting conversion to psychosis and it is possible that the lower levels of Cortisol seen here as associated with higher levels of childhood trauma is associated with a different phenomenon.

Put more simply, these results may indicate that the association or difference between blood-based Cortisol and childhood trauma is not clinically relevant for conversion to psychosis and that childhood trauma is independently predictive of clinical or functional outcomes, while higher levels of blood based Cortisol are predictive of conversion status.The second primary aim of this study was to identify highly correlated networks of inflammatory analytes using exploratory factory analysis. However, lack of correlation between inflammatory analytes and the relatively small sample size indicated that the sample was not suitable for factor analysis. To our knowledge, only one study to date has used EFA to understand the correlation between inflammatory cytokines and severity of psychosis symptoms ,greenhouse racking demonstrating positive correlations between levels of cytokines and the Positive and Negative Symptoms Scale scores in subjects with schizophrenia. used unweighted co-expression network analyses to identify highly correlated networks of analytes in CHR and HC subjects, providing evidence of marked simplification of networks of correlated proteins that regulate tissue remodeling consistent with a hypothesis of blood-brain-barrier dysregulation in schizophrenia. Thus, the investigation of both clusters of inflammatory analytes and networks of inflammatory analytes is important to improving our understanding of high complex interplay between pro-inflammatory and anti-inflammatory processes in the development of psychosis and clinical outcomes. The third primary aim of this study was to determine the relationship between childhood trauma, psychosis risk symptom severity, and functioning in CHR. First, we hypothesized that there would be a significant positive relationship between childhood trauma, and psychosis risk symptom severity, as well as a significant negative relationship between childhood trauma and global/social/role functioning. Consistent with our hypothesis, partial correlation analyses revealed that total childhood trauma was associated with greater positive psychosis risk symptoms and lower global functioning . Both findings are novel compared to Addington et al. ; however, we were unable to replicate the finding that total childhood trauma is associated with global role functioning in this smaller sub-sample. The association between childhood trauma and positive psychosis risk symptoms is consistent with existing research that higher incidence of trauma is associated with higher levels of positive symptoms in CHR . An extensive review on the relationship between childhood trauma and schizophrenia , concluded that childhood trauma is strongly related to symptoms of psychosis, specifically hallucinations and that the relationship may be dose-dependent. Second, we hypothesized that there would be a significant positive relationship between inflammation, total childhood trauma, psychosis risk symptom severity, and functioning, as well as a significant negative relationship between global/social/role functioning and inflammatory analytes in CHR subjects. Consistent with our hypothesis and replicating results from Perkins et al. , the 15-Analyte Index was positively correlated with all SOPS domains and negatively correlated with social, role, and global functioning in CHR subjects. However, a novel finding in this sample was revealed, a negative correlation between CRP and role functioning, indicating that higher levels of CRP are associated with lower scores on GFR. As GFR measures the level of impairment in academic, occupational, and homemaking roles, this is consistent with research linking blood levels of CRP to impaired cognitive performance in acute psychosis .

Further, demonstrated that higher levels of CRP were associated with significantly worse working memory and inversely correlated with cortical thickness in individuals diagnosed with schizophrenia. Thus, the association between higher CRP and lower GFR may be a marker of impaired cognitive performance in CHR subjects. Inconsistent with our hypothesis, inflammatory analytes were not associated with total childhood trauma in CHR subjects. Previous research demonstrating the association between inflammation and childhood trauma and psychosis used a measure of childhood trauma that captured severity and chronicity of trauma occurrence. For example, demonstrated associations between TNF-a and severity of childhood trauma in first episode subjects using the CTQ which captures not only presence of trauma, but also severity and of the trauma experienced . Further, Hepgul et al. demonstrated associations between childhood trauma and CRP using.The childhood experience of care and abuse scale: CECA.Q , which also measures severity of trauma. Thus, the measurement of childhood trauma used in this study did not capture severity or chronicity of the trauma experienced and thus were unable to be examined in the current study. Finally, we hypothesized that inflammation would partially mediate the relationship between childhood trauma and psychosis-risk symptom severity, as well as between childhood trauma and functioning in CHR youth. Using the information gathered from partial correlation analyses, we tested two mediation models. In Model 1, we explored whether the relationship between total childhood trauma and SOPSP was mediated by the 15-Analyte Index. In Model 2, we explored whether the relationship between total childhood trauma and GAF was mediated by the 15-Analyte Index. Inconsistent with our hypothesis, but consistent with the results from the partial correlation analyses, total childhood trauma and the 15-analyte index independently accounted for a significant proportion of variance in SOPS positive symptoms in Model 1. Further, total childhood trauma and the 15-analyte index independently accounted for a significant proportion of variance in GAF in Model 2. Neither model showed significant mediating effect of inflammation on the relationship between childhood trauma and clinical outcome due to lack of association between inflammation and childhood trauma. Thus, we can conclude that childhood trauma and the 15-Analyte Index may have additive effects in predicting SOPS positive and GAF, and that the effects of total childhood trauma on clinical outcomes is not mediated by inflammatory processes. These results have several possible explanations. It is possible that the lack of association between childhood trauma and inflammation was due to the inability to account for severity of childhood trauma experienced. Thus, with a measure of severity of childhood trauma, perhaps the relationship between total severity/chronicity of trauma experienced would be associated with Cortisol, CRP, IL-6, TNF-a, or the 15-Analyte index. However, it is also possible that the individual analytes included in the 15-analyte index are uniquely and independently predictive of SOPS positive symptoms and GAF, thus childhood trauma may not be associated with those specific inflammatory analytes irrespective of the childhood trauma indices used. Several studies cite the significant relationships between inflammation, childhood trauma, and in first episode psychosis ,but no studies to our knowledge to date have evaluated the mediating effect of inflammation on the relationship between childhood trauma and clinical outcomes in CHR subjects to date.Lastly, we explored the effect of psychosis-risk conversion status and trauma history on inflammation, psychosis risk symptom severity, and functioning in CHR. Group stratification revealed that there were no significant differences between CHR-C and CHR-NC groups in total trauma, meaning that CHR individuals who progressed to psychosis from an at-risk state did not demonstrate higher total trauma as compared to CHR subjects that did not progress to psychosis.

There are several recent examples of adequately powered genome-wideassociation studies of endophenotypes. For example, impulsivity, which has been defined as “actions which are poorly conceived, prematurely expressed, unduly risky or inappropriate to the situation, and that often result is undesirable consequences”appears to meet the criteria for an endophenotype for multiple psychiatric disorders, including attentiondeficit/hyperactivity disorder and several substance use disorders . Numerous genetic studies have now shown that various measures of impulsivity and sensation seeking are heritable and that they are genetically correlated with both ADHD and various substance use related traits. In addition, risk tolerance , which has also been proposed as an endophenotype for both ADHD and substance use disorders, was recently measured in over one million individuals . Although risk tolerance was measured using a minimal phenotype , risk tolerance was clearly heritable and the large sample size allowed identification of 124 genome-wide significant loci. Some of these loci have also been implicated in clinically defined traits. Furthermore, risk tolerance was positively genetically correlated with numerous clinically relevant traits . This study illustrates the power of minimal phenotyping to capture an endophenotype that informs complex disorders and also conforms to the RDoC framework. In a third example, Ibrahim-Verbaas et al performed a GWAS for executive function, which can be considered an endophenotype for multiple psychiatric traits. Intriguingly, GWAS of sensation seeking, risk tolerance18 and executive function all identified a locus that included the gene CAMD2, which was subsequently associated with AUD9 . Whether all of these associations are due to a single locus or multiple loci is far from clear,drying room but the index SNPs for these studies are typically co-inherited , consistent with a single causal locus.

Another example of an intriguing endophenotype is self-reported loneliness , which is a strong predictor of mortality and life satisfaction and appears to precede the onset of MDD. Several recent GWAS of loneliness have identified several significant loci and shown that a genetic predisposition to loneliness is genetically correlated with psychiatric, cardiovascular, and metabolic disorders. By assigning polygenic risk scores to individuals for whom electronic medical records were also available, Dennis et al showed that genetic liability for loneliness increased the risk to develop coronary artery disease more robustly than MDD. Thus, loneliness is an endophenotype that is relevant to both MDD and a variety of somatic disorders. While some endophenotypes may be amenable to minimal phenotyping, others represent extremely deep and rich data types. For example, by passively collecting data from wearable devices and smartphones, certain endophenotypes relevant to psychiatric disorders can be measured. In a recent GWAS of circadian rhythm, wearable devices were used to gather objective measures of sleep timing, duration and quality. More recently, structural connectivity from fMRI was proposed as endophenotype for IQ. Elliott et al used 3,144 functional and structural brain imaging phenotypes from UKB to conduct GWAS that identified novel associations that included genes relevant to brain development, pathway signaling and plasticity.The approach we are proposing will be orthogonal to the efforts of the PGC because RDoC traits and endophenotypes “split” diagnostic categories into discrete units of analysis. The SUD field provides a good example of how a complex disorder can be split into smaller, more biologically meaningful units. SUD develop in accordance with an obligate longitudinal pattern: drug experimentation → regular use → harmful use → transition to compulsive use → quit attempts → relapse . Approaching SUD with a case control framework merges the genetic liability for each of these stages into a single phenotype, obscuring the distinct biological factors relevant at each stage.

In contrast, several recent projects have focused on individual stages of SUD, whichcan help to address this limitation. For example, GSCAN used data from almost 1 million individuals to examine a number of SUD-related traits, including smoking initiation48. In another example, the genetic relationship between alcohol consumption and AUD was explored using the AUDIT, a 10- item questionnaire that measures alcohol use and misuse. By dissecting the genetic contribution for alcohol consumption vs problematic use , Sanchez-Roige et al and Kranzler et al showed a surprisingly low correlation between alcohol consumption and AUD ; however, the correlation between problematic alcohol use and AUD was stronger. Even when the temporal stages of a psychiatric disorder cannot be so clearly delineated, it can be helpful to split diagnoses into endophenotypes that are associated with the disease of interest. For example, a recent GWAS of insomnia, which is a core symptom of multiple psychiatric disorders and a DSM criterion for MDD, identified 202 loci and showed strong genetic correlations with MDD and several other psychiatric conditions . Similarly, neuroticism, which shares a common genetic basis with MDD but can be more easily measured, could serve as a clinical stratifying factor for antidepressant actions. However, it can be difficult to determine what level of dissection is required; a recent study suggested that neuroticism reflected two genetic dimensions, one capturing depressed affect, and another capturing worry. Another example comes from several GWAS of impulsive personality, which has been proposed as an endophenotype for several psychiatric disorders including ADHD. The UPPS-P is a self-reported questionnaire that measures 5 different aspects of impulsive personality. Only two of those five were significantly associated with ADHD; in contrast, all three sub-scales of BIS-11, which is another impulsive personality questionnaire, were significantly associated with ADHD. These examples illustrate how disease phenotypes can be dissected into component parts.

Nonetheless, despite the original claim that endophenotypes would have a simpler genetic architecture, all studies conducted to date have shown that both disease diagnoses and endophenotypes are highly polygenic. Once the traits that reflect domains of normal function have been measured in genotyped cohorts, it becomes possible to explore their empirical relationships with one another beyond those that are already defined by traditional psychiatric nosology . Genomic SEM27 and related techniques are now being used in a number of such efforts. Luningham et al used genomic SEM to test multiple models of psychopathology among fourteen psychiatric disorders and related traits. They identified three factors , and an uncorrelated Neurodevelopmental Disorders factor. These factors showed distinct patterns of genetic correlations and accounted for substantial genetic variance. These empirically identified clusters may provide better targets for GWAS than individual disorders. In another example, Baselmans et al showed that it was possible to increase power by using Genomic SEM to integrate multiple traits into a measure of “well-being spectrum”. By aggregating data from different sources of correlated traits, they reached a sample size of over 2.3 million individuals, which allowed them to identify 304 independent signals associated with well-being; a similar analysis suggested a two factor model that distinguishes “lower end” and “higher end” well-being factors. In a third example, Thorp et al used Genomic SEM to identify two factors, which they referred to as “psychological” and “somatic” from the 9-item Patient Health Questionnaire . Recently, several related methods have been developed . Using RGWAS, Dahl et al proposed a stress sub-type in MDD, and identified three novel sub-types of metabolic traits. Using BUHMBOX , Han et al found that seropositive and seronegative rheumatoid arthritis could be subdivided to form a new subgroup within seronegative-like cases. Conversely, they identified a genetic correlation between MDD and SCZ, but there was no evidence that this correlation was due to subgroup heterogeneity.Clumping has been used to test the hypothesis, originally suggested by twin studies,trimming marijuana plants that psychiatric disorders share a single common genetic factor. One of the earliest studies to use GWAS data to test this hypothesis showed that SNPs associated with schizophrenia were also associated with bipolar disorder. Specific genes have been identified that confer risk for multiple psychiatric disorders . Evidence that the risk for substance abuse is shared across multiple substances is also consistent with earlier results from twin studies showing both substance-specific and substance-independent genetic risk. An example of this genetic overlap is the gene CADM2, which has been associated several substances and risky behavior. Joint analysis of correlated traits may outperform that of single phenotypes and allows the possibility to disentangle genetic effects that are specific to each trait from those that capture a latent construct . Clumping can also lead to new splits. For example, Bansal et al used GWAS results from two correlated traits: schizophrenia and educational attainment to propose two distinct etiologies of schizophrenia, one that resembled bipolar disorder and was characterized by high education, and another that reflected a cognitive disorder and was independent of education. Studies like this one provide greater flexibility to explore the phenotypic space, which can lead to novel insights and challenge established nosologies.Throughout this perspective, we have alluded to GWAS producing novel biological insights; however GWAS have numerous limitations65 and do not themselves produce actionable new knowledge.Indeed, a recent meta-analysis indicated that among those with ED, the lifetime prevalence rate of a comorbid SUD was 21.9% . Tobacco, caffeine, and alcohol are reported as the most prevalent SUDs for individuals with EDs . Sedatives, cannabis, stimulants, and over-the-counter products such as laxatives, diuretics, and diet pills are also commonly abused . Research suggests that ED patients with co-occurring SUDs experience lower rates of treatment response, higher relapse rates, more severe medical complications, greater impairment, poorer long-term outcome, and are at higher risk of early mortality .

Given the high-risk nature of individuals with co-occurring EDs and SUDs , and poor outcomes associated with their treatment, it is important to identify whether effective treatment interventions for this population. A major barrier to identifying treatment targets for ED-SUD is the paucity of research comprehensively characterizing the treatment-seeking ED-SUD patient population. Below, we outline the existing literature characterizing ED-SUD and associated features.Separately, EDs and SUDs have the highest and second-highest mortality rates of all psychological disorders . Both EDs and SUDs often present with comorbid mood disorders, anxiety disorders, post traumatic stress disorder , and borderline personality disorder . Becker and Grilo found that among patients with binge eating disorder , those with both mood and substance use disorders had the most severe ED symptoms, and higher rates of personality disorders. In a retrospective chart review, Kirkpatrick et al. found that for adolescents with ED, those with comorbid SUD had higher rates of self-harm and purging, and had a higher BMI at intake. Finally, a small study of an inpatient sample showed that those with ED-SUD were more likely to be diagnosed with a Cluster B personality disorder compared with those with ED alone . ED Diagnosis. Several studies have investigated whether co-occurring SUD is more common in anorexia nervosa-restricting type , anorexia nervosabinge-purge type , or bulimia nervosa. Theoretically, it is believed that binge-purge behaviors are more closely linked to substance abuse, as there is evidence for an increased association between these behaviors and impulsivity and emotion regulation difficulties . One large study found that within ED patients, BN, and AN-BP patients had the highest prevalence of comorbid substance use, whereas AN-R participants generally had the lowest . Root et al. found that across eating disorder groups, the BN and AN-BP groups were more likely to report alcohol abuse and diet pill use relative to the AN group, and the AN-BP group was more likely than the AN-R group to have alcohol abuse, use diet pills, stimulants, and engage in polysubstance abuse. Along the same lines, Fouladi et al. found patients with BN used substances with higher frequencies compared to patients with ANR, BED, and EDNOS, and those with AN-BP were more likely to use substances than those with AN-R. Moreover, higher frequencies of binge eating and purging were associated with higher frequencies of substance use. Finally, a meta-analysis on this topic by Bahji et al. revealed that prevalence rates of SUD were significantly higher among individuals with binge-purge behaviors than those with only restrictive behaviors.Temperament and underlying emotion regulation difficulties serve as common risk and maintenance factors for EDs and SUDs. Recent research provides compelling support for theories of emotion regulation to explain the co-occurrence of disordered eating and substance abuse . Specifically, these theories posit that individuals engage in these maladaptive coping strategies to alleviate negative affect . In support of this, existing findings indicate that affective instability, impulsivity, negative urgency, and novelty seeking are common in individuals with EDs who engage in substance abuse . For example, a study investigating temperament found that binge eating was associated with increased impulsivity and risky decision-making .

In past focus group discussions with clinic patients, quality of life emerged as one of the most important outcomes of interest for patients themselves, and it is one that clinicians and other care team members want for patients as well. At the same time, viral suppression is a major focus of the HIV Care Continuum and remains a national priority in HIV/AIDS care and treatment. Thus, we elected to focus on trauma’s impact on one patient- centered outcome and one HIV Care Continuum outcome in this analysis. All analyses were conducted using Stata 14 . Participants in the study were 104 women living with HIV . Four participants identified as transgender or intersex; they were included in all analyses as the intervention being evaluated is clinic-wide and the four women represent an important portion of the clinic’s patient population. The participants’ mean age was 52 years and almost 80% were women of color. Approximately half had a high school education or less, only 20% were working for pay, and 61% reported food insecurity in the past year. Almost all participants were living in stable housing. The mean ACE score was 4.2, and more than half of participants reported four or more ACEs. In this study, lifetime trauma and recent trauma were also common , and many participants reported having experienced threats, abuse,cannabis curing and violence as a result of disclosing their HIV status to others . Participants who reported four or more ACEs were significantly more likely to report both lifetime and recent trauma. ACE scores and THS scores were highly correlated . Most study participants had been living with HIV for a substantial number of years, and the majority reported that they were currently on ART medications .

Of the 96 participants who had available viral load data, 68 had an undetectable viral load . Of the 83 participants who reported being on HIV medications and who had available viral load data, 66 had an undetectable viral load. Two participants who reported not being on ART also had undetectable viral loads. Study participants experienced considerable behavioral health symptoms. One-third met the diagnostic criteria for PTSD ; almost one-half reported at least moderate levels of depression symptoms ; and more than one-quarter reported at least moderate levels of anxiety symptoms . Although the mean alcohol use disorder screening scores were low overall and 52.4% of participants reported no current alcohol use at all, 17% of participants reported binge drinking and 22.1% met the threshold for further alcohol use disorder screening, indicating high levels of use among those who do drink. Almost one-half of participants reported tobacco use in the past three months; 27.9% reported use of cocaine, amphetamines, sedatives, and/or illicit opioids in the past 3 months; and 17.3% reported at least moderate levels of drug abuse, reaching the threshold for further investigation or intensive assessment. Ratings of patient-provider relationship were very high with a mean of 1.2. We also investigated various forms of social health. Among study participants, the mean total Empowerment Scale score was 3.0 out of a total possible score of 4.0. Mean social support for all participants was 3.2. When asked how open or ‘out’ they were about their HIV status, 24 reported being completely out, while 24 reported being not at all out, and 7 participants had never told anyone of their HIV-positive status. However, participants overall reported only moderate levels of total HIV related stigma . The mean quality of life score was 13.8, with 54.8% of participants scoring below 13, indicating poor quality of life. Next, we examined relationships between trauma and various indicators of health . Experiences of lifetime trauma, as measured by the THS, were significantly associated with ART medication use among participants; for each additional trauma experienced, participants had significantly reduced odds of being on ART medications .

Similarly, participants with higher numbers of trauma experiences had significantly lower odds of reporting good 30-day HIV medication adherence . In contrast, there were no significant relationships between trauma and CD4 count, or whether the participant had an undetectable viral load . We then considered the relationship between trauma and behavioral health outcomes. Experiencing more traumatic events was significantly associated with higher PTSD symptom scores , higher depressive symptom scores , and higher anxiety symptom scores , as well as greater odds of reaching the diagnostic thresholds for all three . In addition, although higher counts of traumatic events were significantly associated with higher alcohol use scores , they were not significantly associated with the AUDIT screening threshold that would indicate an alcohol use disorder . Higher THS counts were also not associated with self-reported use of tobacco, cannabis, or sedatives in the past three months, but were significantly associated with recent use of cocaine , amphetamines , and illicit opioids . Higher counts on the THS were also associated with higher odds of self-reported overall “hard” drug use . Finally, more traumatic experiences was associated with higher drug abuse screening raw scores and with greater odds of having a positive drug abuse diagnosis . In examining well-being and social health outcomes, we found that trauma was associated with significantly greater HIV stigma . Trauma was also significantly negatively associated with quality of life and mental well being; those with more traumatic experiences had lower quality of life scores , as well as lower psychological well being scores . Trauma was not, however, significantly associated with empowerment, social support, or disclosure. As a last step, we used bivariate linear and logistic regression analysis to examine factors that are associated with our main outcomes of interest. White women reported significantly lower quality of life scores compared to women of color . Women who had more PTSD, depression, and anxiety symptoms also reported significantly lower quality of life scores . In contrast, participants who reported greater empowerment and greater social support reported significantly higher quality of life . In examining undetectable viral load we found that older women and white women had significantly greater odds of having an undetectable viral load , as did women who were currently taking ART medications and those with higher CD4 counts.

However, women who had higher drug abuse screening test scores had significantly lower odds of having an undetectable viral load .In this sample of women living with HIV, we found near-universal reports of lifetime trauma, including childhood and adult trauma, as well as a significant minority who reported incidents of abuse and threats in the past 30 days. These findings support the growing body of literature documenting high rates of trauma and PTSD among WLHIV , and uniquely add to it by documenting high mean ACE scores in a population of WLHIV for the first time. In examining quality of life as one of our two main outcomes of interest, we found that over half of the women experienced poor quality of life despite the broad availability and use of antiretroviral therapy and despite most participants having an undetectable viral load. Those who had experienced more trauma had significantly poorer overall quality of life compared to those who had experienced less trauma. We also found that traumatic experiences were significantly associated with greater symptoms of depression, anxiety, and PTSD,drying weed worse HIV-related stigma, and poorer mental well being. In addition, trauma was associated with greater alcohol and drug use and higher drug abuse screening test scores. The link between adverse childhood experiences and later substance use and substance use disorders has been well described . The high level of substance use in this population is very concerning due to the known disproportionally high rates of death among WLHIV from substance use . In examining the impact of trauma on our second main outcome of interest, we did not find a significant relationship between trauma and having an undetectable viral load. However, trauma was significantly negatively associated with being on antiretroviral medications for HIV and with ART adherence, both of which are key outcomes on the HIV Care Continuum and are key contributors to the likelihood of achieving an undetectable viral load. These findings support prior research that has documented the impact of trauma sequelae such as PTSD and depression symptoms on HIV medication adherence . For individuals who have experienced significant trauma, the increased risk of PTSD symptoms such as avoidance behaviors, depression, and HIV-related stigma may make it more difficult to engage in self-care and to adhere to treatment regimens. Although we did not identify a significant relationship between trauma and an undetectable viral load, other studies have documented this relationship . In addition, the high rates of virologic suppression in our sample may have affected this study’s ability to detect the link between trauma and virologic suppression despite the identified association of trauma with the key predictors of it. This study had several limitations. First, because the data reported here are cross-sectional, causality cannot be determined.

However, the associations between lifetime trauma and poor quality of life, PTSD, depression, anxiety, and substance use suggest a role for trauma in later health outcomes for WLHIV. Second, the sample size was relatively small. Within this clinic, however, the 104 patients who participated in the study accounted for approximately two thirds of all clinic patients who were eligible for the study at baseline. At the same time, the clinic population is fairly representative of the national population of women living with HIV, particularly in urban areas. Therefore, the study has some degree of generalizability to the larger population of WLHIV in the United States. Another limitation of the study was the measurement of trauma. Although we used three different measures that covered childhood, lifetime, and recent trauma, there are many other types of trauma that we did not measure. For example, although we recorded race, we did not include a specific measure of experiences and impact of racism in the study. Similarly, many patients in the clinic have been involved with the foster care and/or the prison systems, where trauma and violence are common, and we did not record this information or the impact that it may have had on their health outcomes. It is possible that individuals may have experienced other traumatic events that we did not measure. The overall study, however, has many strengths. These baseline data, as well as data from the parallel study with clinic staff , are being used to inform implementation of TIHC in the clinic. This includes educating staff about the impact of trauma on health, creating a safe and welcoming environment for patients, screening patients for the consequences of trauma, and using data to identify the most effective ways to respond to past and ongoing trauma . In addition, the results presented here are from the baseline stage of a larger longitudinal mixed-methods study that will allow us to evaluate the impact of trauma-informed health care on health outcomes for WLHIV. This larger study includes survey and EHR data collection at multiple times over a number of years, as well as qualitative data collection with both patients and staff to contextualize the findings of survey data. Although this baseline study was neither designed nor powered to elucidate the pathways to explain the relationship between trauma, poor quality of life, and other poor health outcomes, the results add to a growing recognition that the current national focus on virologic suppression is insufficient as a measure for health and well-being of WLHIV .In the United States, over half a million people experience homelessness each night.The proportion of single homeless adults over age 50 is increasing.Homeless adults age 50 and over experience a higher prevalence of geriatric conditions than adults 20 years older in the general population.In the general population, falls are prevalent, occurring in approximately one-third of adults age 65 or older.Falls are associated with adverse outcomes including restricted mobility, deconditioning, and loss of independence.In the United States, medical costs due to fatal and non-fatal falls are approximately $50 billion a year.Individual risk factors for falls include medical problems , health-related behaviors, and social factors . Environmental triggers are factors external to the individual that heighten the risk for slipping or tripping. These include surface , ambient , and weather-related conditions.