The scarce research on the effects of moderate alcohol consumption on mental health among older adults suggests a protective effect against depression. We prospectively examined the association between patterns of moderate alcohol consumption, depression and psychological distress, using information from 5,299 community-dwelling older adults from the ELSA and Seniors-ENRICA cohorts. A Mediterranean drinking pattern (MDP) was defined as moderate alcohol intake  with a preference for wine and drinking only with meals. Depression was ascertained with the 10-item Geriatric Depression Scale (GDS-10), a self-report of clinically-diagnosed depression, or being on anti-depressant medication (Seniors-ENRICA); and with the 8-item Center for Epidemiologic Studies Depression Scale (CES-D) (ELSA). Psychological distress was assessed with the General Health Questionnaire-12 (GHQ-12). Compared to never drinkers, moderate drinkers showed comparable scores on the ENRICA-GDS-10 (PRR (95%CI): 1.03 (0.84–1.26)), the ENRICA-GHQ-12 (0.88 (0.73–1.06)), the ELSA-CES-D (0.92 (0.79–1.06)) and the ELSA-GHQ-12 (0.75 (0.55–1.01). The MDP was not associated with the GDS-10 or GHQ-12 scores, or with clinically-diagnosed depression; however drinkers with a preference for wine showed an increased number of psychological distress symptoms (1.31 (1.03–1.66)). In conclusion, we found no consistent protective association between moderate alcohol consumption and depression in older adults. According to the Global Burden of Disease Study, in 2015 the number of Disability Adjusted Life Years (DALYs) for depressive disorders in older adults ranged from 750 per 100,000 among those aged 80 and over to 1050 per 100,000 among those aged 60–652. Depression in these age groups frequently coexists with other chronic diseases, cognitive impairment, and psychosocial problems . Moreover, depression in older adults is associated with a higher use of healthcare services3, and is a risk factor of physical function limitations4, suicide5, and premature mortality7.Among older adults, depression is the most common mental illness8. Major illnesses associated with alcohol intake include cancers 9, cardiovascular diseases 8, and gastrointestinal conditions 10. Nevertheless, moderate alcohol consumption has been associated with a reduction of some health risks; for instance, compared to non- drinkers, moderate alcohol drinkers display a reduced risk of coronary artery disease11, ischemic stroke11, heart failure11, and type 2 diabetes12.Heavy alcohol consumption significantly contributes to the burden of disease in many countries13. However, studies have seldom examined the psychological and mental health effects of light to moderate alcohol consumption, and the scarce longitudinal reports have rendered inconsistent results19. Thus, the main objective of this work was to examine the prospective association between moderate alcohol intake and depression or psychological distress in two cohorts of community-dwelling older adults: the Seniors-ENRICA (Study on Nutrition and Cardiovascular Risk in Spain) and the ELSA . Given that the effects of alcohol on mental health might be context-specific, analyzing data from these two cohorts may facilitate determining whether any associations found differ between “Mediterranean” countries like Spain, where alcohol is traditionally used as a nutritional element and most drinking occurs during meals, and “Non-Mediterranean” countries like England, where alcohol is consumed in greater amounts and mainly used as a psychotropic-relaxant. In this work we also assessed the impact of the Mediterranean Drinking Pattern (MDP) on depression and psychological distress. The MDP, characterized by moderate alcohol intake, a preference for wine, and drinking only with meals, is the traditional pattern of alcohol consumption in Spain and other regions of the Mediterranean basin20. Previous studies among older adults have reported the MDP to be associated with a reduced risk of functional limitations21, frailty22 and falls23, and with better scores on the Physical Component Summary of the12-item Short Form Health Survey24. However, its effects over mental health are unknown.A large body of research has traditionally documented the deleterious relationship between alcohol abuse and depression25. For these analyses, we used information from 2,519 subjects participating in wave 2 (2012) and followed through wave 3 (2015)26. In these two waves, information regarding sociodemographic variables, health behaviors and morbidity was collected using a computer assisted telephone interview. There is evidence from Spanish population studies that telephone surveys yield similar distributions of health behaviors and morbidities as face-to-face interviews28. In particular, the Spanish telephone-administered geriatric depression scale has shown a high correlation with the validated personal administration of the scale27. An advantage of the telephone-administered geriatric depression scale is that it may increase participation, as depressed individuals are less likely to respond to fac-e-to-face questions on depression27. After telephone interviews, a diet history and a physical exam were performed by trained staff during at-home visits.This cohort was established during 2008–2010 with individuals selected by multi-stage stratified random sampling from the non-institutionalized Spanish population aged ≥60 years (wave 1)La Paz University Hospital in Madrid approved the study. All methods were performed in accordance with the relevant guidelines and regulations.From the initial sample of 2,519 participants in 2012, 82 (3.3%) died and 616 (24.5%) were lost to follow-up; thus, in 2015 data on depression and psychological distress came from 1821 individuals. Participants remaining in the study were slightly younger, had higher educational level, fewer comorbidities and lower scores in the GDS and GHQ-12 scales. Never drinkers and ex-drinkers were more likely to be lost to follow-up. All participants gave informed written consent, and the Clinical Research Ethics Committee of the 29. The present research analyzed data from Waves 0, 1 and 3. As in previous reports31, a combination of Wave 0  and Wave 1 (which included those households from Wave 0 where at least one member was aged ≥50 years between March 2002 and March 2003), was used to define the baseline sample . Information from the initial sample was collected using a personal face-to-face Computer Assisted Personal Interview, a nurse visit and a self-completion questionnaire. From the initial sample, we excluded those individuals aged <60 years .This cohort comprises people aged ≥50 years living in private households in EnglandDuring follow-up, 241 participants died (3.3%), 1928 (26.7%) refused to participate or could not be contacted, and 488 (6.8%) became ineligible . Thus, in 2006–2007, information on depression and physiologic distress was collected from 4,568 participants aged ≥60 years. Participants remaining in the study were more frequently women, younger, had higher educational level, lower tobacco consumption, fewer comorbidities and lower scores in the CES-D. The National Research Ethics Service (MREC/01/2/91) provided the ethical approval for ELSA.32. The diet history collected consumption data for 34 alcoholic beverages and used photographs depicting different glass sizes to help quantify serving sizes. Alcohol content, in grams, was then estimated using standard composition tables. According to the average alcohol intake, participants were classified as (1) never drinkers , (2) ex-drinkers (those reporting having stopped drinking for at least a year before the interview), (3) moderate drinkers and 4) heavy drinkers. We set the threshold between moderate and heavy drinking at ≥40 g/day for men and ≥24 g/day for women33. Among drinkers (categories 3 and 4 in the previous classification), a preference for a specific type of alcoholic beverage (wine or other) was acknowledged when more than 80% of alcohol intake was derived from such drink22. According to the consumption of alcohol with meals (lunch or dinner), drinkers (categories 3 and 4) were also classified into three groups: those who drank exclusively during mealtimes, those who drank exclusively outside meal times, and those who drank at any time. Finally, a Mediterranean Drinking Pattern (MDP) was defined as moderate average intake of alcohol (and no binge drinking), with wine preference and alcohol consumption only with meals22.In the Seniors-ENRICA study, alcohol consumption was estimated based on a validated diet history, developed from the one used in the EPIC cohort study in SpainFor the ELSA-cohort analyses, information on alcohol consumption and frequency was derived from Wave 0 but not from Wave 1 because this wave collected information only on the frequency of drinking. According to the average alcohol intake, and having defined 10 grams of pure alcohol as equivalent to an alcohol unit, participants were classified as never drinkers, ex-drinkers, moderate drinkers, and heavy drinkers. The threshold between moderate and heavy drinking was set at 28 units of alcohol/week in men and 21 units/week in women.34. Individuals missing ≥2 items were excluded from the analyses. A higher score in the GDS indicates a greater level of depression.Geriatric Depression Scale (GDS): To assess depressive symptoms, the Seniors-ENRICA study used the 10-item version of the GDS35. A higher score in the CES-D indicates a greater level of depression.Center for Epidemiologic Studies Depression Scale (CES-D): The ELSA study used the 8-item version of the CES-D)Self-reported depression: In the Seniors-ENRICA study this variable was defined as a positive answer to the question “Has a doctor ever told you that you have depression” or as being on antidepressant medication.Depression was ascertained with three instruments:The Seniors-ENRICA and the ELSA studies used the 12-item version of the General Health Questionnaire (GHQ-12), a screening tool for psychological distress. Individuals missing ≥2 items were excluded from the analyses. Higher scores in the GHQ-12 indicate higher psychological distress.37. In the ELSA study, participants were asked about the frequency  of participation in vigorous-, moderate-, and light-intensity activities. An overall measure of physical activity was generated by multiplying activity frequency by the metabolic equivalent value for each type of activity . In the Seniors-ENRICA, adherence to the Mediterranean diet was captured using the Mediterranean Adherence Screener (MEDAS) index 38, and energy intake was calculated based on Spanish food composition tables. In both cohorts, baseline weight and height were measured with standard methods. BMI was calculated as (weight in kg)/(height in m)2. Normal weight was defined as a BMI <25, overweight as a BMI 25–29.9, and obesity as a BMI ≥30. Finally, in both cohorts, participants also reported whether they had previously been diagnosed with any of the following diseases: cardiovascular disease , diabetes, chronic lung disease , and osteomuscular disease (osteoarthritis or arthritis); as well as the number of medications they were taking. In the Seniors-ENRICA, study staff compared self-reported information on medication use with medication packages stored at home.Baseline self-reported data on age, sex, educational status, and tobacco consumption were collected in both cohorts. In the Seniors-ENRICA cohort, information on physical activity  and on the number of hours/day spent watching television was assessed using validated questionnairesFrom the initial 1,821 participants in the Seniors-ENRICA cohort, we excluded 200 (11%) subjects with incomplete data on alcohol consumption or potential confounders. Additionally, for analyses on depression we excluded subjects lacking information on the GDS at baseline or follow-up . For analyses on psychological distress we excluded individuals with missing data on the GHQ-12 at baseline or follow-up . Similarly, from the initial 4,568 participants in the ELSA cohort, 440 (9.6%) subjects were excluded due to incomplete data on alcohol consumption or potential confounders. Also, we excluded individuals with missing information on the CES-D at baseline or follow-up  for analyses on depression, and individuals with no data on the GHQ-12 at baseline or follow-up  for analyses on psychological distress. Baseline socio-demographic, lifestyle, and clinical characteristics of individuals with and without missing information were similar, although the latter were on average younger, were more likely to be moderate drinkers, and showed a lower prevalence of diabetes and osteomuscular disease.Associations between alcohol consumption and depression or psychological distress were analyzed with generalized regression models because of the highly skewed distribution of the dependent variables , which mirrored that of count variables  were further adjusted for total alcohol consumption (grams/day).We conducted separate sensitivity analyses. First, we excluded subjects with baseline cardiovascular disease or cancer as well as participants under anxiolytic, antipsychotic, or antiepileptic medication at baseline. Second, to facilitate comparisons between cohorts, we reran analyses with abstainers (never drinkers and ex-drinkers) as the reference category, and reduced the threshold between moderate and heavy intake to 15 g/day for both genders. Third, we split moderate consumption into two categories: below or above the median average alcohol intake. Fourth, we evaluated the risk of depression as defined by a score above 3 in the CESD or GDS using logistic regression. Finally, we modeled the association between alcohol consumption patterns and changes  in the GDS-10, GHQ-12, and CES-D, using the VCE (bootstrap) command in Stata to estimate confidence intervals based on 100 resamples   or the MDP  and incidence of self-reported depression (defined as a physician-diagnosis of depression or as being on antidepressant medication) .Overall, we found no consistent protective association between moderate alcohol consumption and depression in older adults. Moreover, in the Seniors-ENRICA cohort, adherence to certain alcohol consumption patterns such as drinking only with meals or the MDP failed to show an association with either of the studied mental health outcomes. However, results showed some non-significant tendency to a lower risk of depression (Spanish sample) and psychological distress (both samples) associated with heavy drinking, which should be further investigated in studies with a larger number of heavy drinkers.17. By contrast, Norway’s Nord-Trøndelag Health Survey of 38,930 individuals with a mean age of 48 years, ascertained that low-to-moderate drinkers had a lower risk of case-level anxiety and depression  than non-drinkers . Unfortunately, the study’s partial cross-sectional design hindered drawing causal inference39. Also, a Spanish cohort study of 13,619 university graduates (mean age: 38 years) followed for 10 years showed that female – but not male- moderate drinkers (5–15 g/day) were less likely to self-report suffering from depression than abstainers15. However, a study of midlife alcohol consumption of the Whitehall II cohort of British civil servants, concluded that there was no association between drinking patterns, including a moderate (<40 g/day) one, and risk of depression. The 28-year follow-up study consisted of 7,478 men and women between the ages of 35 and 55 years and depression was assessed by the GHQ-3040. More recently, results based on 3,201 individuals aged 18–65 years, who were primary care attenders in the WHO collaborative study of Psychological Problems in General Health Care, suggested a possible protective effect of moderate (defined as AUDIT <8 points) drinking in the risk of developing a new onset of depression and generalized anxiety disorder (GAD)14.Previous research on the link between moderate alcohol intake and mental health in adults has yielded inconsistent results. In the National Psychiatric Morbidity Survey in England, which followed 2,413 adults for 18 months, moderate drinking , showed no association with incident anxiety or depression  when compared to abstaininget al. followed 5,505 high-risk men and women (55 to 80 y) from the PREDIMED Trial. Unlike the WHO collaborative study, participants in PREDIMED were initially free of depression or a history of depression, and did not have any history of alcohol-related problems. After 7 years of follow-up, moderate drinkers (5–15 g/day) of both genders were less likely to self-report a diagnosis of depression than abstainers16. Specifically, wine consumption in the range of 2–7 drinks/week decreased the risk of incident depression in this population16. Results in our study using abstainers (never drinkers and ex-drinkers) as the reference category or changing the threshold between moderate and heavy intake to 15 g/day showed no association between moderate alcohol intake and depression. A partial explanation for the discrepant results between the PREDIMED study and ours might be that participants in the PREDIMED trial were primary-care patients participating in an intensive group-based health education intervention; thus, we speculate that the intervention-related social support very likely geared towards a greater adherence to a Mediterranean diet (including moderate drinking)41, received by PREDIMED participants may have contributed to a lower depression risk42. Moreover, greater adherence to a healthy diet also reduces the incidence of cardiovascular disease, diabetes and other chronic diseases which, in turn, are strong risk factors or triggers for depression.To our knowledge only one study has focused on older adults. Gea 16 -which found a protective association between moderate alcohol intake and mental health- and studies in community samples40 which did not find such association (i.e. ours), could be partially explained by the self-medication hypothesis, whereby alcohol intake is used to ameliorate mental and other health problems; this phenomenon could operate more strongly in clinical than community samples due to their worse health status.In some cases, differences between clinic-based studies16, we distinguished between never drinkers and ex-drinkers. Since ex-drinkers might have quit drinking due to ill health, including depression, studies incorporating ex-drinkers in the reference category may overestimate the protective effect of moderate alcohol drinking on depression. Second, we adjusted our analyses for a larger number of lifestyle and morbidity variables than previous reports17. Third, as far as we are aware of, this is the first study to provide detailed analyses on the association between different patterns of moderate alcohol consumption, including the MDP, and mental health outcomes16. Fourth, we used a validated diet history to estimate alcohol consumption in the Seniors-ENRICA cohort. In fact, the Pearson correlation coefficient between alcohol consumption data from the diet history and seven 24-h recalls over the course of one year was a satisfactory 0.6532. Finally, we obtained consistent results using two cohorts characterized by different patterns of alcohol consumption and different follow-up periods. This is important because it suggests that the association, or lack thereof, between moderate alcohol intake and depression does not differ by cultural and social context, i.e., it may be similar in “wet and “dry” countries. Additionally, the ELSA 7.4-year mean follow-up suggests that the failure to detect an association is not due to failing to follow individuals “long enough to see an effect”.Our work has several strengths compared to published research. First, unlike previous studies43. In this sense, although numbers were similar to those reported in previous population-based studies45, the percentage of heavy drinkers in our cohorts was rather low (5% in Spain and 10% in the UK). In any case, there is evidence that telephone interviews are less affected by social desirability bias than personal interviews. Second, we lacked repeated measurements of alcohol intake during follow-up to update the information on exposure to alcohol. Third, although we used validated depression and psychological distress scales, these were not confirmed by a clinical diagnosis. Thus, we cannot rule out the existence of diagnostic bias, which effect on these results remains unknown. However, in the Seniors-ENRICA, were we had information on previous physician-diagnoses of depression or being under antidepressant treatment (which was confirmed against drug packages at home), we observed a similar prevalence of depression either using this information or the GDS scale. Fourth, our results may not be generalizable to institutionalized older adults. Finally, in both cohorts we observed an association between heavy drinking and decreased number of psychological distress symptoms approaching statistical significance. However, the small number of heavy drinkers in this cohort makes these results unreliable.The main limitation of the study was that alcohol consumption was self-reported with the corresponding risk of recall error and social desirability bias. It is known that questions on alcohol habits are commonly subject to under-reporting, particularly among heavy drinkersOur results do not support the presence of a protective effect derived from moderate alcohol consumption in general, and wine in particular, on the risk of developing depression or psychological distress among older adults. Given the inconsistency in this literature on the general population and the scarce research on older adults, future research should assess whether and how changes in alcohol consumption patterns affect depression risk using repeated measures of alcohol intake and clinical diagnoses of depression in this vulnerable population.Supplementary Information - Prospective association between alcohol consumption patterns and the risk of self-reported incident depression in older adults


Schizophrenia is associated with a reduced life expectancy of 15 to 20 years owing to a high prevalence of cardiometabolic disorders. Obesity, a key risk factor for the development of cardiometabolic alterations, is more prevalent in individuals with schizophrenia. Although obesity is linked to the altered reward processing of food cues, no studies have investigated this link in schizophrenia without the confounds of antipsychotics and illness chronicity.To investigate neural responsivity to food cues in first-episode psychosis without the confounds of antipsychotic medication or illness chronicity.A case-control study was conducted from January 31, 2015, to September 30, 2018, in London, United Kingdom, of 29 patients with first-episode psychosis who were not taking antipsychotic medication and 28 matched controls.Participants completed a food cue paradigm while undergoing a functional magnetic resonance imaging scan. Neural activation was indexed using the blood oxygen level–dependent hemodynamic response. The Dietary Instrument for Nutrition Education was used to measure diet, and the International Physical Activity Questionnaire was used to measure exercise.t46 = –3.046; P = .004) and undertook less high-intensity  and low-intensity  weekly exercise. There were no group differences in neural responses to food vs nonfood cues in whole-brain or region-of-interest analyses of the nucleus accumbens, insula, or hypothalamus. Body mass index was inversely correlated with the mean blood oxygen level–dependent signal in the nucleus accumbens in response to food vs nonfood cues in controls  but not patients .There were no significant differences in age, sex, or body mass index between the 29 patients  and 28 controls . Relative to controls, patients consumed more saturated fat (Relative to controls, patients with first-episode psychosis who were not taking antipsychotic medication consumed more saturated fat and showed an altered association between body mass index and neural response to food cues in the absence of differences in neural responses to food cues. These findings highlight how maladaptive eating patterns and alterations in the association between body mass index and neural responses to food cues are established early in the course of schizophrenia. This case-control study investigates neural responsivity to food cues in patients with first-episode psychosis without the confounds of antipsychotic medication or illness chronicity. Do patients with first-episode psychosis who are not taking antipsychotic medication show altered neural responses to food cues?In a case-control study comparing 29 patients with first-episode psychosis who were not taking antipsychotic medication and 28 healthy controls, patients with first-episode psychosis consumed significantly greater amounts of saturated fat relative to healthy controls in the absence of significant differences in neural responses to food cues.Although neural responses to food cues are not intrinsically dysregulated in schizophrenia, maladaptive eating patterns and alterations in the association between body mass index and neural responses to food cues are established early in the course of schizophrenia. Relative to controls, patients with schizophrenia showed decreased striatal activation in response to food cues under fasting conditions26 and alter striatal functional activation.28 Thus, it remains unclear whether altered striatal responses to food cues are secondary to the effects of antipsychotics or are an intrinsic component of the pathophysiologic characteristics of the disorder. Determining whether there is a primary alteration in the processing of food cues is critical to guiding the development of interventions to prevent and treat weight gain and cardiometabolic dysfunction in individuals with schizophrenia.However, the patients in both these studies were taking antipsychotic medications, which block striatal dopamine signaling25 we hypothesized that patients who were not taking antipsychotic medication would show decreased functional activation in the ventral striatum in response to food cues.In view of this, we aimed to investigate whether in the fasted state, patients with first-episode psychosis, who were not taking antipsychotic medication, show functional alterations in the ventral striatum in response to food cues. Consistent with the previous study, although it was conducted in patients taking antipsychotic treatment,24 albeit in patients with chronic schizophrenia, a power calculation indicated that 9 individuals per group were needed to allow for the detection of effect sizes greater than 0.9 (α = .05) using a 2-tailed hypothesis. The study obtained ethical approvals from the Camberwell St Giles ethics committee and adhered to the guidelines described by the Declaration of Helsinki.29 Written informed consent was obtained from all participants. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.In this case-control study, 57 volunteers, including 29 patients with first-episode psychosis and 28 healthy controls matched by age were recruited in London, United Kingdom, between January 31, 2015, and September 30, 2018. The patients with first-episode psychosis were recruited from early intervention services for psychosis, and the healthy controls were recruited via local advertising. After screening 459 individuals, 35 patients were enrolled in the study. Because 6 of these patients had started antipsychotic treatment, only 29 patients were included in the final analysis. Based on a study investigating striatal activation in response to food vs nonfood cues in individuals with schizophrenia,DSM-IV-TR (SCID-I/P); (4) comorbid axis I diagnosis as determined by the DSM-IV-TR (SCID-I/P); (5) current or recent (within the last month) recreational use of illicit substances; (6) positive results on a Δ9-tetrahydrocannabinol urine toxicology test with a 0.05-μg/mL cutoff that can detect 11-nor-9-carboxy-Δ9-tetrahydrocannnabinol metabolites for up to 30 days; (7) positive results on a multipanel drug screening test detecting cocaine, amphetamine, cannabis, opiates, and benzodiazepines; or (8) a history of neurological diseases or other brain abnormalities. Healthy controls met the following inclusion criteria: no current or lifetime history of an axis I disorder as determined by the SCID-I/P and no family history of an axis I disorder in first-degree and second-degree relatives as determined by the Family Interview for Genetic Studies.30 There were no exclusion criteria for weight or body mass index (BMI) for all participants. Patients with first-episode psychosis met the following inclusion criteria: diagnosis of schizophrenia or schizoaffective disorder as determined by the SCID-I/P; antipsychotic naive or free from all pharmacological treatments acting on the central nervous system  for at least 6 weeks; no prior use of depot medication; and illness duration of less than 3 years.All participants were 18 to 65 years of age and were able to give written informed consent. Individuals were excluded if they had any of the following: (1) a history of a head injury leading to loss of consciousness; (2) contraindications to undergoing magnetic resonance imaging (MRI); (3) current or lifetime history of substance use or dependence as determined by the Structured Clinical Interview for 31 Educational level and years of education were recorded using the methods described in 32 Current and previous use of alcohol, nicotine, and illicit substances were recorded.Age, sex, weight, and height were recorded. Socioeconomic status, employment status, and race/ethnicity were defined by the participant and classified using the Medical Research Council Sociodemographic Schedule.33 Healthy controls were screened for personal and family history of mental health problems using the SCID-I/P and the Family Interview for Genetic Studies.30The age at illness onset, illness duration, and clinical symptom severity were determined using the Positive and Negative Syndrome Scale.34 Weekly exercise levels were recorded using the International Physical Activity Questionnaire.35Self-reported questionnaires were used to measure individuals’ weekly dietary intake of saturated fat, unsaturated fat, and fiber using the Dietary Instrument for Nutrition Education.am; participants fasted  for more than 12 hours before undergoing the MRI scan. The food cue functional MRI (fMRI) paradigm as described by Karra and colleagues36 was used. During the task, participants viewed 192 color photographs including 64 photographs of high-calorie items, 64 photographs of low-calorie items, and 64 photographs of nonfood items. Images of sweet and savory food items were presented for high-calorie items  and low-calorie items . Nonfood items included 64 images of household and office supplies  with a whole-brain, interleaved bottom-up acquisition using a sagittal orientation and using an 8-channel head coil . A total of 294 fMRI echo planar imaging 2-dimensional gradient echo volumes were collected , with a whole-brain, sequential bottom-up acquisition for each functional time point using an oblique orientation and using an 8-channel head coil .37 using Matlab, version 8.5.38 The preprocessing pipeline consisted of the manual reorientation of the structural and functional images so that the anterior commissure lay on the origin , slice timing correction, head motion correction, coregistration of the functional image to the structural file, segmentation, normalization to Montreal Neurological Institute space, and smoothing using an 8-m Gaussian kernel to minimize noise and residual differences in gyral anatomy. The blood oxygen level–dependent (BOLD) response was modeled using a block design in which a canonical hemodynamic response function was convolved with regressors encoding the onset and duration for the following block conditions: high-calorie cues, low-calorie cues, and nonfood cues. Rest trials were left unmodeled and served as an implicit baseline. Ratings of the subjective appeal of cues were modeled as parametric modulators to control for block-to-block variance in individual subjective responses to food images and thereby reduce residual variance. Framewise displacement was calculated using methods described elsewhere.39 High-velocity motion spikes were regressed out by including scan nulling (censoring) regressors for volumes with volume-to-volume framewise displacement greater than 0.5 mm. Individual fixed-effects analyses were performed for each participant to identify regional differences in relative activation using the following linear contrasts of parameter estimates: food  cues vs nonfood cues, high-calorie cues vs low-calorie cues, and high-calorie cues vs nonfood cues.Data were analyzed with Statistical Parametric Mapping software 2 test and the independent samples t test for normally distributed categorical variables and the independent samples t test for continuous demographic variables. Group differences for variables that were not normally distributed were investigated using the Mann-Whitney test.Data normality was assessed using the Shapiro-Wilk test. Group differences were determined using the χt tests were used to investigate group differences in mean framewise displacement and mean ratings of the subjective appeal of high-calorie, low-calorie, and nonfood cues. Group-level random-effects analyses involved a 1-sample t test used to examine the effects of food  cues vs nonfood cues, high-calorie cues vs low-calorie cues, and high-calorie vs nonfood cues in controls. Independent samples t tests were used to examine group differences between controls and patients in response to food  cues vs nonfood cues, high-calorie cues vs low-calorie cues, and high-calorie cues vs nonfood cues. Age and mean framewise displacement during the fMRI scan were included as covariates. Independent samples t tests were also used to examine group differences between controls and patients in neural response to food  cues relative to nonfood cues. For these models, BMI or saturated fat intake were included as a second-level covariate. In all cases, a result was deemed significant if it survived familywise error correction on the basis of the peak-level extent (P < .05) using the Statistical Parametric Mapping default uncorrected height threshold of P < .001 for cluster formation.Independent samples 40 in addition to the hypothalamus, defined using the Brodmann atlas and the wfu pickatlas tool . Independent samples t tests were conducted to investigate regional (ROI-based) group differences in response to food cues relative to nonfood cues, high-calorie cues vs low-calorie cues, and high-calorie vs nonfood cues. In all cases, a result was deemed significant if it survived familywise error correction on the basis of the peak-level extent (P < .05) using a height threshold of P < .001 for cluster formation. For a priori ROI analyses, small volume corrections using familywise error corrections for multiple comparisons on the basis of response amplitude (peak-level) were used (indicated by a corrected P < .05). Mean activation in the nucleus accumbens in response to food  cues vs nonfood cues was extracted using Marsbar  using an independently derived ROI obtained from the Hammersmith Atlas.40 Pearson correlations were used to investigate the association between mean striatal activation in response to food vs nonfood cues and BMI, weekly dietary intake of saturated fat, unsaturated fat, and fiber. All P values were from 2-tailed tests, and results were deemed statistically significant at P < .05.To test our primary hypothesis that functional activation to food cues would be reduced in patients with first-episode psychosis, region-of-interest (ROI) analyses were conducted for the nucleus accumbens and insula, defined using the Hammersmith Atlas,24 = 19.455; P = .001), quantity of weekly high-intensity exercise , low-intensity exercise , and weekly dietary intake of saturated fat . However, there were no group differences in dietary intake of unsaturated fat  or fiber   or self-reported ratings of the appeal of high-calorie cues , low-calorie cues , or nonfood cues .Fifty-seven fasting volunteers  took part in the study. There were no significant group differences in age, sex, weight, BMI, race/ethnicity, educational level, or socioeconomic status . HoweverP = .14) . During t = 3.87; z = 3.39; cluster size = 6; P = .005 corrected for familywise error; Montreal Neurological Institute coordinates x = –4, y = 8, z = –6)  , but notThere were no group differences when using contrasts and whole-brain or ROI analyses of the insula, hypothalamus, or the nucleus accumbens of controls and patients for food vs nonfood cues, high-calorie cues vs low-calorie cues, or high-calorie cues vs nonfood cues. Controls did not show greater activation relative to patients, or vice versa. These findings remained unchanged when including BMI or saturated fat intake as covariates. See R = –0.499; P = .01), but patients did not ; a Fisher r-to-z transformation indicated that associations were significantly different between groups  , unsaturated fat , or fiber . Patients showed no association between mean activation in the nucleus accumbens in response to food cues vs nonfood cues and weekly dietary intake of saturated fat , unsaturated fat , or fiber .Controls showed a significant inverse association between BMI and mean activation in the nucleus accumbens in response to food cues vs nonfood cues , they were not lower in carbohydrate or sugar content relative to the high-calorie condition, which may explain why the controls failed to show differences in functional activation in response to high-calorie cues vs low-calorie cues. Our study was powered to detect the effect size reported by Grimm et al.46 patients and controls activated appetite-related neural networks including the striatum, insula, and orbitofrontal cortex in response to food cues. Although we found no evidence of striatal alterations in response to food cues in patients, paradigms involving the administration of monetary rewards have reported striatal alterations in patients with both treated and untreated schizophrenia.20 Thus, taken together with these prior findings, our findings indicate that patients with first-episode psychosis who are not taking antipsychotic medication do not show global impairments in striatal function. Instead, striatal dysfunction in individuals with schizophrenia may be specific to certain aspects of reward processing. This possibility warrants further testing in studies investigating multiple aspects of striatal function in the same patients.Consistent with previous literature,25 our results indicate that antipsychotics may dysregulate neural processing of food cues, suggesting a mechanism for antipsychotic-associated weight gain. However, future longitudinal studies are needed to investigate this possibility.Our finding that neural responses to food cues are unaltered early in the course of illness indicates that the neural mechanisms underlying subjective food preferences are not intrinsically dysregulated in individuals with schizophrenia. Taken with previous findings of altered striatal response to food cues in patients taking antipsychotics,47 Poor diets in patients may also be explained by differences in employment status between controls and patients with first-episode psychosis. In line with this finding, previous literature has shown that living in a low-income neighborhood is associated with the prevalence of obesity and poor dietary choices.48Our finding that patients with first-episode psychosis who were not taking antipsychotic medication consume greater levels of saturated fat may be explained by differences in the homeostatic mechanisms involved in signaling satiety, such as peptide hormones involved in inhibiting food intake.49 Our finding that patients do not show an association between BMI and neural responses to food cues adds to the literature to suggest that the neural regulation of BMI may be altered in individuals with schizophrenia. However, further work is required to determine the direction of causality and the mechanisms involved.There are shared genetic risk factors for schizophrenia and decreased BMI.50 future studies are also needed to disentangle the relative contributions of genetic and environmental factors for cardiometabolic dysfunction.Because making healthy dietary choices requires effective planning, future studies could also investigate whether negative symptom severity and/or cognitive deficits contribute to poor dietary choices in individuals with schizophrenia. Because unaffected first-degree relatives of patients with schizophrenia also show cardiometabolic alterations,We show for the first time, to our knowledge, that patients with first-episode psychosis who are not taking antipsychotic medication consume greater amounts of saturated fat relative to healthy controls but show normal neural responses to food cues in the fasted state. Although the neural mechanisms underlying subjective food preferences are not intrinsically dysregulated in individuals with schizophrenia, maladaptive eating patterns and alterations in the association between BMI and neural responses to food cues are established early in the course of schizophrenia.


Management of leptomeningeal metastasis-related hydrocephalus (LM-H) is particularly challenging regarding the control of severe headache, nausea, and vomiting due to intracranial hypertension. To investigate the improvements of performance status and outcome with cerebrospinal fluid (CSF) shunt surgery for LM-H in patients with lung adenocarcinoma.Data on patients with leptomeningeal metastasis-related hydrocephalus from lung adenocarcinoma diagnosed by MR imaging and/or cytological examination were retrospectively analyzed. Between August 2008 and July 2017, the authors reviewed 31 patients requiring CSF shunt, who underwent ventriculo-peritoneal or lumbo-peritoneal shunt.The patients consisted of 11 men and 20 women with a median age of 59 years. Twenty-six patients received EGFR-tyrosine kinase inhibitors (TKIs). CSF shunt surgery yielded rapid improvement in the performance status of 90.3% of patients. Median overall survival from the diagnosis of LM in patients with ECOG performance status less than 2 was 7.7 months, and this was significantly longer than those in patients with PS 3 or 4 . Multivariate analysis by Cox regression revealed survival differences according to PS at diagnosis of LM , controlled extracranial disease , and post-shunt EGFR-TKI for LM treatment . Postoperative symptomatic peritoneal carcinomatosis was observed in one patient (3.2%).CSF shunting may be a safe and effective strategy in patients with LM-H from lung adenocarcinoma. A prospective study is needed to establish the effectiveness and safety of palliative CSF shunt for LM-H. Leptomeningeal metastasis (LM) is a devastating complication of cancer that affects 5% to 8% of all patients with solid tumors . The medAs described previously , the treSystemic chemotherapy is a main option to treat systemic disease, but data on its effect for patients with LM are lacking. Although a few recent case series on epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) use for patients with LM have been reported, these studies included only a small number of patients , 9, 10.As described in detail previously , withoutWe investigated the outcomes of CSF shunting and concomitant multimodal therapy for LM with hydrocephalus (LM-H) from lung adenocarcinoma in our institution.Approved for this study was obtained from the institutional research ethics board of Shizuoka Cancer Center (28-J173-28-1-3). The requirement for written informed consent was waived. We searched the electronic database of the division of neurosurgery at our institution, all data were fully anonymized before assessment. We reviewed 31 patients with LM-H from lung adenocarcinoma requiring CSF shunting between August 2008 and July 2017. The patients with LM diagnosed by MR imaging and cytological examination. CSF shunting followed by targeted therapy and/or radiotherapy was indicated when a patient had controlled extra-central nervous system (CNS) metastases and systemic life expectancy longer than three months after the control of LM-H. The patients underwent either VP (n = 13) or LP (n = 18) shunting for hydrocephalus. An adjustable valve  was used with the shunt system  for all cases.This study did not include patients treated with IT chemotherapy. Because this study cohort is from 2008 to 2017, in the era of EGFR-TKI, we expected that EGFR-TKI is more effective for leptomeningeal metastasis than IT chemotherapy for EGFR mutant population.We reviewed the patients’ charts for their characteristics, indications for a CSF shunt, shunt procedures, and complications. Survival was analyzed using Kaplan-Meier estimates; potential prognostic factors were evaluated using Cox proportional hazards model. Statistical analysis was performed using JMP .The patients consisted of 11 men and 20 women with a median age at LM-H of 59 years (range 36–76). Twenty-one patients had EGFR mutation and five patients EGFR wild-type NSCLC . The othMedian overall survival (OS) was 4.5 months from the onset of LM and 3.5 months after CSF shunt. Those with the longest survival were alive 15 months from the diagnosis of LM-H. Five patients  was long term survival over 300 days from diagnosis of leptomeningeal metastasis . These pMedian OS from the diagnosis of LM-H (LM-OS) in patients with ECOG performance status (PS) less than 2 at the diagnosis of LM was 7.7 months, and this was significantly longer than those in patients with PS 3 or 4 , controlled extracranial disease , and post-shunt EGFR-TKI  .One patient (3.2%) suffered from peritoneal cancer dissemination that we thought not related to shunt procedure, but likely to be the progression of the systemic cancer. Infection occurred in two patients (6.5%) after VP shunt. One patient suffered from catheter disposition hat needed a revision surgery after VP shunt. And another presented low intracranial pressure that was immediately controlled by alternating valve pressure after LP shunt. There were no instances of obstructive shunt malfunction.LM is one of the most devastating complications and remains a serious concern in the clinical course of lung adenocarcinoma. The survival time of lung adenocarcinoma patients affected by LM is approximately 3 months, which is shorter than that of patients with LM from other cancers, such as breast cancer and hematological malignancies –16. MoreIn this study, the median overall survival of the patients after the diagnosis of LM-H was 4.5 months and survival after shunt surgery was 3.5 months. Omuro et al. reported on VP shunt for LM-H in 37 patients, with improvement of symptoms being achieved in 77% despite the relatively short median survival of 2 months after shunt . In addiOur study showed that patients who received TKI therapy after shunt surgery had significantly longer LM-OS than patients without TKI therapy . Multivariate analysis revealed that there were survival differences according to PS at the diagnosis of LM , controlled extracranial disease , and post-shunt EGFR-TKI for LM treatment .Several studies have reported that EGFR-TKIs are a potential treatment option for patients with LM from NSCLC , 20, 21.The present study showed good PS at the diagnosis of LM as a significant prognostic factor regarding LM-OS . CarefulIntrathecal chemotherapy with methotrexate, cytarabine (DepoCyte), and thioTEPA has usually been used for the treatment of LM, however, no clear evidence demonstrating that it confers a survival advantage , 27. As Our results of implicated that three factors were associated with better outcome after shunt surgery: treatment with TKIs, good PS, and controlled extracranial cancer. This supports that patients treated with shunt for LM-H have similar survival outcomes and similar clinical factors of improved survival concordant with previous studies of survival in LM. From the present study, we concluded these three criteria may become an optimal indication for CSF shunting for patients with LM-H.We demonstrated that patients’ PS rapidly improved after shunt surgery and they recovered to a state matching the indication criteria for EGFR-TKI administration for lung adenocarcinoma. CSF shunt is a powerful tool against severe headache and uncontrollable intracranial hypertension, and leads to a survival benefit with EGFR-TKI therapy following shunt surgery.Lumbo-peritoneal shunting may be a more effective method for a poor condition because it is less invasive than ventriculo-peritoneal shunting, due to the short operation time and the wound being outside of the field in whole-brain radiotherapy , 31.There are several limitations to this study. First, this was a retrospective study of therapeutic outcome, so patient selection bias remained a potential source of error. Second, because of the retrospective nature of this study, the treatment regimen was selected for each individual case. Third, the number of patients was relatively small.In conclusion, our data demonstrate that CSF shunting may effectively control intracranial hypertension due to LM-H from lung adenocarcinoma in patients with an EGFR mutation, especially for patients with a good ECOG PS and controlled extracranial cancer. A prospective study is necessary to establish the efficiency of CSF shunting and targeted therapy for LM-H from lung adenocarcinoma with an EGFR sensitive mutation.S1 Table(DOCX)Click here for additional data file.


We aimed to test the association between low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease (CVD), cancer, and all-cause mortality in non-statin users. A total of 347,971 subjects in Kangbuk Samsung Health Study  were tested. To validate these associations, we analyzed data from another cohort . All subjects treated with any lipid-lowering therapy and who died during the first 3 years of follow up were excluded. Five groups were defined according to baseline LDL-C concentration . A total of 2028 deaths occurred during follow-up in KSHS. The lowest LDL-C group (LDL < 70 mg/dL) had a higher risk of all-cause mortality , CVD mortality , and cancer mortality  compared to the reference group (LDL 120–139 mg/dL). In the validation cohort, 2338 deaths occurred during follow-up. The lowest LDL-C group (LDL < 70 mg/dL) had a higher risk of all-cause mortality  compared to the reference group. Low levels of LDL-C concentration are strongly and independently associated with increased risk of cancer, CVD, and all-cause mortality. These findings suggest that more attention is needed for subjects with no statin-induced decrease in LDL-C concentrations. For decades, low-density lipoprotein cholesterol (LDL-C) has been considered to be the major causative factor in the development of atherosclerotic cardiovascular disease (CVD) and CVD mortality . NumerouIn contrast to the enormous evidences from previous studies regarding CVD, the correlation between low plasma concentrations of LDL-C and mortality outcome is still uncertain especially in relatively healthy populations. In most randomized controlled trials or observational studies, subjects with unusually low concentration of LDL-C level have been excluded in analysis. Therefore, to date, we could not clearly find the impact of lower LDL-C on mortality outcome, especially in subjects who does not take lipid lowering agents. Moreover, some recent Japanese epidemiological studies have shown that high total cholesterol is not a risk factor for CVD and it is rather conversely associated with overall mortality . SimilarSince the effect of low concentrations of LDL-C on cancer and overall mortality remains controversial, we have investigated the associations between low levels of serum LDL-C, and cancer, all-cause mortality, and even CVD mortality in a very large, young, and well characterized, relatively healthy occupational cohort  during a median 5.82-year follow-up. To validate these associations, we then analyzed other dataset from a large population-based cohort study with government funding, named the Korean genome and epidemiology study (KoGES).n = 396,951). The purpose of the screening program was to promote health through early detection of chronic diseases and their risk factors. Additionally, the Korean Industrial Safety and Health Law demands working individuals participate in an annual or biennial health examination. For this analysis, subjects were excluded for one or more of the following reasons: Subjects with missing data for smoking, alcohol, exercise, or lipid profiles at baseline ; subjects with lipid medication (n = 3667); subjects with histories of malignancy (n = 5342); subjects with mortality within 3 years after baseline (n = 649). Some of the excluded subjects had more than one of the above exclusion criteria. The total number of eligible subjects for testing associations with all-cause and CVD mortality was 347,971 (median follow up: 5.82 (IQR 2.62–8.63) years and mean (SD) follow up: 5.64 (±3.27) years). This study was approved by the Institutional Review Board of Kangbuk Samsung Hospital. Requirement for informed consent was waived as de-identified information was retrieved retrospectively.The study population consisted of individuals who participated in a comprehensive health screening program with serum LDL-C at Kangbuk Samsung Hospital, Seoul, Korea from 2002 to 2012 (n = 4149); subjects with lipid medication ; subjects with histories of malignancy (n = 6578); and subjects with mortality within 3 years after baseline (n = 1556). The total number of eligible subjects for testing associations with all-cause and CVD mortality was 183,943 (mean (SD follow up: 8.57 (±2.59) years). The percentile of women was 65.4%. At each visit, informed written consent was obtained from all participants. The study protocol was approved by the Ethics Committee of the Korean Center for Disease Control and the Institutional Review Boards of Yonsei University Wonju College of Medicine.In the validation cohort, the cohort profile of KoGES has been previously reported . The KoGAs part of the health screening program, individuals completed questionnaires related to their medical and social history and medication use. Individuals were asked about duration of education (years), frequency of exercise ), smoking history  and alcohol consumption (grams (g)/week). Trained staff also collected anthropometric measurements and vital statistics. Body weight was measured in light clothing with no shoes to the nearest 0.1 kg using a digital scale. Height was measured to the nearest 0.1 cm. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Blood pressure was measured using standard mercury sphygmomanometers. Blood samples were collected after minimum 10 h of fasting and analyzed in the same core clinical laboratory. The core clinical laboratory has been accredited and participates annually in inspections and surveys by the Korean Association of Quality Assurance for Clinical Laboratories. Serum levels of total cholesterol, triglycerides, LDL-C, and high-density lipoprotein cholesterol (HDL-C) were measured using Bayer Reagent Packs  on an automated chemistry analyzer .Deaths among participants were identified by matching the information to death records from the National Statistical Office using identification numbers assigned to subjects at birth. Causes of death were coded centrally by trained coders using the ICD-10 classification . In this study, CVD mortality was defined as ICD-10 codes I00 to I99.p values were two-tailed, and <0.05 were considered statistically significant. The distribution of continuous variables was evaluated and transformations were conducted for nonparametric variables. We divided our subjects according to plasma LDL-C concentrations  at baseline. Cox proportional hazards models stratified by five groups were used to estimate hazard ratios . This LDL-C 100-129 mg/dL group was chosen as the reference because this group contained the mean LDL-C concentration for adults in Korea over the last 10 years (approximately 110 mg/dL) [p < 0.05 was considered significant.The statistical analysis was performed using STATA version 14.0 . Reported 0 mg/dL) . We checA total of 347,971 subjects (mean age 39.6 years) (57.4% men) were studied in KSHS over a mean follow up of 5.64 ± 3.27 years. Five groups were defined according to the level of baseline LDL-C concentration . There were 1379 deaths (0.40%) during follow up in KSHS cohort (Mean age of death: 58.2 (13.8). Of these deaths, 675 deaths were due to cancer, (482 deaths in men and 193 deaths in women). There were 188 deaths from CVD (134 in men and 54 deaths in women). The results of cox regression models showing risk of all-cause mortality, CVD mortality, and cancer mortality according to baseline LDL-C concentrations are shown in In the validation cohort (KoGES), 2338 deaths (1823 from cancer and 199 from CVD) occurred during follow-up of (mean ± SD) 8.57 ± 2.59 years. Our novel results show that low levels of LDL-C (<70 mg/dL) were associated with increased risk of CVD mortality, cancer mortality, and even all-cause mortality especially in men who were not treated with lipid lowering therapy. The finding of increased CVD mortality in men with low levels of LDL-C (<70 mg/dL) was observed in both different cohorts even though it showed a U shape. In this study, we were able to take account of multiple confounders and the young age of the cohort helped decrease the influence of potential reverse causality between clinically relevant outcomes and low levels of plasma LDL-C concentrations. Additionally, we excluded subjects who died within 3 years of follow up to avoid the possibility of reverse causality. Furthermore, to validate these associations, we then analyzed other dataset from a large population-based cohort study with government funding, named the Korean genome and epidemiology study (KoGES) which consists of community-dwellers aged ≥40 years at baseline.We chose the third LDL-C group  as the reference group, because as indicated above this group contained the mean LDL-C concentration for the Korean population as measured in the Korean National Health and Nutrition Examination Survey during 1998 to 2010 . As we eIn line with our findings, another recent study also presented that whereas low LDL-C (<70 mg/dL) was not associated with protective effects on CVD outcome, low hs-CRP appeared to be associated with reduced risk of incident CVD and CVD mortality in high risk population . These fAssociations between lower levels of LDL-C and poor health outcome have been reported in some, but not all, prior studies. Observational cohort studies have revealed that people with low total cholesterol levels  have increased risk of subsequent death in some cancers, respiratory diseases, and other non-medical causes than people with high baseline cholesterol levels . HoweverWhile the exact mechanism remains to be elucidated, several possibilities could explain our findings. Firstly, a low LDL-C concentration increases susceptibility to fatal disease. Some experiments have shown that LDL-C binds to and inactivates a broad range of microorganisms and toxic products which might be a possible causal factor of CVD and cancer ,21. FurtThere are strengths and limitations of our study that should be considered in the interpretation of these controversial data. A number of 347,971 relatively young subjects (mean age 39.6 years) (57.4% men) were studied in a retrospective cohort study design over a median follow up of almost 6 years and data on cardiovascular mortality in men validated in another independent cohort. Additionally, we have excluded the data from individuals who were identified at baseline and who subsequently died during the first three years of follow up. These factors limit the possibility of reverse causality explaining our findings. However, since we excluded all subjects at baseline who were taking any lipid-lowering therapy, it is likely that subjects with extremely highest level of LDL-C have been excluded. Moreover, the weaknesses of our study design is that treatment with LDL-C lowering therapy during the period of follow up is not available, although given what is known about the benefit of statins, treatment with statins would decrease CVD and misclassification bias would operate to bias our results towards the null. Additionally, the fact that the numbers of deaths, especially cardiovascular mortality, are relatively low may attenuate the causal relationship between LDL cholesterol and mortality. We could not measure some specific lipoproteins such as small dense LDL and lipoprotein, which may explain this phenomenon. Another limitation of our study is that the sample was limited to Korean, relatively young-aged participants, and it is uncertain whether the findings are applicable to other ethnic groups.We demonstrated that low levels of LDL-C concentration (<70 mg/dL) was not associated with protective effects on overall mortality in relatively healthy Korean adults who do not take lipid lowering agents. While men with the lowest levels of LDL-C concentration (<70 mg/dL) are at risk of increased all-cause, cancer, and even CVD mortality, and even though the association between LDL-C concentration and CVD mortality was U-shaped in men, the lowest levels of LDL-C concentration were significantly and independently associated with increased risk of CVD mortality. These findings suggest that more attention might be needed for subjects with no statin-induced decrease in LDL-C concentrations. Further large-scale, population-based research with long-term follow up is warranted in other ethnic groups to re-evaluate the relationship between low levels of LDL-C and mortality outcomes.


Adhesion G protein-coupled receptors (aGPCRs) constitute the second largest GPCR subfamily. GPR56/ADGRG1 is a member of the ADGRG subgroup of aGPCRs. Although GPR56 is best known for its pivotal role in the cerebral cortical development, it is also important for tumor progression. Numerous studies have revealed that GPR56 is expressed in various cancer types with a role in cancer cell adhesion, migration and metastasis. In a recent study, we found that the immobilized GPR56-specific CG4 antibody enhanced IL-6 production and migration ability of melanoma cells. In this review, we will summarize the current understanding of GPR56 function and discuss the activation and signaling mechanisms of GPR56 in melanoma cells. G protein-coupled receptor (GPCR) superfamily is the largest receptor family in nature. Because of their signature seven-transmembrane (7TM) domain, GPCRs are also called the 7TM receptors . Based oStructurally distinct from the canonical GPCRs, aGPCRs contain an unusually large extracellular domain (ECD) composed of a diverse range of cell adhesive protein motifs normally arranged in tandem repeats at the N-terminal half –6. This It is now well-accepted that a major activation mechanism of aGPCRs involves the binding of the aGPCR-NTF with its ligand(s) followed by activation and intracellular signaling of the corresponding CTF –12. IndeGPR56/ADGRG1, first reported by Liu et al. and Zendman et al. , 18, belIt is now known that GPR56 participates in a myriad of physiological processes. The best example is the link of GPR56 dysfunction to human developmental disorders –23. IndeIn addition to the cortical development, GPR56 is also involved in oligodendrocyte development and CNS myelination , 31. GPRin vitro, but muscle development in vivo was not affected , encoded by the Col3a1 gene, is expressed mostly in skin and blood vessel and is involved in the normal development of these tissues . While sin vitro –52. Funcpearance . TherefoIn clinical observation, the expression level of GPR56 is correlated inversely to the metastatic ability of melanoma cells, suggesting an inhibitory role in melanoma metastasis , 18, 39.Besides the two protein ligands described above, heparin was verified by us recently as a novel glycosaminoglycan (GAG) binding partner of GPR56 –59. The q/11 from which at least two distinct activation mechanisms can be induced. It was concluded that CD81 probably acted as a GPCR-scaffolding protein that promotes and stabilizes the GPR56 signaling complex  has facilitated the functional delineation of the receptors. Indeed, several GPR56-specific Abs have been produced to help dissect its activation mechanism and cellular functions. Iguchi et al. first detected strong GPR56 expression in neural progenitor cells (NPCs) using polyclonal Abs against the GPR56-NTF. GPR56 overexpression in NPCs was shown to negatively regulated cell migration. Importantly, they subsequently identified an agonistic activity of the GPR56-specific polyclonal Abs which were able to functionally inhibit NPC migration in a Gαt manner . In recet manner . One of q- and Rho-signaling pathways. Interestingly, the agonistic mAbs were found to enhance NTF-CTF interaction as revealed by co-immunoprecipitation analysis ..in vivo 12/13 and RhoA pathways, resulting in IL-6 production. Interestingly, the CG4-induced NTF shedding required the presence of CD9/CD81 as CD9/CD81 knockdown significantly reduced IL-6 secretion. It was further shown that the dissociation of GPR56-NTF unmasked the Stachel peptide of GPR56-CTF, which was responsible for activating CTF and the signaling transduction. Hence, our results are in line with the tethered agonist model of aGPCRs of which the receptor activation requires the release of the NTF of a fully GPS-cleaved receptor in a Stachel peptide-dependent manner ..12/13 anWhile these studies provide important insights into the role of GPR56 in tumorigenesis, especially in melanoma progression, our understanding of GPR56 function in tumor biology is just at its infancy. For example, conflicting outcomes were observed in the involvement of GPR56 in the development of endogenous tumors . More reGPR56/ADGRG1 not only involves in the normal tissue development but also in tumorigenesis. Previous studies have identified numerous cellular binding partners/ligands and developed specific Abs/monobodies of GPR56. Meanwhile, distinct GPR56-mediated signaling pathways are being revealed. These unique reagents provide excellent research tools for the functional delineation of GPR56 and identify GPR56 as an important player in melanoma development. Functional studies with these GPR56-specific reagents including mAbs, monobodies, and small-molecule compounds have demonstrated effective modulation of its signaling activities , 46, 70.K-YH and H-HL drafting and writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


BAP1. Still, the mechanisms that drive metastatic spread are largely unknown. This study aimed to elucidate the potential role of microRNAs in the metastasis of UM. Using a next-generation sequencing approach in 26 UM samples we identified thirteen differentially expressed microRNAs between high-risk UM and low/intermediate-risk UM, including the known oncomirs microRNA-17-5p, microRNA-21-5p, and miR-151a-3p. Integration of the differentially expressed microRNAs with expression data of predicted target genes revealed 106 genes likely to be affected by aberrant microRNA expression. These genes were involved in pathways such as cell cycle regulation, EGF signaling and EIF2 signaling. Our findings demonstrate that aberrant microRNA expression in UM may affect the expression of genes in a variety of cancer-related pathways. This implies that some microRNAs can be responsible for UM metastasis and are promising potential targets for future treatment.Uveal melanoma (UM) is the most frequently found primary intra-ocular tumor in adults. It is a highly aggressive cancer that causes metastasis-related mortality in up to half of the patients. Many independent studies have reported somatic genetic changes associated with high metastatic risk, such as monosomy of chromosome 3 and mutations in  GNAQ or GNA11 mutation. These mutations are considered to be tumor-initiating mutations and do not increase the risk of metastasis [Uveal melanoma (UM) is an aggressive cancer that arises from melanocytes located in the uveal tract of the eye. Although treatment of primary tumors has a high success rate, up to half of the patients develop metastasis which often results in death within several months . UM disptastasis ,3,4. UM tastasis .BAP1), located on chromosome 3 [SF3B1), which is part of a protein complex involved in pre-mRNA splicing [SF3B1 mutations in UM are known to result in aberrantly spliced transcripts that can either be degraded by nonsense-mediated decay or translated into unique, aberrant proteins. Low-risk UM often harbor a mutation in the eukaryotic translation initiation factor 1A (EIF1AX) gene, which is involved in the transfer of methionyl initiator tRNA to the small ribosomal subunit during translation [High-risk UM harbor a mutation in the tumor suppressor gene BRCA-associated protein  are small, single-stranded, non-coding RNAs that can regulate gene expression by binding to mRNA ,14. AlthEIF1AX mutation. These patients were included in the low-risk group and did not show disease progression. Twelve patients with a mean DFS of 103 months and an SF3B1 mutated UM were included in the intermediate-risk group. The high-risk group consisted of seven patients with a mean DFS of 28 months, a BAP1 mutated tumor, and a negative BAP1 immunohistochemistry (IHC). Within the high-risk UM, all patients died due to metastasis, whereas in the intermediate group three patient were still metastasis-free and died because of other causes. From all 26 samples, mRNA and miRNA sequencing was performed and differentially expressed (DE) miRNA and mRNA were identified  and mutation status). Clinical, molecular, and histopathological characteristics of all patients are listed in entified . DE-miRNTo investigate which miRNAs might be involved in the metastatic progression of UM, differential count analyses were performed among the three risk groups. We found 423 mature miRNAs to be expressed in UM. To identify samples with a similar miRNA expression, we generated a principal component analysis (PCA) plot based on total miRNA expression. Unsupervised clustering revealed different clusters; one containing the high-risk UM and the other cluster containing low-risk UM A. The inp-value of less than 0.05 were separated into two clusters; one cluster contained all genes that showed downregulation in the high-risk UM and the other group contained the upregulated genes (n = 106)  .The 106 identified target genes were analyzed by Ingenuity Pathway Analysis (IPA) software, to elucidate which canonical pathways were mainly affected by aberrant miRNA expression . One of In this study we identified a set of miRNAs that are likely to be involved in the metastatic progression of UM by comparing miRNA expression in high-metastatic-risk UM and low/intermediate-metastatic-risk UM. Hierarchical clustering of total miRNA expression showed three different clusters, which corresponded to metastatic risk. In the UM samples, 423 mature miRNAs were shown to be present, of which 13 miRNAs were differentially expressed between low-, intermediate- or, high-risk UM. MiRNAs that are highly expressed in high-risk UM include several known oncomirs such as miRNA-17-5p ,26,27, mp-values do show some differences. This could be explained by a platform bias, but also by the fact that we could not differentiate in our own analysis of the TCGA dataset between the 3p- and 5p-miRNAs.Several studies have investigated miRNA expression in UM, of which most are done in cell lines or very small sample sizes. These studies already identified miRNAs that were shown to be differentially expressed in high-risk UM, such as miRNA-21, miRNA-146b, miRNA-143, miRNA-199a, and miRNA-134 ,23,32. HIn order to determine the downstream effect of the DE-miRNAs, we integrated miRNA data with matching mRNA data containing expression data of target genes by at least two different prediction algorithms. Since miRNAs are known to downregulate or degrade mRNA of their target genes, we only selected genes that were negatively correlated with miRNA expression. Four of these identified target genes  play a crucial role in the regulation of the cell cycle. The development of cancer is tightly linked to changes in the activity of the cell cycle . In normAnother pathway that could affect the metastatic potential of UM cells is epidermal growth factor (EGF) signaling. Several studies show involvement of aberrant EGF signaling in the development of several cancer types . The EGFBecause of their stable nature in tissues and body fluids, it is often suggested that miRNAs are excellent biomarkers for clinical applications. They could serve as early prognosis indicators and as a marker for therapy efficiency ,49. In oThis study shows that miRNAs play an important role in the deregulation of several oncogenic pathways in UM and can, thereby, promote metastatic spreading to distant organs, such as the liver. Differentially expressed miRNAs could be an interesting biomarker for metastatic risk in diagnostics, furthermore it also offers us a promising therapeutic target. Until now, no successful treatment has been developed for metastatic UM. miRNA mimics and molecules targeted at miRNAs (anti-miRs) have shown promising results in preclinical development and could compensate for the upregulation of oncogenic pathways, and thereby aid in UM management and treatment ,52,53.26 patients diagnosed with UM were selected from our Rotterdam Ocular Melanoma Studygroup (ROMS) database. The specimens were collected from enucleated eyes between 1995 and 2010 at the Erasmus University Medical Centre and the Rotterdam Eye Hospital . Shortly after surgery, half of the tumor was snap-frozen in liquid nitrogen to allow for DNA and RNA extraction. The other half of the eye was formalin-fixed paraffin-embedded and stained with hematoxylin and eosin for routine histological examination by an ophthalmic pathologist to verify neoplastic nature. This study was performed according to the guidelines of the Declaration of Helsinki  and informed consents were obtained at the time of diagnosis.EIF1AX, SF3B1 and BAP1 was carried out using Sanger sequencing as reported in previous publications [DNA was extracted from fresh tumor tissue using the QIAmp DNA-mini kit  according to the manufacturer’s instructions. Mutation analysis of ications ,54 Total RNA was isolated from sections of snap-frozen tumor samples, using the Qiagen miRNeasy isolation kit (Qiagen) according to the manufacturer’s manual. The quantity and purity of the RNA was determined using Bioanalyzer . A total amount of 4 μg RNA (RIN > 7.0) was used for the preparation of the small RNA and larger RNA libraries using the Ion Total RNA-seq kit  following the manufacturer’s protocol. Both RNA libraries were subsequently sequenced with the Ion Proton sequencer (Thermofisher Scientific).Adapter sequences, low quality reads, and reads containing poly-N were removed from the generated RNA sequenced data using the Torrent Suite Software V 4.4.3 . Reads shorter than 15 nucleotides were removed from downstream analysis in the small RNA dataset. The remaining reads were aligned against a miRBase reference genome using an in-house developed script . Read peTo obtain functional information from the differentially expressed miRNAs we integrated mRNA expression data with the miRNA expression data by cluster analysis. A list of putative target genes from the differentially expressed miRNAs was composed using miRwalk 3.0 , Targetshttps://portal.gdc.cancer.gov/).miRNA expression data of 80 UM samples  were retIn this study we elucidated the potential role of miRNAs in the early metastasis of UM by integrating miRNA and mRNA sequencing data derived from 26 UM samples. We showed that differentially expressed miRNAs could play an important role in several oncogenic pathways, such as cell cycle regulation and EGF signaling, which could contribute to the early metastasis of UM. These results do not only bring us one step closer to unraveling the mechanisms that drive UM metastasis, but it also provides us with a promising potential target for future treatment. Targeting these differentially expressed miRNAs could compensate for the deregulation of oncogenic pathways and, thereby, aid in UM treatment.


Stroke is a leading cause of death, morbidity and disability worldwide. Infection is a common complication in the acute phase after stroke. Herpes zoster is a common viral disease, in which the most debilitating complication is post-herpetic neuralgia, which can have a very large negative impact on quality of life. The aim of this study was to investigate whether stroke increases the risk of herpes zoster.This cohort study compared patients who had herpes zoster with and without a first incident of stroke. The Taiwan National Health Insurance Research Database was utilized to identify 20,551 stroke patients and 20,551 controls matched for age, gender, age categories and Charlson Comorbidity Index (CCI) score categories at a one-to-one ratio. Cox proportional-hazards regression models were employed to estimate herpes zoster risk in the stroke group relative to general population.Compared to the control group, the stroke group had a greater risk for herpes zoster, especially within 1 year after stroke (adjust HR = 25.27). Both hemorrhagic stroke and ischemic stroke were significantly associated with herpes zoster ; ischemic type ). However, the hemorrhagic stroke patients had a higher risk of herpes zoster ophthalmicus  whereas the ischemic stroke patients had a higher risk of post-herpetic neuralgia .Physicians should know about that adults with stroke have a higher than normal risk of herpes zoster. Thus, physicians must be acquainted with proper antiviral therapy and pain control to bring down the morbidity that ensues from herpes zoster. Use of herpes zoster vaccine may be considered in stroke patients. Stroke is a leading cause of death, morbidity and disability worldwide. BecauseHerpes zoster (HZ) is caused by reactivation of a latent varicella-zoster virus (VZV) residing in sensory ganglia and dorsal roots after primary infection. This diet al. showed a significant increased risk of severe HZ requiring hospitalization in ischemic stroke. However, no studies have linked the risk of HZ occurrence to hemorrhagic stroke[Post-stroke infection, which reportedly occurs in 23–65% of stroke patients, is associated with increased mortality and poor patient outcome . Even thic stroke. TherefoThe National Health Insurance (NHI) program of Taiwan is a mandatory, single-payer system established in 1995; approximately 98% of all Taiwan residents are currently enrolled, and almost all medical care providers in Taiwan are contracted to provide outpatient and inpatient services. The NHI claims records include information for inpatient, ambulatory, and home medical care. Currently, the National Health Insurance Research Database (NHIRD) is among the largest nationwide population-based databases in the world. The complete NHIRD and several dozen extracted datasets are available to researchers. Double-scrambling protocol is managed to deal with the original information so that each individual is encrypted to protect privacy. Therefore, patients can be followed up by linking claims for individual patients across the extracted datasets noted above. The LHID2010 constitutes registration and claims data collected by the NHI program for a nationally representative group of 1 million individuals. All participants were enrolled in the NHI during the period from January 1, 1996, to December 31, 2010. The design of this study was reviewed and approved by the Institutional Review Board of Chang Gung Medical Foundation (Number 201900594B1).The HZ risk after stroke was estimated by analysis of a nationwide population-based cohort. The cohort dataset used in the analysis included patients with and without a first-time incident of stroke and HZ. The study cohort included patients older than 18 years who were still alive in 2010. All diagnoses of patients with linked data were coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The dataset for this cohort study included 20,551 stroke cases that required hospitalization since January 1, 1996 . Propensity score matching method was used to match the patients with stroke to a control group of 20,551 subjects without stroke for age, gender, age categories and Charlson Comorbidity Index (CCI) score categories. The CCI scores were calculated as follows: myocardial infarction (1 point), congestive heart failure (1 point), peripheral vascular disease (1 point), dementia (1 point), chronic pulmonary disease (1 point), rheumatologic disease (1 point), peptic ulcer disease (1 point), mild liver disease (1 point), diabetes mellitus (1 point uncomplicated), diabetes mellitus (2 points if end-organ damage), hemiplegia or paraplegia (2 points), renal disease (1 point), any malignancy (2 points), liver disease (3 points if moderate to severe), metastatic solid tumor (6 points), and AIDS (6 points). The CCIHerpes zoster was defined according to ICD-9-CM coding system as HZ with ophthalmicus (053.2), other trigeminal area (053.12), otitis externa (053.71), or unspecified site (053.x)requiring hospitalization or outpatient treatment. Post-herpetic neuralgia was defined as 053.1. To limit the analysis to patients with a first-time incident of stroke or HZ, individuals were excluded if they had any evidence of stroke or HZ before the study period (n = 1557). The subjects were followed up for development of HZ during the next 15 years (1996–2010).The SCCS method was used to compare within-patient risks during different time periods. All patients who had both a stroke accident and HZ event were identified. Since it’s hard to collect data for the confounding factors completely, observational study is not able to effectively capture crucial differences between patients with and without stroke, which leads to residual confounding. As a reParametric continuous data were compared across groups by Student t-test,one-way analysis of variance or Kruskal-Wallis test when categorical data were compared by Chi-square test as appropriate. Survival times were determined across from stroke occurrence to the date of theHZ event or to the end of the study period , whichever occurred first. Kaplan-Meier method was used to construct the survival curves, and log-rank test was used to compare homogeneity between groups. The hazard ratios (HRs) and 95% confidence intervals (CIs) for HZ events were estimated by Cox proportional hazards model after adjustment for age, gender and CCI. Poisson regression analysis was performed to calculate incident rate ratio (IRR).The SCCS method was used for within-patient comparisons of risks during different time periods. The exposure period began with the onset of stroke accident and ended 12 months later. The non-exposure time period was defined as all other observation time period. The primary analyses estimated the effects of different stroke types  on the risk of HZ; further analyses were done to assess the different types of HZ risk such as ophthalmic, other trigeminal, unspecified-site, and post-herpetic neuralgia. Conditional Poisson regression analysis was utilized to determine IRRs and 95% CIs for HZ within each stratum of the exposure period in comparison with non-exposure time period after adjustment for age at the index date for HZ and gender.All data were processed and analyzed using Statistical Analysis Software, version 9.4  with a statistically significant level of 2-tailed P-value < 0.05In this cohort set, 1,539 of 20,551 stroke cases and 2,844 of 20,551 matched controls experienced HZ events. Interestingly, at the 1-year follow up and 5-year follow up, 262 and 930 of 20,551 stroke patients had HZ whereas only 11 and 371 of 20,551 matched controls had HZ. That is, the incidence of HZ over a 1-year period was significantly greater in stroke patients (13.51 per 1000 person-years) compared to controls (0.54 per 1000 person-years). Furthermore, the incidence of HZ over a 5-year period was also significantly greater in stroke patients (12.18per 1000 person-years) compared to controls (3.63 per 1000 person-years). Our results showed that stroke significantly (P<0.0001) increased the risk of HZ events over a 1-year period (adjusted HR = 25.27) and over a 5-year period (adjusted HR = 3.44). Stratification by gender and age similarly showed a significantly higher risk in stroke patients compared to controls. In stroke patients, the incidence of HZ did not significantly differ between males and females, but increase with age.Next, a self-controlled case-series study method was used to compare within-patient  stroke risk during different time periods.After controlling for covariates, patients with stroke had a 25.27 times higher risk of HZ compared to the general population over a 1-year follow-up period and a 3.44 times higher risk of HZ over a 5-year follow-up period. After stratification by gender, the incidence of HZ events was significantly higher in both male and female stroke patients compared to controls. Furthermore, the incidence of HZ events was significantly higher in stroke patients at different ages compared to controls after the stratification by age. Both hemorrhagic stroke and ischemic stroke were significantly associated with increased risk of HZ. Specifically, hemorrhagic stroke was associated with an increased risk of HZ ophthalmicus and ischemic strokewas associated with an increased risk of post-herpetic neuralgia. To our knowledge, this is the first cohort study to compare HZ risk between hemorrhagic stroke and ischemic stroke.Risk factors for HZ include female gender, mechanical trauma, genetic susceptibility, interleu4. The excessive inflammatory response in the brain paradoxically prompts an immune-suppression state in the peripheral tissues. Therefore, stroke patients are at risk for fatal secondary infections[et al. reported that MDSCscirculating in the blood stream can shape systemic inflammatory responses that may induce post-stroke immune-suppression[Firstly, stroke results in a localized depletion of oxygen and energy, which causes death of cells in affected areas. Dying cnfections, 32. On nfections. Cholinenfections. On the nfections. Activitppression. Patientet al. showed that mood disorders, including depression, were associated with increased risk of HZ. In a retrospective population-based cohort study, Liao et al. revealed that patients with depression are at a raised risk of HZ, especially those aged 45 to 54 years and those with comorbidities, including hypertension, hyperlipidemia, renal diseases, rheumatic diseases, anxiety, sleep disorder and malignant conditions[Secondly, depression is a common complication after stroke; post-stonditions. Depressonditions–51. Furtonditions–54, bothonditions. Hence, Herpes zoster is mostly observed in elderly immunocompromisedpatients, which is consistent with our result which showed the incidence of HZ increased with age in stroke patients. LiteratA notable strength of this study is its use of a large-population database, which provided sufficient statistical power to analyses. Secondly, this study used propensity-score matching to lessen confounded associations and selection bias. Another strength is its analysis of a relatively homogenous Taiwan population. Most subjects were ethnically Han Chinese, which reduces potential confounding effects of racial differences since ethnicity may be a risk factor for HZ.However, several limitations should be considered in this analysis. First, misclassification is possible because the HZ diagnoses were based on ICD-9 codes by physicians. However, the clinical presentations of HZ are characteristic, and patients in Taiwan do not require a referral letter from a general practitioner before their initial visit with a dermatologist. Hence, an HZ misdiagnosis was probably a rare occurrence in our study population. Although some patients with mild HZ may not seek medical help, the number of patients with HZ who did not visit a physician was probably low because the Taiwan health insurance system requires only a small copayment for each visit. Second, the database lacks information regarding possible confounding factors such as smoking habits, alcohol consumption, dietary habits, nutritional status, physical activities and laboratory confirmations. Additionally, the administrative database did not contain information about stroke severity or location and level of consciousness; hence, the effects of these factors on the occurrence of HZ could not be determined. Furthermore, it was not possible to evaluate all risk factors and to avoid all confounders. Most comorbidities related to the risk of HZ were identified in CCI except depression. However, propensity-score matching was utilized in our analysis; hence, all adjusted HRs for HZ in all subclasses of stroke patients indicated increased HZ risk, which validates the findings of this study. Moreover, recurrent stroke among those stroke patients experiencing HZ episode can’t be easily identified just by using ICD-9-CM codes. Finally, further research is warranted although the mechanisms of post-stroke HZ infections arebeyond the scope of the current study.In conclusion, this population-based study showed that, in comparison with a control group without stroke, adult stroke patients have an increased risk for HZ, especially within 1 year after stroke. Both hemorrhagic stroke and ischemic stroke were significantly associated with HZ risk. Moreover, hemorrhagic stroke had a strong association with HZ ophthalmicus, and ischemic stroke had a strong association with post-herpetic neuralgia. Post-herpetic neuralgia lasting for months or years is the major morbidity caused by HZ, which consumes substantial medical resources; treatin