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O'Halloran JA, Parra-Rodriguez L, Goss CW, Agarwal M, Cooley S, Wu K, Westerhaus E, Presti R, Ances BM, Tassiopoulos K, Erlandson KM. Impact of Integrase Strand Transfer Inhibitors on Cognition in the HAILO Cohort. J Acquir Immune Defic Syndr 2023; 94:437-444. [PMID: 37949447 DOI: 10.1097/qai.0000000000003297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/21/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Integrase inhibitors (INSTIs) have been associated with poorer cognition in people with HIV (PWH). We examined the impact of switching to INSTIs on neuropsychological (NP) outcomes in PWH 40 years of age and older. METHODS From the AIDS Clinical Trials Group observational cohort study, HAILO, we identified PWH who switched to INSTIs, had ≥2 NP assessments before and at least 1 after switch, and maintained viral suppression while on INSTIs. NP performance was assessed with a composite score (NPZ4) including Hopkins Verbal Learning Test (HVLT-R), Digit Symbol test (DSY), Trail Making A, and Trail Making B, while adjusting for covariates and learning effects. Outcomes changes from preswitch and postswitch periods were estimated using piecewise linear mixed models. RESULTS Among 395 PWH (mean age 54 years, 81% male, 20% Hispanic, and 29% Black) NPZ4 increased preswitch and postswitch. There was no difference in slopes between periods for NPZ4 [preswitch 0.036/year (95% CI: 0.03 to 0.043); postswitch 0.022/year (95% CI: 0.006 to 0.005); P = 0.147]. All tests scores improved preswitch (P < 0.01). Postswitch, Trail Making A and DSY increased (all P < 0.01) without differences in rate of change (all P > 0.05). HVLT-R had a nonsignificant decrease postswitch (P = 0.22), resulting in a significant preswitch vs postswitch difference in slopes (P = 0.03). CONCLUSIONS NP performance improved regardless of INSTI use. There was an attenuation of improvement in verbal memory in the postswitch vs preswitch period. The clinical significance of these changes is unclear but, overall, INSTIs did not have a consistent detrimental effect on NP outcomes.
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Affiliation(s)
| | | | | | - Mansi Agarwal
- Washington University School of Medicine, St Louis, MO
| | - Sarah Cooley
- Washington University School of Medicine, St Louis, MO
| | - Kunling Wu
- Harvard T. H. Chan School of Public Health, Boston, MA; and
| | | | - Rachel Presti
- Washington University School of Medicine, St Louis, MO
| | - Beau M Ances
- Washington University School of Medicine, St Louis, MO
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Burdo TH, Robinson JA, Cooley S, Smith MD, Flynn J, Petersen KJ, Nelson B, Westerhaus E, Wisch J, Ances BM. Increased Peripheral Inflammation Is Associated With Structural Brain Changes and Reduced Blood Flow in People With Virologically Controlled HIV. J Infect Dis 2023; 228:1071-1079. [PMID: 37352555 PMCID: PMC10582906 DOI: 10.1093/infdis/jiad229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND While antiretroviral therapy (ART) has improved outcomes for people with HIV (PWH), brain dysfunction is still evident. Immune activation and inflammation remain elevated in PWH receiving ART, thereby contributing to morbidity and mortality. Previous studies demonstrated reduced functional and structural changes in PWH; however, underlying mechanisms remain elusive. METHODS Our cohort consisted of PWH with ART adherence and viral suppression ( < 50 copies/mL; N = 173). Measurements included immune cell markers of overall immune health (CD4/CD8 T-cell ratio) and myeloid inflammation (CD16+ monocytes), plasma markers of inflammatory status (soluble CD163 and CD14), and structural and functional neuroimaging (volume and cerebral blood flow [CBF], respectively). RESULTS Decreased CD4/CD8 ratios correlated with reduced brain volume, and higher levels of inflammatory CD16+ monocytes were associated with reduced brain volume in total cortex and gray matter. An increase in plasma soluble CD14-a marker of acute peripheral inflammation attributed to circulating microbial products-was associated with reduced CBF within the frontal, parietal, temporal, and occipital cortices and total gray matter. CONCLUSIONS CD4/CD8 ratio and number of CD16+ monocytes, which are chronic immune cell markers, are associated with volumetric loss in the brain. Additionally, this study shows a potential new association between plasma soluble CD14 and CBF.
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Affiliation(s)
- Tricia H Burdo
- Department of Microbiology, Immunology, and Inflammation, Center for Neurovirology and Gene Editing, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jake A Robinson
- Department of Microbiology, Immunology, and Inflammation, Center for Neurovirology and Gene Editing, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Sarah Cooley
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - Mandy D Smith
- Department of Microbiology, Immunology, and Inflammation, Center for Neurovirology and Gene Editing, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jacqueline Flynn
- Department of Microbiology, Immunology, and Inflammation, Center for Neurovirology and Gene Editing, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Kalen J Petersen
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - Brittany Nelson
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - Elizabeth Westerhaus
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - Julie Wisch
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - Beau M Ances
- Department of Neurology, Washington University in St Louis, St Louis, Missouri, USA
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Cooley S, Nelson BM, Rosenow A, Westerhaus E, Cade WT, Reeds DN, Vaida F, Yarasheski KE, Paul RH, Ances BM. Exercise Training to Improve Brain Health in Older People Living With HIV: Study Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e41421. [PMID: 36943345 PMCID: PMC10131751 DOI: 10.2196/41421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND With the advent of antiretrovirals, people living with HIV are living near-normal lifespans. However, people living with HIV are at greater risk of experiencing cognitive impairment and reduced brain integrity despite well-controlled viremia. A robust literature supports exercise interventions as a method of improving cognition and structural brain integrity in older individuals without HIV. The effects of exercise on cardiometabolic, neurocognitive, and neural structures in middle-aged to older people living with HIV are less well known, with few prospective studies examining these measures. OBJECTIVE This prospective randomized clinical trial will examine the effects of a 6-month exercise training intervention compared to a 6-month stretching intervention (control) on cardiorespiratory fitness, physical function and strength, cognition, and neuroimaging measures of brain volumes and cerebral blood flow in people living with HIV. METHODS Sedentary middle-aged to older people living with HIV (ages≥40; n=150) with undetectable HIV viral load (<20 copies/mL) will be enrolled in the study. At the baseline and final visit, fasting plasma lipid, insulin, glucose, and brain neurotrophic factor concentrations; cardiorespiratory fitness; cognitive performance; brain volumes; and cerebral blood flow via a magnetic resonance imaging scan will be measured. Participants will be randomized in a 2:1 ratio to either the exercise or control stretching intervention. All participants will complete their assigned programs at a community fitness center 3 times a week for 6 months. A professional fitness trainer will provide personal training guidance at all sessions for individuals enrolled in both arms. Individuals randomized to the exercise intervention will perform endurance and strength training exercises, while those randomized to the control intervention will perform stretches to increase flexibility. A midpoint visit (at 3 months) will assess cognitive performance, and at the end point visit, subjects will undergo cardiorespiratory fitness and cognition testing, and a magnetic resonance imaging scan. Physical activity throughout the duration of the trial will be recorded using an actigraph. RESULTS Recruitment and data collection are complete as of December 2020. Data processing, cleaning, and organization are complete as of December 2021. Data analysis began in January 2022, with the publication of study results for primary aims 1 and 2 expected by early 2023. CONCLUSIONS This study will investigate the effects of a 6-month aerobic and resistance exercise training intervention to improve cardiometabolic risk factors, cognitive performance, cerebral structure, and blood flow in sedentary people living with HIV. Results will inform clinicians and patients of the potential benefits of a structured aerobic exercise training program on the cognitive, functional, and cardiometabolic health status of older people living with HIV. Assessment of compliance will inform the development and implementation of future exercise programs for people living with HIV. TRIAL REGISTRATION ClinicalTrials.gov NCT02663934; https://clinicaltrials.gov/ct2/show/NCT02663934. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41421.
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Affiliation(s)
- Sarah Cooley
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Brittany M Nelson
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Alexander Rosenow
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Elizabeth Westerhaus
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - W Todd Cade
- Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, NC, United States
| | - Dominic N Reeds
- Department of Medicine and the Center for Human Nutrition, Washington University in St. Louis, Saint Louis, MO, United States
| | - Florin Vaida
- Division of Biostatistics and Bioinformatics, School of Public Health, University of California San Diego, San Diego, CA, United States
| | - Kevin E Yarasheski
- Division of Endocrinology, School of Medicine, Washington University in Saint Louis, Saint Louis, MO, United States
| | - Robert H Paul
- Department of Psychology, University of Missouri St. Louis, Saint Louis, MO, United States
| | - Beau M Ances
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
- Department of Radiology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
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Strain JF, Cooley S, Kilgore C, Nelson B, Doyle J, Thompson R, Westerhaus E, Petersen KJ, Wisch J, Ances BM. The Structural and Functional Correlates of Frailty in Persons With Human Immunodeficiency Virus. Clin Infect Dis 2022; 75:1740-1746. [PMID: 35404408 PMCID: PMC10200329 DOI: 10.1093/cid/ciac271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons with HIV (PWH) are at increased risk of frailty, a clinically recognizable state of increased vulnerability resulting from aging-associated decline in multiple physiologic systems. Frailty is often defined by the Fried criteria, which includes subjective and objective standards concerning health resiliency. However, these frailty metrics do not incorporate cognitive performance or neuroimaging measures. METHODS We compared structural (diffusion tensor imaging [DTI]) and functional (cerebral blood flow [CBF]) neuroimaging markers in PWH with frailty and cognitive performance. Virologically controlled PWH were dichotomized as either frail (≥3) or nonfrail (<3) using the Fried criteria. Cognitive Z-scores, both domain (executive, psychomotor speed, language, and memory) and global, were derived from a battery of tests. We identified three regions of reduced CBF, based on a voxel-wise comparison of frail PWH compared with nonfrail PWH. These clusters (bilateral frontal and posterior cingulate) were subsequently used as seed regions of interest (ROIs) for DTI probabilistic white matter tractography. RESULTS White matter integrity connecting the ROIs was significantly decreased in frail compared with nonfrail PWH. No differences in cognition were observed between frail and nonfrail PWH. However, reductions in white matter integrity among these ROIs was significantly associated with worse psychomotor speed and executive function across the entire cohort. CONCLUSIONS We conclude that frailty in PWH can lead to structural and functional brain changes, including subtle changes that are not detectable by standard neuropsychological tests. Multimodal neuroimaging in conjunction with frailty assessment could identify pathological brain changes observed in PWH.
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Affiliation(s)
- Jeremy F Strain
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Sarah Cooley
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Collin Kilgore
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Brittany Nelson
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - John Doyle
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Regina Thompson
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | | | - Kalen J Petersen
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Julie Wisch
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Beau M Ances
- Department of Neurology, Washington University, St. Louis, Missouri, USA
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Bollinger RM, Keleman A, Thompson R, Westerhaus E, Fagan AM, Benzinger TL, Schindler SE, Xiong C, Balota D, Morris JC, Ances BM, Stark SL. Falls: a marker of preclinical Alzheimer disease: a cohort study protocol. BMJ Open 2021; 11:e050820. [PMID: 34526343 PMCID: PMC8444237 DOI: 10.1136/bmjopen-2021-050820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Progression to symptomatic Alzheimer disease (AD) occurs slowly over a series of preclinical stages. Declining functional mobility may be an early indicator of loss of brain network integration and may lead to an increased risk of experiencing falls. It is unknown whether measures of functional mobility and falls are preclinical markers of AD. The purpose of this study is to examine (1) the relationship between falls and functional mobility with AD biomarkers to determine when falls occur within the temporal progression to symptomatic Alzheimer disease, and (2) the attentional compared with perceptual/motor systems that underlie falls and functional mobility changes seen with AD. METHODS AND ANALYSIS This longitudinal cohort study will be conducted at the Knight Alzheimer Disease Research Center. Approximately 350 cognitively normal participants (with and without preclinical AD) will complete an in-home visit every year for 4 years. During each yearly assessment, functional mobility will be assessed using the Performance Oriented Mobility Assessment, Timed Up and Go, and Timed Up and Go dual task. Data regarding falls (including number and severity) will be collected monthly by self-report and confirmed through interviews. This study will leverage ongoing neuropsychological assessments and neuroimaging (including molecular imaging using positron emission tomography and MRI) performed by the Knight Alzheimer Disease Research Center. Relationships between falls and biomarkers of amyloid, tau and neurodegeneration will be evaluated. ETHICS AND DISSEMINATION This study was approved by the Washington University in St. Louis Institutional Review Board (reference number 201807135). Written informed consent will be obtained in the home prior to the collection of any study data. Results will be published in peer-reviewed publications and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04949529; Pre-results.
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Affiliation(s)
- Rebecca M Bollinger
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Audrey Keleman
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Regina Thompson
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Elizabeth Westerhaus
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tammie Ls Benzinger
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Suzanne E Schindler
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David Balota
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Psychological & Brain Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Beau M Ances
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
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Overton ET, Azad TD, Parker N, Demarco Shaw D, Frain J, Spitz T, Westerhaus E, Paul R, Clifford DB, Ances BM. The Alzheimer's disease-8 and Montreal Cognitive Assessment as screening tools for neurocognitive impairment in HIV-infected persons. J Neurovirol 2013; 19:109-16. [PMID: 23345074 DOI: 10.1007/s13365-012-0147-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 12/12/2012] [Accepted: 12/20/2012] [Indexed: 12/21/2022]
Abstract
The diagnosis of human immunodeficiency virus (HIV)-associated neurocognitive impairment is time-intensive and often omitted in busy outpatient settings. Brief screening tools are needed. The Montreal Cognitive Assessment (MoCA) and the Alzheimer's disease (AD)-8 have been used in neurodegenerative disorders. We evaluated the sensitivity and specificity of these brief screening tools in HIV-infected persons. The AD-8, MoCA, and formal neuropsychological testing were administered to 200 HIV-infected patients who were followed at a single institution. Normalized scores on formal neuropsychological testing were used to define neurocognitive impairment. The sensitivity and specificity of the MoCA and AD-8 were assessed to diagnose the impairment. Neurocognitive impairment was highly prevalent in this cohort: 127 persons (64 %) were diagnosed with neurocognitive impairment based on formal testing. Using the AD-8 and MoCA, 113 (57 %) and 101 (51 %) persons were identified with neurocognitive impairment, respectively. The sensitivity and specificity of MoCA were 63 % and 71 %, respectively. The sensitivity and specificity of AD-8 were 61 % and 51 %, respectively. Our findings highlight that brief screening tools correlate with formal neuropsychological testing. However, the sensitivities of these screening tools are lower than desired. Nevertheless, given their ease in administration, these tools could assist as a first line for identifying individuals who may subsequently require formal neuropsychological testing.
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Affiliation(s)
- Edgar Turner Overton
- Department of Medicine, University of Alabama Birmingham, CCB Rm 325, 908 20th St South, Birmingham, AL 35294, USA.
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