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​                  NEURODiversity          Wednesday

Neuro-Diversity and Metabolomic Biomarkers

10/18/2024

 
Val's Take/Conjecture
  • In 2013 when the National Institute of Mental Health (NIMH) determined the then new DSM 5 lacked scientific validity ---
    • It was widely reported, BUT
    • There wasn't a substitute and NIMH's Research Domain Criteria Program was just getting off the ground.
  • The DSM's Subjective Cluster of Symptoms is pretty less than ideal -- but if it is all you've got you probably go with it.
  • Well, the world of BIOMARKERS and specifically METABOLOMIC BIOMARKERS is exploding.
  • It is going to take a minute to get this to Clinicians, but it appears to be on its way.
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Metabolomic Markers in Attention-Deficit/Hyperactivity Disorder (ADHD) among Children and Adolescents-A Systematic Review.  (2024)

Attention-Deficit/Hyperactivity Disorder (ADHD), characterized by clinical diversity, poses diagnostic challenges often reliant on subjective assessments. ...While guiding future research, this overview of the metabolomic findings in A …
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Metabolomic biomarkers in autism: identification of complex dysregulations of cellular bioenergetics (2023)

Autism Spectrum Disorder (ASD or autism) is a phenotypically and etiologically heterogeneous condition. ...We hypothesized that the application of metabolite-based biomarker techniques using decision thresholds derived from quantitative measurements could ide …
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Metabolomic Biomarker Signatures for Bipolar and Unipolar Depression.  (2024)

IMPORTANCE: Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD) because of overlapping symptoms and the lack of objective diagnostic tools. OBJECTIVE: To identify a reproducible metabolomic biomarker signature in patient …
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Metabolome - an overview (2017)

Metabolome: The complete collection of metabolites, or small molecules found in a given organelle, cell, tissue, organ, biofluid, or organism. Metabolomics: The comprehensive characterization of metabolites and other chemical species (both exogenous and endogenous) in biological specimens in response to different perturbations or interventions.
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Metabolomics: an emerging but powerful tool for precision medicine (2015)
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Association Between Human Blood Metabolome and the Risk of Psychiatric Disorders  (2023)
 
BACKGROUND AND HYPOTHESIS: To identify promising drug targets for psychiatric disorders, we applied Mendelian randomization (MR) design to systematically screen blood metabolome for potential mediators of psychiatric disorders and further predict target-mediated side effec …
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Mitochondria in precision medicine; linking bioenergetics and metabolomics in platelets (2019)

Mitochondria possess reserve bioenergetic capacity, supporting protection and resilience in the face of disease. ...To test for correlations of platelet metabolites with energetic parameters, we performed an integrated analysis of metabolomics and MST parameters. Su …
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Gut microbiota drives age-related oxidative stress and mitochondrial damage in microglia via the metabolite N(6)-carboxymethyllysine  (2022)

The absence of gut microbiota diminished oxidative stress and ameliorated mitochondrial dysfunction in microglia from the brains of aged mice. Unbiased metabolomic analyses of serum and brain tissue revealed the accumulation of N(6)-carboxymethyllysine (CML) in the …

Dostoyevsky, Irritability & Sensory Processing

10/8/2024

 
Val's Take/Conjecture

The National Institute of Mental Health is identifying "IRRITABILITY" in children and adults as a significant factor in Mental Health issues.
  • IRRITABILITY is so ubiquitous in this society.
  • Further, if you're really sophisticated -- you're trying to attach that IRRITABILITY to some NOBLE CAUSE.
  • When you're not masking it.
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Dostoyevsky
In Dostoyevsky's "The Brothers Karamazov" one of the main characters observes that he loves HUMANITY with all his heart --- but he can't really stand to be in the same room with another human being for 24 hours -- he finds people so IRRITATING.
“I love mankind, he said, "but I find to my amazement that the more I love mankind as a whole, the less I love man in particular.”
― Fyodor Dostoyevsky, The Brothers Karamazov
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Associations Between Chronic Irritability and Sensory Processing Difficulties in Children and Adolescents (2023)
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Irritability in Youths: A Critical Integrative Review (2024)
Abstract

Irritability, defined as proneness to anger that may impair an individual's functioning, is common in youths. There has been a recent upsurge in relevant research.

The authors combine systematic and narrative review approaches to integrate the latest clinical and translational findings and provide suggestions for addressing research gaps.

Clinicians and researchers should assess irritability routinely, and specific assessment tools are now available. Informant effects are prominent, are stable, and vary by age and gender.

The prevalence of irritability is particularly high among individuals with attention deficit hyperactivity disorder, autism spectrum disorder, and mood and anxiety disorders. Irritability is associated with impairment and suicidality risk independent of co-occurring diagnoses.

Developmental trajectories of irritability (which may begin early in life) have been identified and are differentially associated with clinical outcomes.

Youth irritability is associated with increased risk of anxiety, depression, behavioral problems, and suicidality later in life. Irritability is moderately heritable, and genetic associations differ based on age and comorbid illnesses.
Irritability is also associated with Cancer, Huntington's Disease and Dementia.

19th Century painters & Imagine Dragons ---"I'm gonna say all the words inside my head"

9/11/2024

 
Val's Take/Conjecture
  • When we're talking about people with Hyper-Connected Brains as a result of Maternal Immune Activation
    • We're often talking --- eccentricity and idiocyncracy.
    • So trying to find a "Community" can be hard.
  • There are a lot of 19th Century Painters --- the ones I'm going to focus on are Gauguin and Van Gogh. [I just learned that Gauguin was only 5'4"]
  • I would say both Gauguin and Van Gogh were neuro-divergent and were different from one another, often on each other's nerves.
When I first learned about these 19th Century Painters in a "Modern Art Theory Class" --- I was impressed by the art, and largely thought these guys were  nuts --- I really didn't  know why they were living the  lives they were living.

"Lifestyle Choices" are a big concept in Medicine, society generally and are often invoked in our public policy discussions regarding various issues.
Adhd, Autism, Sensory Neurons, Pain & an Intense World
Imagine Dragons
Believer
Due to the Eugenics movement of the 1920s and Nazi Germany, etc.  --- people became rightly suspect regarding "biological inferiority" claims.

Unfortunately, we've also become suspect of BIOLOGICAL DIFFERENCE claims.  I think that is not a good thing and leads to FALSE PREMISES which lead some of our public policy debates to become nonsensical.
Val's Take:  I'm not a painter, I'm kinda becoming a musician --- but I'm really an ABSTRACT THINKER.
Ted-Ed
Math & Van Gogh's Starry, Starry Night

For Neuro-Divergent people --- these hyper-connected brains can generate a lot of emotions and ideas that are taking up enormous amounts of space in your thinking --- and you need to have some way to download that.

That is  a PHYSIOLOGICAL NEED --- it's not really a lifestyle choice.
Further, I think that it can look selfish and self-absorbed and narcissistic.

Additionally, I think it can look "lazy" because the person is often dealing with low-grade fatigue.

Better understanding the dynamics of the biology will help better understand the life.

Speech Differences

9/11/2024

 
Val's Take & Conjecture
  • I was in Speech Therapy in Elementary School.
  • I don't remember ever being bullied in school for Speech Differences or Impediments. (Maybe I was and I just didn't know it, maybe I was blissfully unaware).
  • Further, my speech issues have waxed and waned and morphed.
    • Does stress play into it --- yeah probably
    • Dental Work
    • Orthodontics -- did help --- that's been awhile
    • allergies
    • the structure of my face
    • the list goes on

Further, if you take certain medications you can have Tardive Dyskinesia.

So I actually had speech issues as a young child and minor speech issues as an adult.

As an adult and now older adult taking psychiatric medication, I am having to more specifically address tardive dyskinesia issues.
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Speech motor control and orofacial point pressure sensation in adults with ADHD.  (2021)

"Attention-Deficit Hyperactivity Disorder (ADHD) is a predominant neurobehavioral disorder of childhood with motor and sensory symptoms often persisting into adulthood. ...Young adults with ADHD have subtle differences in speech …"
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Dopamine, Vocalization, and Astrocytes (2021)
"Dopamine’s effects are widespread and include modulation of a number of voluntary and innate behaviors.

"Vigilant regulation and modulation of dopamine levels throughout the brain is imperative for proper execution of motor behaviors, in particular speech and other types of vocalizations."
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10 Most Common Speech-Language Disorders & Impediments  (2024)
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Speech and language patterns in autism: Towards natural language processing as a research and clinical tool. (2024)

Speech and language differences have long been described as important characteristics of autism spectrum disorder (ASD). ...Heterogeneity of findings and a reliance on qualitative, subjective ratings, however, limit a full understanding of linguistic phenotyp …
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Alogia and pressured speech do not fall on a continuum of speech production using objective speech technologies.  (2023)

"Speech production is affected in a variety of serious mental illnesses (SMI; e.g., schizophrenia, unipolar depression, bipolar disorders) and at its extremes can be observed in the gross reduction of speech (e.g., alogia) or increase of speech (e.g., press …"

Justice Sensitivity

8/31/2024

 
I love it when attorneys start pontificating on how much they have a "passion for justice" ---

COME TELL MAMA ALL ABOUT IT.
Especially in Law & Medicine, I think there are a lot of people who would be hard to classify as "straight" ADHD or Autism.

They fly under the radar of other people, professionals, and even themselves.

Further, there are other professions that are maybe more associated with ADHD or Autism.  

Engineering coming to mind for Autism --- I'm sure that is a stereotype.

My personal observations  may be of limited persuasive value --- But as we get more and more biomarkers --- that will change  views.
The Bizarre Intersection between Law & Giftedness: Adulting with Exceptionalities in the Criminal Justice System
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Image Credit: Liberty Maniacs

P.S.  I think Comedians are taking in an enormous amount of information and condensing it --- and are often emotionally dysregulated.

Can look like  Major Depression.
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Robin Williams and the link between comedy and depression (2014)
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Justice Sensitivity Is Plaguing Autistic & ADHD Individuals—Here's What to Know (2024)

Neurodivergent folks are prone to high levels of justice sensitivity
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Well, WHAT IS JUSTICE?

It depends a lot on your sensory processing ---

and we're not processing everything

and we're processing things differently.
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Inflammation-induced mitochondrial and metabolic disturbances in sensory neurons control the switch from acute to chronic pain (2023)
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Transdiagnostic Patterns of Sensory Processing in Autism and ADHD (2024)

Sensory processing abilities are highly variable within and across people diagnosed with autism and attention-deficit/hyperactivity disorder (ADHD).

This study examined the transdiagnostic nature of sensory processing
…

"Personality Disorders" and Neuro-Developmental Disorders

8/25/2024

 
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Rashomon (1950)
Val's Take/Conjecture
  • There's a certain "Rashomon effect" to societal discussions about Human Behavior.
  • Even beyond different people in the same time and place having different perspectives of the same incident, we have people in different times and places having greatly different perspectives.
  • What I want to submit is:   Assuming that people are  telling the truth as best they can:
    • How can these accounts all be true "in some respect" / not all respects --- and reconciled to avoid a complete Contradiction.
  • This website has addressed Anti-Social Personality Disorder and the emerging view that it is in fact a form of "ADHD."
    • "Anti-Social Personality Disorder" and "ADHD" are categories in the DSM 5.
  • More recently, there is no shortage of speculation that the Myers-Brigg category of "INFJ" is actually Autism, including by a psychiatrist at Harvard and YouTubers with Autism.     Hmmm. . .
  • The challenge with these discussions is we don't have FIRM (RELIABLE) DEFINITIONS --- we have definitions of categories that are in flux, have been called into question and are in the process of being re-conceptualized
Myers-Briggs
  • Discover Magazine (2023)
    •  The Myers-Briggs test is not considered valid.
 
DSM 5
  • Psychology Today (2013)
    • The NIMH [National Institute of Mental Health] Withdraws Support for DSM-5
Personality Disorder: Unscientific & Vague --- Must be Reformed
anti-social personality disorder as a form of adhd
The "DSM" Personality Disorders were trying to cluster together personality traits that were  seriously problematic.

Interestingly, a prominent historian of psychiatry challenged whether these were in fact "disorders" or just "people who couldn't get it together."
I would say a few things:
There's a lot of "unconscious bias" in all this:
  • The Public Health System "may" be deemed a more appropriate place for you if you are White and Middle Class.
  • If you are White and Poor or a Person of Color ---- a jail or prison may seem a more appropriate placement.  [I'm talking here about people who may have an average or above average IQ, but nonetheless have significant needs]
Families, communities, government agencies, private agencies are struggling FINANCIALLY under the weight of Neuro-Developmental Disorders that last:
  • a lifetime and are not static
  • are not well recognized or accommodated
  • often are getting worse because we haven't had biomarkers and most researchers and some clinicians would admit the treatment is "rudimentary."
"ADHD" is over-represented in Criminal Justice Systems around the world and is more and more openly acknowledged by law enforcement, attorneys and first responders.
  • NeuroLaunch:  Can You Be a Police Officer with ADHD? Exploring Challenges and Opportunities (August 4, 2024)
  • ADHD Alliance (UK):  Helping the
    Emergency Services Understand
    ADHD           "We help staff in the Emergency Services live with ADHD and drive change throughout the Criminal Justice System."
  • ADDITUDE:   How An ADHD Diagnosis Changed My Life: A Lawyer’s Story                                                                      "When I first opened my coaching practice in Washington, D.C., I was surprised by the number of high-powered attorneys with ADHD who sought my help."
  • Fire Rescue (Florida):  Dealing with Attention Deficit Hyper-Activity Disorder in Emergency Services

Inflammation & Neuro-Diversity

8/17/2024

 
Val's Take/Conjecture
  • People used to think that "biomarkers" in neuro-developmental and psychiatric disorders were going to be "genes."
  • There are "genes" but they are often shared across "disorders." 
  • Further, we may still find genetic biomarkers useful.
  • BUT the BIG NEWS is Maternal Immune Activation and Neuro-Developmental Inflammation.
    • Maternal immune activation and neuroinflammation in human neurodevelopmental disorders (2021)
  • On top of that, a dysregulated Epigenome.
    • Epigenetics in Neurological and Psychiatric Disorders: A Comprehensive Review of Current Understanding and Future Perspectives (2023)
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The Role of Maternal Immune Activation in the Pathogenesis of Autism: A Review of the Evidence, Proposed Mechanisms and Implications for Treatment (2021)
This review is focused on the hypothesis that MIA [Maternal Immune Activation] induces microglial activation, oxidative stress, and mitochondrial dysfunction, a deleterious trio in the brain that can lead to neuroinflammation and neurodevelopmental pathologies in offspring.

Are you synapse rich & Energy  Poor?

8/10/2024

 
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Synapses: The Brain’s Energy-Demanding Sites (2022)
The brain is one of the most energy-consuming organs in the mammalian body, and synaptic transmission is one of the major contributors. To meet these energetic requirements, the brain primarily uses glucose, which can be metabolized through glycolysis and/or mitochondrial oxidative phosphorylation.
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Deep proteomics identifies shared molecular pathway alterations in synapses of patients with schizophrenia and bipolar disorder and mouse model (2023)
Abstract

Synaptic dysfunction is implicated in the pathophysiology of schizophrenia (SCZ) and bipolar disorder (BP).

We use quantitative mass spectrometry to carry out deep, unbiased proteomic profiling of synapses purified from the dorsolateral prefrontal cortex of 35 cases of SCZ, 35 cases of BP, and 35 controls.

Compared with controls, SCZ and BP synapses show substantial and similar proteomic alterations.

Network analyses reveal upregulation of proteins associated with autophagy and certain vesicle transport pathways and downregulation of proteins related to synaptic, mitochondrial, and ribosomal function in the synapses of individuals with SCZ or BP.

Some of the same pathways are similarly dysregulated in the synaptic proteome of mutant mice deficient in Akap11, a recently discovered shared risk gene for SCZ and BP.

Our work provides biological insights into molecular dysfunction at the synapse in SCZ and BP and serves as a resource for understanding the pathophysiology of these disorders.
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TREMendous 2 Be Social (2018)
Abstract

TREM2 is known for its role in microglial phagocytosis and in neurodegenerative diseases.

In this issue of Immunity, Filipello et al. (2018) show that microglial TREM2 is required for synaptic pruning in early development.

TREM2-deficient mice show altered social behavior in adulthood, linking TREM2 to neurodevelopmental disease.
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Microglia at the Tripartite Synapse during Postnatal Development: Implications for Autism Spectrum Disorders and Schizophrenia (2023)
Abstract

Synapses are the fundamental structures of neural circuits that control brain functions and behavioral and cognitive processes.

Synapses undergo formation, maturation, and elimination mainly during postnatal development via a complex interplay with neighboring astrocytes and microglia that, by shaping neural connectivity, may have a crucial role in the strengthening and weakening of synaptic functions, that is, the functional plasticity of synapses.
Indeed, an increasing number of studies have unveiled the roles of microglia and astrocytes in synapse formation, maturation, and elimination as well as in regulating synaptic function.

Over the past 15 years, the mechanisms underlying the microglia- and astrocytes-dependent regulation of synaptic plasticity have been thoroughly studied, and researchers have reported that the disruption of these glial cells in early postnatal development may underlie the cause of synaptic dysfunction that leads to neurodevelopmental disorders such as autism spectrum disorder (ASD) and schizophrenia.
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The Synaptic and Circuit Functions of Vitamin D in Neurodevelopment Disorders (2023)
 Abstract

Vitamin D deficiency/insufficiency is a public health issue around the world.

According to epidemiological studies, low vitamin D levels have been associated with an increased risk of some neurodevelopmental disorders, including autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD).


Animal models reveal that vitamin D has a variety of impacts on the synapses and circuits in the brain. A lack of vitamin D affects the expression of synaptic proteins, as well as the synthesis and metabolism of various neurotransmitters.

Depending on where vitamin D receptors (VDRs) are expressed, vitamin D may also regulate certain neuronal circuits through the endocannabinoid signaling, mTOR pathway and oxytocin signaling.

While inconsistently, some data suggest that vitamin D supplementation may be able to reduce the core symptoms of ASD and ADHD.

This review emphasizes vitamin D's role in the synaptic and circuit mechanisms of neurodevelopmental disorders including ASD and ADHD.

Future application of vitamin D in these disorders will depend on both basic research and clinical studies, in order to make the transition from the bench to the bedside.
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Lack of neuron ‘pruning’ may be behind many brain-related conditions (2023)
Brain scans show that adolescents with more symptoms of certain mental health conditions, autism or ADHD have undergone less pruning than usual of synaptic connections between neurons."

Energy Issues vs. intelligence or reasonableness issues

8/5/2024

 
Val's Take/Conjecture
  • Reframing Neuro-Developmental and Psychiatric Disorders as Brain Energy issues is a major paradigm shift and it brings with it waves and waves of new insight.
  • This new insight is for the society and clinicians, and most importantly for individuals themselves.
  • If you're getting pushed to do things you don't have the energy to do, and at some point you push back, this typically does not end well for the neuro-diverse person.
  • Further, the good news and the bad news is that many neuro-diverse people have average to above average intelligence.
  • Additionally, many neuro-diverse people have Hyper-Plastic Brains.  This turns out to be a mixed blessing.
  • Further, many neuro-diverse people have a Hyper-Connected Brain and this turns out to be  a mixed blessing.
As conjecture, I would submit that Hyper-Plastic, Hyper-Connected Brains require more energy, and Neuro-Typical Brains require about 20% of the human energy supply. [Synapses lead to energy leakage and energy consumption in brain --- see link above]
  • Children with Autism Have Extra Synapses in Brain (2014)
  • Lack of neuron ‘pruning’ may be behind many brain-related conditions (2023)

We are getting "Metabolomic" biomarkers for Bipolar Disorder and Depression.

When we think about Metabolism we typically think about our ability to lose weight, but it is a lot more than that.
Metabolism is the set of life-sustaining chemical reactions in organisms.

The three main functions of metabolism are: the conversion of the energy in food to energy available to run cellular processes; the conversion of food to building blocks of proteins, lipids, nucleic acids, and some carbohydrates; and the elimination of metabolic wastes. --- Wikipedia

Neuro-diversity, Energy and Strength-Based Employment

8/4/2024

 
Val's Take/Conjecture
  • The categories in the DSM can be misleading, and what we need to be focusing  on is NEURO-DEVELOPMENTAL INFLAMMATION.
  • Further, that NEURO-DEVELOPMENTAL INFLAMMATION can be quite idiosyncratic.
  • Some of us arrived considerably PRE-INFLAMED.
  • Additionally Adverse Childhood Experiences can make a challenging situation worse.
  • For many of us, Adulthood posed challenges we didn't understand and neither did anyone else.
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Medium:  Conservative Friends of Neurodiversity
An Overview of Neurodiversity and Recommendations for Inclusivity in the Workplace (2023)
Individuals with Neuro-Developmental Disabilities and an IQ over 70, with or without Brain Injury ---make up a big part of the Criminal Justice Population and the Chronically Homeless Population.

There are many things to consider.  Two of them are:
  • Brain Energy and the need for perhaps more ATP to run a differently wired brain; and
  • Access to Strengths-Based Employment as Essential for Proper Brain Functioning.

 I think so many neuro-diverse people do want to get their challenges out on the table and honestly deal with those issues in a way past generations were afraid to or didn't understand.

But they also need their STRENGTHS recognized and developed.

Accommodations for Neuro-Developmental Disabilities and an IQ over 70 is probably the most significant Olmstead Issue we're currently facing.

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Composing to Avoid Cacophony --- Understanding Asynchrony
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    Neuro-Diversity
    Wednesday

    (with variable spellings of Neurodiversity)


    NEURODIVERSITY  is BLURRED. 

    What people are keying off of is:  EXECUTIVE FUNCTIONING DIFFERENCES or DEFICITS --- and saying "Hey, that's me."

    BUT they are also saying:  "Hey, I've got some BIG TIME STRENGTHS and I need those recognized too." 

    ​
     

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    • What We Want --- SAMHSA Grant Opportunities Due Jan. 22, 2019
    • Anti-Social Personality Disorder >
      • DECONSTRUCTING ANTISOCIAL PERSONALITY DISORDER AND PSYCHOPATHY: A GUIDELINES-BASED APPROACH TO PREJUDICIAL PSYCHIATRIC LABELS [Hofstra Law Review 2013]
      • Personality Disorders -- Unscientific & Vague -- Must Be Reformed
    • Executive Functioning & "Prison Brain" >
      • Job Accommodation Network on Executive Functioning Deficits
    • Medicaid & Medicare Network Adequacy >
      • OIG: STATE STANDARDS FOR ACCESS TO CARE IN MEDICAID MANAGED CARE (Sept. 2014)
      • OIG: ACCESS TO CARE: PROVIDER AVAILABILITY IN MEDICAID MANAGED CARE (Dec. 2014)
      • GAO 15-710: MEDICARE ADVANTAGE: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy (Aug. 2015)
      • CMS: Promoting Access in Medicaid and CHIP Managed Care: A Toolkit for Ensuring Provider Network Adequacy and Service Availability (April 2017)
    • Medicaid Mental Health & Substance Use Disorder Parity >
      • CMS Parity Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance Programs [Jan. 17, 2017]
      • Frequently Asked Questions: Mental Health and Substance Use Disorder Parity Final Rule for Medicaid and CHIP [CMS October 11, 2017]
    • Olmstead Disability Rights >
      • Statement of the Department of Justice on Enforcement of the Integration Mandate of Title II of the Americans with Disabilities Act and Olmstead v. L.C. (2011)
      • Comprehensive Olmstead Planning
      • the Logical Long Term Consequences of our failure to provide Intensive Community MH Treatment
      • Olmstead Nation ---State Pages: How Far to Comply with Olmstead?
  • Take A Walk Around Orchid's Resource Block
  • Colorado Abuse & Neglect Scandals Involving People with Disabilities
  • Mental Health By The Numbers
  • New Science Is Amazing AND It Has HUGE Moral Implications for Our Society: NOW
  • Olmstead & Homelessness
  • Double V
  • " 'Defund the Police" Means 'Invest in the Resources Our Communities Need' " or Don't Cost Shift to the Police
  • VAGUE OLMSTEAD PLANS, EXPENSIVE LITIGATION
  • Updating & Reforming our Understanding & Treatment of "Anti-Social Personality Disorder" Blog
  • Reform of " Anti-Social Personality Disorder" in Criminal Justice
  • CO HB22-1278
  • New Understandings Matter
  • Mental Health, Ethics & Law
  • CO Olmstead Disability Homeless Law & Policy Project
  • Inflammation, the Immune System, Neuro-Developmental Disorders, Psychiatric Disorders, Substance Use Issues & Chronic Disease
  • Microglia and the Brain's Immune System
  • Substance Issues & the Immune System