Practical recommendations for timely, accurate diagnosis of symptomatic Alzheimer's disease (MCI and dementia) in primary care: a review and synthesis.

The critical role of primary care clinicians (PCCs) in Alzheimer's disease (AD) prevention, diagnosis and management must evolve as new treatment paradigms and disease-modifying therapies (DMTs) emerge. Our understanding of AD has grown substantially: no longer conceptualized as a late-in-life syndrome of cognitive and functional impairments, we now recognize that AD pathology builds silently for decades before cognitive impairment is detectable. Clinically, AD first manifests subtly as mild cognitive impairment (MCI) due to AD before progressing to dementia. Emerging optimism for improved outcomes in AD stems from a focus on preventive interventions in midlife and timely, biomarker-confirmed diagnosis at early signs of cognitive deficits (i.e. MCI due to AD and mild AD dementia). A timely AD diagnosis is particularly important for optimizing patient care and enabling the appropriate use of anticipated DMTs. An accelerating challenge for PCCs and AD specialists will be to respond to innovations in diagnostics and therapy for AD in a system that is not currently well positioned to do so. To overcome these challenges, PCCs and AD specialists must collaborate closely to navigate and optimize dynamically evolving AD care in the face of new opportunities. In the spirit of this collaboration, we summarize here some prominent and influential models that inform our current understanding of AD. We also advocate for timely and accurate (i.e. biomarker-defined) diagnosis of early AD. In doing so, we consider evolving issues related to prevention, detecting emerging cognitive impairment and the role of biomarkers in the clinic.

Gene expression and linkage analysis implicate CBLB as a mediator of rituximab resistance.

Elucidating resistance mechanisms for therapeutic monoclonal antibodies (MAbs) is challenging, because they are difficult to study in non-human models. We therefore developed a strategy to genetically map in vitro drug sensitivity, identifying genes that alter responsiveness to rituximab, a therapeutic anti-CD20 MAb that provides significant benefit to patients with B-cell malignancies. We discovered novel loci with genome-wide mapping analyses and functionally validated one of these genes, CBLB, which causes rituximab resistance when knocked down in lymphoma cells. This study demonstrates the utility of genome-wide mapping to discover novel biological mechanisms of potential clinical advantage.

Assessment of dementia risk in aging adults using both FDG-PET and FDDNP-PET imaging.

BACKGROUND: In a previous study, positron emission tomography (PET) with 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile (FDDNP), a molecule that binds to plaques and tangles in vitro, identified three subgroups of non-demented subjects according to FDDNP binding patterns: low global (LG) binding; high frontal, parietal, medial temporal binding (HF/PA); and high medial and lateral temporal and posterior cingulate (HT/PC) binding. In this follow-up investigation, we compared 2-deoxy-2-[F-18]fluoro- d-glucose (FDG)-PET cerebral metabolic patterns in the three FDDNP-PET binding subgroups. METHODS: Fifty-four subjects with normal aging (N = 28) or amnestic forms of mild cognitive impairment (N = 26) underwent FDDNP-PET and FDG-PET scanning. Subjects in the LG, HF/PA, and HT/PC FDDNP subgroups were compared according to visual ratings, statistical parametric mapping, and automated region of interest analyses of their FDG-PET data. RESULTS: The FDDNP-PET subgroups demonstrated different glucose metabolic patterns according to visual ratings, region of interest, and statistical parametric mapping analyses of FDG-PET data. The LG FDDNP subgroup showed no areas of significant hypometabolism relative to the other subgroups and had low Alzheimer's disease risk by FDG-PET standards. The HF/PA FDDNP subgroup demonstrated hypometabolism in bilateral inferior parietal/parietotemporal, bilateral posterior cingulate, perisylvian, mid-temporal gyrus, and dorsolateral prefrontal regions, which is a pattern suggestive of high Alzheimer's disease risk. The HT/PC FDDNP subgroup demonstrated heterogeneous FDG-PET patterns with predominant anterior frontal and anterior temporal hypometabolism, suggestive of mixed etiologies, including fronto-temporal dementia risk. CONCLUSIONS: The FDG-PET data provided independent validation that different patterns of FDDNP-PET binding in non-demented individuals may be associated with differential dementia risk.

FDDNP binding using MR derived cortical surface maps.

OBJECTIVES: To assess quantitatively the cortical pattern profile of regional FDDNP binding to beta-amyloid and neurofibrillary tangles on MR derived cortical maps, FDDNP PET images were corrected for movement and partial volume (PV), and optimized for kernel size. METHODS: FDDNP DVR PET images from 23 subjects (7 with Alzheimer's disease (AD), 6 with mild cognitive impairment and 10 controls) were obtained from Logan analysis using cerebellum as reference. A hemispheric cortical surface model for each subject was extracted from the MRI. The same transformations were applied to the FDDNP DVR PET images to map them into the same space. The cortical map with PV correction was calculated as the ratio of the DVR cortical surface and that of the simulated map, created from the mask derived from MRI and smoothed to the PET resolution. Discriminant analysis was used to order the FDDNP DVR cortical surfaces based on subjects' disease state. Linear regression was used to assess the rate of change of DVR vs. MMSE for each hemispheric cortical surface point. RESULTS: The FDDNP DVR cortical surface corrected for movement and PV had less hemispheric asymmetry. Optimal kernel size was determined to be 9 mm. The corrected cortical surface map of FDDNP DVR showed clear spatial pattern that was consistent with the known pathological progression of AD. CONCLUSION: Correcting for movement, PV as well as optimizing kernel size provide sensitive statistical analysis of FDDNP distribution which confirms in the living brain known pathology patterns earlier observed with cognitive decline with brain specimens.

Translocation of acyl-CoA oxidase into peroxisomes requires ATP hydrolysis but not a membrane potential.

An efficient system for the import of newly synthesized proteins into highly purified rat liver peroxisomes was reconstituted in vitro. 35S-Labeled acyl-CoA oxidase (AOx) was incorporated into peroxisomes in a proteinase K-resistant fashion. This import was specific (did not occur with mitochondria) and was dependent on temperature, time, and peroxisome concentration. Under optimal conditions approximately 30% of [35S]AOx became proteinase resistant. The import of AOx into peroxisomes could be dissociated into two steps: (a) binding occurred at 0 degrees C in the absence of ATP; (b) translocation occurred only at 26 degrees C and required the hydrolysis of ATP. GTP would not substitute for ATP and translocation was not inhibited by carbonylcyanide-m-chlorophenylhydrazone, valinomycin, or other ionophores.

Import of the carboxy-terminal portion of acyl-CoA oxidase into peroxisomes of Candida tropicalis.

We report the sequence of a cDNA clone that codes for the carboxy-terminal portion of the peroxisomal protein, acyl-CoA oxidase, from the yeast, Candida tropicalis. This is a newly identified acyl-CoA oxidase sequence, most likely a second allele of POX4. The cDNA clone was expressed by in vitro transcription followed by translation. The major product, a 43-kD protein, associated with isolated peroxisomes in an in vitro import assay. More than half of the peroxisome-associated protein was protected from added protease, implying that it was internalized within the organelle. These findings indicate that there is sufficient information in the carboxy-terminal portion of the protein to target it to peroxisomes.

Hole-burning spectroscopy and relaxation dynamics of amorphous solids at low temperatures.

The magnitude and temperature dependence of most of the properties of amorphous solids are anomalous at very low temperatures ( less, similar1 Kelvin). Phonon-assisted tunneling of a distribution of glassy bistable configurations, or two-level systems, can account for these anomalies. A unified understanding of the low-temperature properties is required for an understanding of the glassy state. Persistent nonphotochemical hole burning of impurity optical transitions allows a glass state to be produced that is thermally inaccessible to the preburn state, and that allows the probing of tunneling dynamics on time scales that range between picoseconds and days. These data combined with recently obtained distribution functions for the two-level systems offer new insights into the tunneling dynamics.

A photoinduced persistent structural transformation of the special pair of a bacterial reaction center.

Structural modification of photosynthetic reaction centers is an important approach for understanding their charge-separation processes. An unprecedented persistent structural transformation of the special pair (dimer) of bacteriochlorophyll molecules can be produced by light absorption alone. The nonphotochemical hole-burned spectra for the reaction center of Rhodopseudomonas viridis show that the phototransformation leads to a red shift of 150 wave numbers for the special pair's lowest energy absorption band, P960, and a comparable blue shift for a state at 850 nanometers, which can now be definitively assigned as being most closely associated with the upper dimer component. Additional insights on excited-state electronic structure include the identification of a new state.

Protection against mucoid Pseudomonas aeruginosa in rodent models of endobronchial infections.

Chronic endobronchial infection with mucoid Pseudomonas aeruginosa accounts for much of the morbidity and mortality in patients with cystic fibrosis (CF). Reduced morbidity is observed when infection is absent. Clinical investigations have implicated opsonizing antibody specific for the mucoid exopolysaccharide (MEP) surrounding these bacteria as a potential immunologic protective mechanism, whereas nonopsonizing antibody to MEP is not protective. Mice and rats immunized with doses of MEP that elicited opsonizing antibody had reduced levels of infection compared with nonimmune controls after intratracheal challenge with mucoid P. aeruginosa enmeshed in agar beads. Doses of MEP that elicited nonopsonizing antibody were not protective. Parallel experiments in which passive transfer of polyclonal and monoclonal opsonizing and nonopsonizing antibody were used yielded similar results. These data indicate that MEP-specific opsonizing antibody can protect against chronic P. aeruginosa infection in this model of disease.

Peroxisomal membrane ghosts in Zellweger syndrome--aberrant organelle assembly.

Peroxisomes are apparently missing in Zellweger syndrome; nevertheless, some of the integral membrane proteins of the organelle are present. Their distribution was studied by immunofluorescence microscopy. In control fibroblasts, peroxisomes appeared as small dots. In Zellweger fibroblasts, the peroxisomal membrane proteins were located in unusual empty membrane structures of larger size. These results suggest that the primary defect in this disease may be in the mechanism for import of matrix proteins.

Fluorescence-line-narrowed spectra of polycyclic aromatic carcinogen-DNA adducts.

The laser excited fluorescence-line-narrowed spectrum of DNA modified with (+/-)-r-7,t-8-dihydroxy-t-9,10-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (BPDE), the ultimate carcinogenic metabolite of benzo[a]pyrene (BP), has been obtained in a water-glycerol-ethanol glass at 4.2 K. The spectrum was well resolved and highly characteristic of the chromophore. Comparisons were made between the spectrum of this modified DNA and the isolated deoxyguanosine-BPDE adduct and a series of other 7,8,9,10-tetrahydro-BP (THBP) derivatives. 9-Hydroxy-BP 4,5-oxide, which is also involved in the binding of BP to DNA, and THBP have very similar conventional broadband fluorescence spectra. However, the fluorescence-line-narrowed spectra of their derivatives were readily distinguishable either as individual components or as mixtures.

Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer's disease in late onset families.

The apolipoprotein E type 4 allele (APOE-epsilon 4) is genetically associated with the common late onset familial and sporadic forms of Alzheimer's disease (AD). Risk for AD increased from 20% to 90% and mean age at onset decreased from 84 to 68 years with increasing number of APOE-epsilon 4 alleles in 42 families with late onset AD. Thus APOE-epsilon 4 gene dose is a major risk factor for late onset AD and, in these families, homozygosity for APOE-epsilon 4 was virtually sufficient to cause AD by age 80.

Clinical experience of patients referred to a multidisciplinary cardio-oncology clinic: an observational cohort study.

Introduction: Cardiovascular disease is the 2nd leading cause of long-term morbidity and mortality in cancer survivors. Cardio-oncology clinics (cocs) have emerged to address the issue; however, there is a paucity of data about the demographics and clinical outcomes of patients seen in the coc setting. Methods: Cancer patients referred to The Ottawa Hospital coc were included in this retrospective observational study. Data collected were patient demographics, cancer type and stage, reason for referral, cardiac risk factors, cardiac assessments and treatment, and clinical outcomes. Results: Between 2008 and 2015, 779 patients (516 women, 66%; 263 men, 34%) were referred to the coc. Median age of the patients at cancer diagnosis was 60 years (range: 18-90 years). The most frequent reasons for referral were decreased left ventricular ejection fraction (33%), pre-chemotherapy assessment (14%), and arrhythmia (14%). Treatment with cardiac medication was given in 322 patients (41%), 181 (56%) of whom received more than 2 cardiac medications, with 57 (18%) receiving an angiotensin-converting enzyme inhibitor (acei), 46 (14%) receiving an acei and a beta-blocker, and 38 (12%) receiving a beta-blocker. Of 163 breast cancer patients, 129 (79%) were able to complete targeted therapy with coc co-management. Most of the 779 patients (n = 643, 83%) were alive at the time of the last data collection. Conclusions: This cohort study is one of the largest to report characteristics and clinical outcomes of patients referred to a coc. Collaboration between oncologists and cardiologists resulted in completion of cancer therapy in most patients. Ongoing analysis of referral patterns, management plans, and patient outcomes will help to guide the cardiac care of oncology patients, ultimately optimizing cancer and cardiac outcomes alike.

Amyloid and tau imaging, neuronal losses and function in mild cognitive impairment.

OBJECTIVES: Establish new approaches for early diagnosis of dementia, based on imaging amyloid and tau pathology, cell losses and neuronal function, in subjects with mild cognitive impairment (MCI),. The overall aim is to develop effective tools for monitoring disease progression in the living patient to facilitate discovery of early therapeutic interventions to modify the course of the disease. DESIGN: Use 2-(1-{6-[(2-[F- 18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile ([F-18]FDDNP) in combination with positron emission tomography (PET) to produce dynamic images for quantification of regional cortical brain deposition in MCI patients and compare them with controls subjects and patients with Alzheimer's disease (AD). Comparison with other molecular imaging probes for neuronal losses and function were also made. SETTING: Patients are positioned supine in the tomograph bed with his/her head in the detector ring field. Upon injection of the molecular imaging probe (e.g., [F-18]FDDNP) images are obtained at very short time intervals for up to two hours. This results in dynamic sequences of brain distribution of the probe. PARTICIPANTS: Patients with clinical diagnosis of AD, MCI and control subjects. MEASUREMENTS: Subjects in the categories established above were scanned with [F-18]FDDNP-PET and quantification performed using Logan parametric graphical analysis to measure relative quantitative amyloid loads throughout the brain within patient groups. These results were compared in the same patients with cell losses in hippocampus using 4-[F-18]fluoro-N-{2-[4-(2-methoxyphenyl)- 1-piperazinyl]ethyl}-N-(2-pyridinyl)benzamide,([F-18]MPPF) and regional cerebral glucose metabolic rates using 2-deoxy-2-[F-18]fluoro-2-deoxy-D-glucose (2-[F-18]FDG). RESULTS: [F-18]FDDNP reliably follows neuropathological progression (amyloid plaques [SP]; neurofibrillary tangles [NFT]) in the living brain of AD patients and those with MCI. The distribution of [F-18]FDDNP brain cortical accumulation correlates well with behavioral measures (e.g., MMSE scores) and follows known patterns of pathological distribution observed at autopsy. We have also established conversion of controls to MCI and MCI to AD with precision and sensitivity in patients and control subjects in follow-up studies. Moreover, we have established that hemispheric cortical surface mapping of [F-18]FDDNP binding is a powerful tool for assessment and visualization of the rate of brain pathology deposition. A strong correlation of [F-18]FDDNP binding, cell losses in hippocampus and decreased glucose utilization ([F-18]FDG PET) in several neocortical regions was found in the same AD and MCI subjects. CONCLUSIONS: The combined evaluation of [F-18]FDDNP PET (targeting NFT and_SP) with neuronal losses in the hippocampus and with [F-18]FDG PET (targeting neuronal function) offers the opportunity for reliable, noninvasive detection of MCI patients at risk for AD. The approach offers a glimpse to the molecular and cellular mechanisms associated with dementia and provides a means for their assessment in the living patient. Monitoring disease progression in MCI patients demonstrates the usefulness of this imaging approach for early diagnosis and provides a means for evaluation of neuroprotective agents and drugs aimed at prevention and modification of disease progression.

Global regulatory functions of Oaf1p and Pip2p (Oaf2p), transcription factors that regulate genes encoding peroxisomal proteins in Saccharomyces cerevisiae.

Two transcription factors, Oaf1p and Pip2p (Oaf2p), are key components in the pathway by which several Saccharomyces cerevisiae genes encoding peroxisomal proteins are activated in the presence of a fatty acid such as oleate. By searching the S. cerevisiae genomic database for the consensus sequence that acts as a target for these transcription factors, we identified 40 genes that contain a putative Oaf1p-Pip2p binding site in their promoter region. Quantitative Northern analysis confirmed that the expression of 22 of the genes identified is induced by oleate and that either one or both of these transcription factors are required for the activation. In addition to known peroxisomal proteins, the regulated genes encode novel peroxisomal proteins, a mitochondrial protein, and proteins of unknown location and function. We demonstrate that Oaf1p regulates certain genes in the absence of Pip2p and that both of these transcription factors play a role in maintaining the glucose-repressed state of one gene. Furthermore, we provide evidence that the defined consensus binding site is not required for the regulation of certain oleate-responsive genes.

Alternative topogenic signals in peroxisomal citrate synthase of Saccharomyces cerevisiae.

The tripeptide serine-lysine-leucine (SKL) occurs at the carboxyl terminus of many peroxisomal proteins and serves as a peroxisomal targeting signal. Saccharomyces cerevisiae has two isozymes of citrate synthase. The peroxisomal form, encoded by CIT2, terminates in SKL, while the mitochondrial form, encoded by CIT1, begins with an amino-terminal mitochondrial signal sequence and ends in SKN. We analyzed the importance of SKL as a topogenic signal for citrate synthase, using oleate to induce peroxisomes and density gradients to fractionate organelles. Our experiments revealed that SKL was necessary for directing citrate synthase to peroxisomes. C-terminal SKL was also sufficient to target a leaderless version of mitochondrial citrate synthase to peroxisomes. Deleting this tripeptide from the CIT2 protein caused peroxisomal citrate synthase to be missorted to mitochondria. These experiments suggest that the CIT2 protein contains a cryptic mitochondrial targeting signal.

Citrate synthase encoded by the CIT2 gene of Saccharomyces cerevisiae is peroxisomal.

The product of the CIT2 gene has the tripeptide SKL at its carboxyl terminus. This amino acid sequence has been shown to act as a peroxisomal targeting signal in mammalian cells. We examined the subcellular site of this extramitochondrial citrate synthase. Cells of Saccharomyces cerevisiae were grown on oleate medium to induce peroxisome proliferation. A fraction containing membrane-enclosed vesicles and organelles was analyzed by sedimentation on density gradients. In wild-type cells, the major peak of citrate synthase activity was recovered in the mitochondrial fraction, but a second peak of activity cosedimented with peroxisomes. The peroxisomal activity, but not the mitochondrial activity, was inhibited by incubation at pH 8.1, a characteristic of the extramitochondrial citrate synthase encoded by the CIT2 gene. In a strain in which the CIT1 gene encoding mitochondrial citrate synthase had been disrupted, the major peak of citrate synthase activity was peroxisomal, and all of the activity was sensitive to incubation at pH 8.1. Yeast cells bearing a cit2 disruption were unable to mobilize stored lipids and did not form stable peroxisomes in oleate. We conclude that citrate synthase encoded by CIT2 is peroxisomal and participates in the glyoxylate cycle.