The Multidisciplinary Approach to Alzheimer's Disease and Dementia. A Narrative Review of Non-Pharmacological Treatment

Background: Alzheimer's disease (AD) and dementia are chronic diseases with progressive deterioration of cognition, function, and behavior leading to severe disability and death. The prevalence of AD and dementia is constantly increasing because of the progressive aging of the population. These conditions represent a considerable challenge to patients, their family and caregivers, and the health system, because of the considerable need for resources allocation. There is no disease modifying intervention for AD and dementia, and the symptomatic pharmacological treatments has limited efficacy and considerable side effects. Non-pharmacological treatment (NPT), which includes a wide range of approaches and techniques, may play a role in the treatment of AD and dementia.Aim: To review, with a narrative approach, current evidence on main NPTs for AD and dementia.Methods: PubMed and the Cochrane database of systematic reviews were searched for studies written in English and published from 2000 to 2018. The bibliography of the main articles was checked to detect other relevant papers.Results: The role of NPT has been largely explored in AD and dementia. The main NPT types, which were reviewed here, include exercise and motor rehabilitation, cognitive rehabilitation, NPT for behavioral and psychological symptoms of dementia, occupational therapy, psychological therapy, complementary and alternative medicine, and new technologies, including information and communication technologies, assistive technology and domotics, virtual reality, gaming, and telemedicine. We also summarized the role of NPT to address caregivers' burden.Conclusions: Although NPT is often applied in the multidisciplinary approach to AD and dementia, supporting evidence for their use is still preliminary. Some studies showed statistically significant effect of NPT on some outcomes, but their clinical significance is uncertain. Well-designed randomized controlled trials with innovative designs are needed to explore the efficacy of NPT in AD and dementia. Further studies are required to offer robust neurobiological grounds for the effect of NPT, and to examine its cost-efficacy profile in patients with dementia

Testing the performance of the imputation of MHC region in large datasets when using different reference panels

The major histocompatibility complex (MHC) contains a group of genes (~260 genes in ~4Mb) involved in several inflammatory disorders and immune response including the HLA-C gene. So far, the IPD-IMGT/HLA database reports more than 4000 different HLA-C alleles. Given the highly polymorphic nature of the gene, GWAS generally don’t study or study only a small subset of polymorphic sites of the region. Imputation procedures may help in gaining additional information on this region. However, the successful imputation of the MHC region would require a reference panel with detailed information. The main goal of this study is to investigate whether imputation procedures using appropriate reference panels may effectively increase the number of polymorphic sites of the MHC region for association with complex traits. We studied the MHC region imputation performances using 3 different reference panels (Michigan and TOPMed imputation servers): TOPMed-r2, 1000 Genomes (Phase3, v5), and the novel four-digit multi-ethnic HLA panel (v1, 2021). Here, 5 datasets with more than 1000 individuals each underwent imputation. We then focused on the imputation results of the MHC region that surround the HLA-C gene (hg19: 31234948-31241032). Imputation reported a different number of markers for the different reference panels: 482 in 1000G, 365 in TOPMed, and 1272 in HLA-panel. Of note, the HLA panels gave a higher number of imputed markers than the others. We then selected the 104 common markers imputed by all the 3 reference panels. Moreover, 162 markers were found only by 1000G panel, 194 by TOPMed, and 998 by the HLA-panel. The first preliminary comparisons showed a high concordance value for the genotype calling by the 3 different reference sets. The efficiency of the imputation was measured by the R-squared (R2) values stratifying the markers into 3 groups according to the minor allele frequency (MAF). The 104 common markers showed high R2 values (>0.96). As expected, in the other marker groups, the R2 mean values were lower for markers with MAF<0.1 (>0.65 in 1000G, 0.15-0.20 in TOPMed, >0.40 in HLA panel). In conclusion, imputation-based procedures with dedicated HLA panels can produce much more high-quality information than other general purpose reference panels for the MHC region

Dissection of HLA-C gene region to investigate its association with complex traits

The genomic region of HLA gene cluster (6p21.3) contains several highly polymorphic genes involved in the immune response and therefore, they have been previously associated to several immune and inflammatory disorders. For the present study we investigated more than 3500 known alleles of HLA-C gene (from IPD-IMGT/HLA database, genomic sequences) that are grouped into 14 serogroups (e.g., C*01:02:01:01). All the sequences have been aligned against the human genome reference sequence (both versions; hg19 and hg38). Overall, the HLA-C gene (length ~3000 bp) contains more than 1500 SNPs. We used a clustering approach to understand how the alleles are evolutionarily connected. According to the clustering analysis we observed that sequences of the same serogroup cluster together more often than sequences of other serogroups, even if with several exceptions. This confirms that alleles of the same serogroup share strong identity in their sequence. Interestingly, as general rule, we observed that the main tree presents two branches, containing each a similar structure (relative distance between serogroups). Of note, the sequences of C*07 and C*17 serogroups belonged to one of the two branches only, whereas the sequences of C*06 and C*12 serogroups were observed in the alternative branch of the tree. We are now studying what are the main features that characterize the two branches. Moreover, the study will go on by investigating the association of the HLA-C serogroup SNP-based alleles with kidney related disease (INCIPE study) and Alzheimer’s disease (NIAGADS database) in large cohorts of individuals

Rehabilitation and biomarkers of stroke recovery: study protocol for a randomized controlled trial

Background: Stroke is a leading cause of disability. Nonetheless, the care pathway for stroke rehabilitation takes partially into account the needs of chronic patients. This is due in part to the lack of evidence about the mechanisms of recovery after stroke, together with the poor knowledge of related and influencing factors. Here we report on the study protocol \u201cRehabilitation and Biomarkers of Stroke Recovery,\u201d which consists of 7 work-packages and mainly aim to investigate the effects of long-term neurorehabilitation on stroke patients and to define a related profile of (clinical-biological, imaging, neurophysiological, and genetic-molecular) biomarkers of long-term recovery after stroke. The work-package 1 will represent the main part of this protocol and aims to compare the long-term effects of intensive self-rehabilitation vs. usual (rehabilitation) care for stroke. Methods: We planned to include a total of 134 adult subacute stroke patients (no more than 3 months since onset) suffering from multidomain disability as a consequence of first-ever unilateral ischemic stroke. Eligible participants will be randomly assigned to one of the following groups: intensive self-rehabilitation (based on the principles of \u201cGuided Self-Rehabilitation Contract\u201d) vs. usual care (routine practice). Treatment will last 1 year, and patients will be evaluated every 3 months according to their clinical presentation. The following outcomes will be considered in the main work-package: Fugl-Meyer assessment, Cognitive Oxford Screen Barthel Index, structural and functional neuroimaging, cortical excitability, and motor and somatosensory evoked potentials. Discussion: This trial will deal with the effects of an intensive self-management rehabilitation protocol and a related set of biomarkers. It will also investigate the role of training intensity on long-term recovery after stroke. In addition, it will define a set of biomarkers related to post-stroke recovery and neurorehabilitation outcome in order to detect patients with greater potential and define long-term individualized rehabilitation programs. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04323501

Psychological treatments and psychotherapies in the neurorehabilitation of pain. Evidences and recommendations from the italian consensus conference on pain in neurorehabilitation

BACKGROUND: It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams. OBJECTIVES: To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases. METHODS: A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions. RESULTS: The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache. CONCLUSIONS: Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the pape

Future research directions on the "elusive" white shark

White sharks, Carcharodon carcharias, are often described as elusive, with little information available due to the logistical difficulties of studying large marine predators that make long-distance migrations across ocean basins. Increased understanding of aggregation patterns, combined with recent advances in technology have, however, facilitated a new breadth of studies revealing fresh insights into the biology and ecology of white sharks. Although we may no longer be able to refer to the white shark as a little-known, elusive species, there remain numerous key questions that warrant investigation and research focus. Although white sharks have separate populations, they seemingly share similar biological and ecological traits across their global distribution. Yet, white shark’s behavior and migratory patterns can widely differ, which makes formalizing similarities across its distribution challenging. Prioritization of research questions is important to maximize limited resources because white sharks are naturally low in abundance and play important regulatory roles in the ecosystem. Here, we consulted 43 white shark experts to identify these issues. The questions listed and developed here provide a global road map for future research on white sharks to advance progress toward key goals that are informed by the needs of the research community and resource managers

What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian consensus conference on pain in neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

New insights into the trophic ecology of the scalloped hammerhead shark, Sphyrna lewini, in the eastern tropical Pacific Ocean

Scalloped hammerhead shark, Sphyrna lewini, is considered a generalist predator, showing individual specializations and different trophic levels. This species inhabits both oceanic islands and coastal nursery areas in the eastern tropical Pacific (ETP) Ocean. Existing trophic ecology studies on S. lewini have been focused on stomach contents. This study provides new insights into its foraging preferences, habitat use, and trophic position, using stable isotope analysis (SIA) of muscle tissue. Stable isotope signatures of δC and δN were determined in S. lewini muscles (n = 29) from the Ecuadorian Pacific in 2013. Trophic position (TP), isotopic niches, and overlap of S. lewini were estimated by sex, age, and maturity stages to infer their dietary habits throughout life stages. SIA revealed complex movement patterns related to sex and age classes of S. lewini, highlighting high degrees of dietary plasticity and habitat use, with a stronger relation to coastal regions than previously reported. This study provides crucial information regarding essential areas and the related migration behavior of S. lewini, with important implications for their conservation and management in the ETP.Special thanks to the artisanal fishermen communities who supported the sampling for this project and a great acknowledgement to the Fundación Alium Pacific for logistical support and the Instituto Andaluz de Ciencias de la Tierra in Granada (CSIC-UGR), Spain, for the technical assistance in the analysis. Thanks to D. Edgar for editing our text for English. We thank the anonymous reviewers for improving the manuscript

Stable isotope evidence for movements of hammerhead sharks Sphyrna lewini, connecting two natural protected areas in the Colombian Pacific

Coastal areas are particularly important, as their shallow waters commonly correspond to nursery areas for many species. Unfortunately, these habitats also support many commercial fisheries which overlap with nursery areas and can represent a risk to numerous shark species, including Sphyrna lewini which frequent both coastal waters and offshore islands throughout their lifecycle and are affected by the high fishing activity in coastal areas, particularly during their early life stages. For this reason, it is imperative to identify and establish connectivity between key habitats during their lifecycle to improve conservation strategies. This study provides the first evidence about habitat use and migration corridors between oceanic aggregation zones and coastal areas of the Colombian Pacific, which constitute important habitats for S. lewini. A total of five S. lewini neonates were sampled in the Sanquianga National Natural Park coastal area: the individuals ranged from 48.2 to 52.8 cm in total length and were obtained by artisanal fishermen. Our δC (− 16.3 ± 0.16‰) and δN (15.9 ± 0.11‰) values were similar to those obtained from specimens from the Malpelo isospace (δC: − 16.3 ± 0.1‰ and δN: 15.9 ± 0.11‰). Our isotopic results showed significant use and connectivity between both marine environments (oceanic and coastal areas), the extent of which depended on shark maturity stages, providing evidences of the trophic links of S. lewini between Malpelo waters and the Sanquianga National Natural Park coastal area. Therefore, this study highlights the importance of both habitats in the lifecycle of S. lewini and provides preliminary inferences about S. lewini ecology and habitat preference representing a baseline for further research.We thank the Parques Nacionales Naturales de Colombia, to all teams of the Malpelo FFS, Sanquianga NNP, and Fundación Malpelo y Otros Ecosistemas Marinos for their support in collecting the samples and to the Fundación Alium Pacific for logistical support and the Instituto Andaluz de Ciencias de la Tierra in Granada (CSIC-UGR), Spain, for technical assistance in the analysis. We are especially thankful to the fishing communities who supported the sampling for this project. We would also like to thank the anonymous reviewers for their comments, which improved the manuscript. Thanks go to Daniel Edgar for editing the text for English

Stable isotopic inferences on trophic ecology and habitat use of brown smooth-hound Mustelus henlei in the west coast of Baja California Sur, Mexico

The brown smoothhound shark Mustelus henlei is the most important shark species in the artisanal fisheries of the western coast of Baja California Sur, Mexico. Its trophic ecology was analyzed using carbon (C) and nitrogen (N) stable isotope analysis in the muscle tissue. The values of δC (−18.2 ± 0.6 ‰) and δN (17.7 ± 0.9 ‰) suggest that this species feeds in the Gulf of Ulloa throughout the year. The low values of δC indicate that the sharks feed in oceanic zones; while the δN values suggest that these sharks feed on prey that occupy a high trophic level and/or from a trophic chain with an enriched basal signal. The δC and δN values of this species do not present significant statistical differences between sexes and size. This study provides new insights regarding the habitat use of M. henlei, characterizing its preference for oceanic zones.GM, AJMR, FREV, ATV, and LAM thank the Instituto Politécnico Nacional for the fellowships provided (COFFA, EDI) Mexico. To project CONACYT, Mexico 25370 and Instituto Politécnico Nacional, Mexico grants SIP20181417, SIP20195126 and SIP20196736. We thank two anonymous reviewers for the observations and comments in order to improve the manuscript