Cerebral changes and disrupted gray-matter cortical networks in asymptomatic older adults at risk for Alzheimer's disease

The diagnostic value of cerebrospinal fluid (CSF) biomarkers is well established in Alzheimer's disease, but our current knowledge about how abnormal CSF levels affect cerebral integrity, at local and network levels, is incomplete in asymptomatic older adults. Here, we have collected CSF samples and performed structural magnetic resonance imaging scans in cognitively normal elderly as part of a cross-sectional multicenter study (SIGNAL project). To identify group differences in cortical thickness, white matter volume, and properties of structural networks, participants were split into controls (N = 20), positive amyloid-? (A?1?42 +) (N = 19), and positive phosphorylated tau (N = 18). The A?1?42 + group exhibited thickening of middle temporal regions, while positive phosphorylated tau individuals showed thinning in the superior parietal and orbitofrontal cortices. Subjects with abnormal CSF biomarkers further showed regional white matter atrophy and more segregated cortical networks, the A?1?42 + group showing heightened isolation of cingulate and temporal cortices. Collectively, these findings highlight the relevance of combining structural brain imaging and connectomics for in vivo tracking of Alzheimer's disease lesions in asymptomatic stages.This work was supported by research grants from the Spanish Ministry of Economy and Competitiveness (SAF2011-25463 to J.L.C., PSI2014-55747-R to M.A.), the Carlos III Institute of Health, Spain (PI11/02425 and PI14/01126 to J.F.; PI11/3035 and PI14/1561 to A.L.; PI08/0139, PI12/02288 and PI16/01652 to P.S.J.), jointly funded by Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, “Una manera de hacer Europa”, the Joint Programming in Neurodegenerative Disease Research (DEMTEST to P.S.J.), “Marató TV3” (project 20141210 to J.F. and 20142610 to A.L.), the Regional Ministry of Innovation, Science and Enterprise, Junta de Andalucia (P12- CTS-2327 to J.C.L.), and the CIBERNED program (Signal project)

Obesity impacts brain metabolism and structure independently of amyloid and tau pathology in healthy elderly

Altres ajuts: This study was supported by [...], and the CIBERNED program (Program 1, Alzheimer Disease to Alberto Lleó and SIGNAL study, www.signalstudy.es); and partly jointly funded by Fondo Europeo de Desarrollo Regional, Unión Europea, Una manera de hacer Europa. This work was also supported by the National Institutes of Health (NIA grants 1R01AG056850 - 01A1; R21AG056974, and R01AG061566 to Juan Fortea), Fundació La Marató de TV3 (20141210 to Juan Fortea, 044412 to Amanda Jiménez and Rafael Blesa). This work was also supported by [...] and a grant from the Fundació Bancaria La Caixa to Rafael Blesa. The work of Adriana Pané is supported by the " Ajut a la Recerca Josep Font" (Hospital Clinic de Barcelona). Data collection and sharing for this project was funded by the Alzheimer's Disease Neuroimaging Initiative (ADNI) (National Institutes of Health Grant U01 AG024904) and DOD ADNI (Department of Defense award number W81XWH-12-2-0012). [...]. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health (www.fnih.org).Midlife obesity is a risk factor for dementia. We investigated the impact of obesity on brain structure, metabolism, and cerebrospinal fluid (CSF) core Alzheimer's disease (AD) biomarkers in healthy elderly. We selected controls from ADNI2 with CSF AD biomarkers and/or fluorodeoxyglucose positron emission tomography (FDG-PET) and 3T-MRI. We measured cortical thickness, FDG uptake, and CSF amyloid beta (Aβ)1-42, p-tau, and t-tau levels. We performed regression analyses between these biomarkers and body mass index (BMI). We included 201 individuals (mean age 73.5 years, mean BMI 27.4 kg/m 2). Higher BMI was related to less cortical thickness and higher metabolism in brain areas typically not involved in AD (family-wise error [FWE] <0.05), but not to AD CSF biomarkers. It is notable that the impact of obesity on brain metabolism and structure was also found in amyloid negative individuals. In the cognitively unimpaired elderly, obesity has differential effects on brain metabolism and structure independent of an underlying AD pathophysiology

The Sant Pau Initiative on Neurodegeneration (SPIN) cohort : A data set for biomarker discovery and validation in neurodegenerative disorders

Altres ajuts: The SPIN cohort has received funding from CIBERNED; Instituto de Salud Carlos III; jointly funded by Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, "Una manera de hacer Europa"; Generalitat de Catalunya; Fundació "La Marató TV3" Fundació Bancària Obra Social La Caixa; Fundación BBVA; Fundación Española para el Fomento de la Investigación de la Esclerosis Lateral Amiotrófica (FUNDELA); Global Brain Health Institute; Fundació Catalana Síndrome de Down; and Fundació Víctor Grífols i Lucas. These funding sources had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.The SPIN (Sant Pau Initiative on Neurodegeneration) cohort is a multimodal biomarker platform designed for neurodegenerative disease research following an integrative approach. Participants of the SPIN cohort provide informed consent to donate blood and cerebrospinal fluid samples, receive detailed neurological and neuropsychological evaluations, and undergo a structural 3T brain MRI scan. A subset also undergoes other functional or imaging studies (video-polysomnogram, 18 F-fluorodeoxyglucose PET, amyloid PET, Tau PET). Participants are followed annually for a minimum of 4 years, with repeated cerebrospinal fluid collection and imaging studies performed every other year, and brain donation is encouraged. The integration of clinical, neuropsychological, genetic, biochemical, imaging, and neuropathological information and the harmonization of protocols under the same umbrella allows the discovery and validation of key biomarkers across several neurodegenerative diseases. We describe our particular 10-year experience and how different research projects were unified under an umbrella biomarker program, which might be of help to other research teams pursuing similar approaches

Obesity impacts brain metabolism and structure independently of amyloid and tau pathology in healthy elderly

Aims/hypothesis: Midlife obesity is a risk factor for dementia. We investigated the impact of obesity on brain structure, metabolism, and cerebrospinal fluid (CSF) core Alzheimer's disease (AD) biomarkers in healthy elderly. Methods: We selected controls from ADNI2 with CSF AD biomarkers and/or fluorodeoxyglucose positron emission tomography (FDG-PET) and 3T-MRI. We measured cortical thickness, FDG uptake, and CSF amyloid beta (Aβ)1-42, p-tau, and t-tau levels. We performed regression analyses between these biomarkers and body mass index (BMI). Results: We included 201 individuals (mean age 73.5 years, mean BMI 27.4 kg/m2). Higher BMI was related to less cortical thickness and higher metabolism in brain areas typically not involved in AD (family-wise error [FWE] <0.05), but not to AD CSF biomarkers. It is notable that the impact of obesity on brain metabolism and structure was also found in amyloid negative individuals. Conclusions/interpretation: In the cognitively unimpaired elderly, obesity has differential effects on brain metabolism and structure independent of an underlying AD pathophysiology

Motor cortex transcriptome reveals microglial key events in amyotrophic lateral sclerosis

Altres ajuts: PERIS program SLT006/17/125 to D.A.To identify transcriptomic changes, neuropathologic correlates, and cellular subpopulations in the motor cortex of sporadic amyotrophic lateral sclerosis (ALS). We performed massive RNA sequencing of the motor cortex of patients with ALS (n = 11) and healthy controls (HCs; n = 8) and analyzed gene expression alterations, differential isoform usage, and gene coexpression networks. Furthermore, we used cell type deconvolution algorithms with human single-nucleus RNA sequencing data as reference to identify perturbations in cell type composition associated with ALS. We performed immunohistochemical techniques to evaluate neuropathologic changes in this brain region. We report extensive RNA expression alterations at gene and isoform levels, characterized by the enrichment of neuroinflammatory and synaptic-related pathways. The assembly of gene coexpression modules confirmed the involvement of these 2 major transcriptomic changes, which also showed opposite directions related to the disease. Cell type deconvolution revealed an overrepresentation of microglial cells in ALS compared with HC. Notably, microgliosis was driven by a subcellular population presenting a gene expression signature overlapping with the recently described disease-associated microglia (DAM). Using immunohistochemistry, we further evidenced that this microglial subpopulation is overrepresented in ALS and that the density of pTDP43 aggregates negatively correlates with the proportion of microglial cells. DAM has a central role in microglia-related neuroinflammatory changes in the motor cortex of patients with ALS, and these alterations are coupled with a reduced expression of postsynaptic transcripts

Obesity impacts brain metabolism and structure independently of amyloid and tau pathology in healthy elderly

Altres ajuts: This study was supported by [...], and the CIBERNED program (Program 1, Alzheimer Disease to Alberto Lleó and SIGNAL study, www.signalstudy.es); and partly jointly funded by Fondo Europeo de Desarrollo Regional, Unión Europea, Una manera de hacer Europa. This work was also supported by the National Institutes of Health (NIA grants 1R01AG056850 - 01A1; R21AG056974, and R01AG061566 to Juan Fortea), Fundació La Marató de TV3 (20141210 to Juan Fortea, 044412 to Amanda Jiménez and Rafael Blesa). This work was also supported by [...] and a grant from the Fundació Bancaria La Caixa to Rafael Blesa. The work of Adriana Pané is supported by the " Ajut a la Recerca Josep Font" (Hospital Clinic de Barcelona). Data collection and sharing for this project was funded by the Alzheimer's Disease Neuroimaging Initiative (ADNI) (National Institutes of Health Grant U01 AG024904) and DOD ADNI (Department of Defense award number W81XWH-12-2-0012). [...]. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health (www.fnih.org).Midlife obesity is a risk factor for dementia. We investigated the impact of obesity on brain structure, metabolism, and cerebrospinal fluid (CSF) core Alzheimer's disease (AD) biomarkers in healthy elderly. We selected controls from ADNI2 with CSF AD biomarkers and/or fluorodeoxyglucose positron emission tomography (FDG-PET) and 3T-MRI. We measured cortical thickness, FDG uptake, and CSF amyloid beta (Aβ)1-42, p-tau, and t-tau levels. We performed regression analyses between these biomarkers and body mass index (BMI). We included 201 individuals (mean age 73.5 years, mean BMI 27.4 kg/m 2). Higher BMI was related to less cortical thickness and higher metabolism in brain areas typically not involved in AD (family-wise error [FWE] <0.05), but not to AD CSF biomarkers. It is notable that the impact of obesity on brain metabolism and structure was also found in amyloid negative individuals. In the cognitively unimpaired elderly, obesity has differential effects on brain metabolism and structure independent of an underlying AD pathophysiology

Diagnostic Accuracy of Magnetic Resonance Imaging Measures of Brain Atrophy Across the Spectrum of Progressive Supranuclear Palsy and Corticobasal Degeneration

Altres ajuts: Global Brain Health Institute (GBHI), Alzheimer's Association, and Alzheimer's Society (GBHI ALZ UK-21-720973, AACSF-21-850193); NIH grants (AG019724, AG032306, AG045390, NS092089, AG045333, AG056749, AG062422, K24AG053435, K08AG052648, R01AG059794, R01AG056850-01A1, R21AG056974, R01AG061566, K23AG059888); Fondo de Investigaciones Sanitario; Centro de Investigación en Red-Enfermedades Neurodegenerativas program (Program 1, Alzheimer Disease); Fondo Europeo de Desarrollo Regional, Unión Europea, una manera de hacer Europa; La Marató de TV3 (20141210); Generalitat de Catalunya; Banco Bilbao Vizcaya Argentaria foundation.Importance: The accurate diagnosis of progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) is hampered by imperfect clinical-pathological correlations. Objective: To assess and compare the diagnostic value of the magnetic resonance parkinsonism index (MRPI) and other magnetic resonance imaging-based measures of cerebral atrophy to differentiate between PSP, CBD, and other neurodegenerative diseases. Design, Setting, and Participants: This prospective diagnostic study included participants with 4-repeat tauopathies (4RT), PSP, CBD, other neurodegenerative diseases and available MRI who appeared in the University of California, San Francisco, Memory and Aging Center database. Data were collected from October 27, 1994, to September 29, 2019. Data were analyzed from March 1 to September 14, 2021. Main Outcomes and Measures: The main outcome of this study was the neuropathological diagnosis of PSP or CBD. The clinical diagnosis at the time of the MRI acquisition was noted. The imaging measures included the MRPI, cortical thickness, subcortical volumes, including the midbrain, pons, and superior cerebellar peduncle volumes. Multinomial logistic regression models (MLRM) combining different cortical and subcortical regions were defined to discriminate between PSP, CBD, and other pathologies. The areas under the receiver operating characteristic curves (AUROC) and cutoffs were calculated to differentiate between PSP, CBD, and other diseases. Results: Of the 326 included participants, 176 (54%) were male, and the mean (SD) age at MRI was 64.1 (8.0) years. The MRPI showed good diagnostic accuracy for the differentiation between PSP and all other pathologies (accuracy, 87%; AUROC, 0.90; 95% CI, 0.86-0.95) and between 4RT and other pathologies (accuracy, 80%; AUROC, 0.82; 95% CI, 0.76-0.87), but did not allow the discrimination of participants with CBD. Its diagnostic accuracy was lower in the subgroup of patients without the canonical PSP-Richardson syndrome (PSP-RS) or probable corticobasal syndrome (CBS) at MRI. MLRM combining cortical and subcortical measurements showed the highest accuracy for the differentiation between PSP and other pathologies (accuracy, 95%; AUROC, 0.98; 95% CI, 0.97-0.99), CBD and other pathologies (accuracy, 83%; AUROC, 0.86; 95% CI, 0.81-0.91), 4RT and other pathologies (accuracy, 89%; AUROC, 0.94; 95% CI, 0.92-0.97), and PSP and CBD (accuracy, 91%; AUROC, 0.95; 95% CI, 0.91-0.99), even in participants without PSP-RS or CBS at MRI. Conclusions and Relevance: In this study, the combination of widely available cortical and subcortical measures of atrophy on MRI discriminated between PSP, CBD, and other pathologies and could be used to support the diagnosis of 4RT in clinical practice

Association of Apolipoprotein E ɛ4 allele with clinical and multimodal biomarker changes of Alzheimer Disease in adults with Down syndrome

Importance: Alzheimer disease (AD) is the leading cause of death in individuals with Down syndrome (DS). Previous studies have suggested that the APOE ɛ4 allele plays a role in the risk and age at onset of dementia in DS; however, data on in vivo biomarkers remain scarce. Objective: To investigate the association of the APOE ɛ4 allele with clinical and multimodal biomarkers of AD in adults with DS. Design, setting, and participants: This dual-center cohort study recruited adults with DS in Barcelona, Spain, and in Cambridge, UK, between June 1, 2009, and February 28, 2020. Included individuals had been genotyped for APOE and had at least 1 clinical or AD biomarker measurement; 2 individuals were excluded because of the absence of trisomy 21. Participants were either APOE ɛ4 allele carriers or noncarriers. Main outcomes and measures: Participants underwent a neurological and neuropsychological assessment. A subset of participants had biomarker measurements: Aβ1-42, Aβ1-40, phosphorylated tau 181 (pTau181) and neurofilament light chain (NfL) in cerebrospinal fluid (CSF), pTau181, and NfL in plasma; amyloid positron emission tomography (PET); fluorine 18-labeled-fluorodeoxyglucose PET; and/or magnetic resonance imaging. Age at symptom onset was compared between APOE ɛ4 allele carriers and noncarriers, and within-group local regression models were used to compare the association of biomarkers with age. Voxelwise analyses were performed to assess topographical differences in gray matter metabolism and volume. Results: Of the 464 adults with DS included in the study, 97 (20.9%) were APOE ɛ4 allele carriers and 367 (79.1%) were noncarriers. No differences between the 2 groups were found by age (median [interquartile range], 45.9 [36.4-50.2] years vs 43.7 [34.9-50.2] years; P = .56) or sex (51 male carriers [52.6%] vs 199 male noncarriers [54.2%]). APOE ɛ4 allele carriers compared with noncarriers presented with AD symptoms at a younger age (mean [SD] age, 50.7 [4.4] years vs 52.7 [5.8] years; P = .02) and showed earlier cognitive decline. Locally estimated scatterplot smoothing curves further showed between-group differences in biomarker trajectories with age as reflected by nonoverlapping CIs. Specifically, carriers showed lower levels of the CSF Aβ1-42 to Aβ1-40 ratio until age 40 years, earlier increases in amyloid PET and plasma pTau181, and earlier loss of cortical metabolism and hippocampal volume. No differences were found in NfL biomarkers or CSF total tau and pTau181. Voxelwise analyses showed lower metabolism in subcortical and parieto-occipital structures and lower medial temporal volume in APOE ɛ4 allele carriers. Conclusions and relevance: In this study, the APOE ɛ4 allele was associated with earlier clinical and biomarker changes of AD in DS. These results provide insights into the mechanisms by which APOE increases the risk of AD, emphasizing the importance of APOE genotype for future clinical trials in DS.This study was funded in part by the Fondo de Investigaciones Sanitario; Instituto de Salud Carlos III (grants PI14/01126 and PI17/01019 to Dr Fortea, grants PI13/01532 and PI16/01825 to Dr Blesa, grant PI18/00335 to Dr Carmona-Iragui, grants PI18/00435 and INT19/00016 to Dr Alcolea, grant PI18/00327 to Dr Belbin, and grants PI14/1561 and PI17/01896 to Dr Lleó); Center of Biomedical Investigation Network for Neurodegenerative Diseases (CIBERNED) Program 1, Alzheimer Disease (Dr Lleó) and SIGNAL study, which was partly jointly funded by Fondo Europeo de Desarrollo Regional, Unión Europea, and Una Manera de Hacer Europa; National Institutes of Health (NIH; grants 1R01AG056850-01A1, R21AG056974, and R01AG061566 to Dr Fortea); Departament de Salut de la Generalitat de Catalunya, Pla Estratègic de Recerca i Innovació en Salut (grant SLT002/16/00408 to Dr Lleó); Fundació La Marató de TV3 (grant 20141210 to Dr Fortea and grant 044412 to Dr Blesa); Fundació Catalana Síndrome de Down and Fundació Víctor Grífols i Lucas (Dr Fortea); Generalitat de Catalunya (grant SLT006/17/00119 to Dr Fortea, grant SLT006/17/95 to Dr Vilaplana, and grant SLT006/17/00125 to Dr Alcolea); Fundació Bancaria La Caixa to Dr Blesa; NIHR Cambridge Biomedical Research Centre; NIHR Collaborations in Leadership for Applied Health Research and Care (CLAHRC) for the East of England; NIHR Cambridge Dementia Biomedical Research Unit; Down Syndrome Association; and the Health Foundation. Dr Bejanin was supported by a Juan de la Cierva Incorporación grant (IJCI-2017-32609) from the Spanish Ministry of Economy and Competitiveness and by a Miguel Servet I grant (CP20/00038) from the Carlos III Health Institute. Dr Iulita was supported by the Jérôme Lejeune Foundation and Sisley D’Ornano Foundations. Dr Estellés was supported by grant CM19/00017 from Pío del Río Hortega. Dr Padilla was supported as a Sara Borrell Postdoctoral Fellow (CD20/00133) at the Carlos III Health Institute. Dr Illán-Gala was supported by a Juan Rodés contract (JR21-00018) and the Pilot Award for Global Brain Health Leaders (GBHI ALZ UK-21-720973). Dr Belbin was supported by a Miguel Servet II grant (CP18/00011). Dr Osorio was supported by grants R01AG056031, R01AG056531, R01AG066870, and R21AG067549 from the NIH and grant 98480 from the Medical Research Council. Dr Lehmann was supported by grants from the Programme Hospitalier de Recherche Clinique National program, grant NeuroMET2 #18HLT09 from the European Union (EU) European Metrology Programme for Innovation and Research, and the Marie Skłodowska-Curie grant agreement 860197 from the EU Horizon 2020 research and innovation programme. Dr Holland was supported by CLAHRC for the East of England at Cambridgeshire and Peterborough NHS Foundation Trust. Dr Zetterberg was supported by grant 2018-02532 from the Swedish Research Council; grant 681712 from the European Research Council; grant ALFGBG-720931 from the Swedish State Support for Clinical Research; grant 201809-2016862 from the Alzheimer Drug Discovery Foundation (ADDF); grants ADSF-21-831376-C, ADSF-21-831381-C, and ADSF-21-831377-C from the Alzheimer’s Strategic Fund and the Alzheimer's Association; Olav Thon Foundation; Erling-Persson Family Foundation; grant FO2019-0228 from the Stiftelsen för Gamla Tjänarinnor, Hjärnfonden, Sweden; the Marie Skłodowska-Curie grant agreement 860197 from the EU Horizon 2020 research and innovation programme; and the UK Dementia Research Institute at UCL. Dr Blennow was supported by grant 2017-00915 from the Swedish Research Council; grant RDAPB-201809-2016615 from the ADDF; grant AF-742881 from the Swedish Alzheimer Foundation; grant FO2017-0243 from Hjärnfonden, Sweden, the Swedish state under the agreement between the Swedish government and the County Councils; grant ALFGBG-715986 from the ALF agreement; and grant JPND2019-466-236 from the EU Joint Program for Neurodegenerative Disorders. Dr Zaman was supported by CLAHRC for the East of England at Cambridgeshire and Peterborough NHS Foundation Trust and grant 98480 from the Medical Research Council. Dr Fortea was supported by grants from the Jérome Lejeune Foundation

Clinical and biomarker changes of Alzheimer's disease in adults with Down syndrome : a cross-sectional study

Altres ajuts: Instituto de Salud Carlos III, Fundació Bancaria La Caixa, Fundació La Marató de TV3, Medical Research Council, and National Institutes of Health.Alzheimer's disease and its complications are the leading cause of death in adults with Down syndrome. Studies have assessed Alzheimer's disease in individuals with Down syndrome, but the natural history of biomarker changes in Down syndrome has not been established. We characterised the order and timing of changes in biomarkers of Alzheimer's disease in a population of adults with Down syndrome. We did a dual-centre cross-sectional study of adults with Down syndrome recruited through a population-based health plan in Barcelona (Spain) and through services for people with intellectual disabilities in Cambridge (UK). Cognitive impairment in participants with Down syndrome was classified with the Cambridge Cognitive Examination for Older Adults with Down Syndrome (CAMCOG-DS). Only participants with mild or moderate disability were included who had at least one of the following Alzheimer's disease measures: apolipoprotein E allele carrier status; plasma concentrations of amyloid β peptides 1-42 and 1-40 and their ratio (Aβ), total tau protein, and neurofilament light chain (NFL); tau phosphorylated at threonine 181 (p-tau), and NFL in cerebrospinal fluid (CSF); and one or more of PET with 18 F-fluorodeoxyglucose, PET with amyloid tracers, and MRI. Cognitively healthy euploid controls aged up to 75 years who had no biomarker abnormalities were recruited from the Sant Pau Initiative on Neurodegeneration. We used a first-order locally estimated scatterplot smoothing curve to determine the order and age at onset of the biomarker changes, and the lowest ages at the divergence with 95% CIs are also reported where appropriate. Between Feb 1, 2013, and June 28, 2019 (Barcelona), and between June 1, 2009, and Dec 31, 2014 (Cambridge), we included 388 participants with Down syndrome (257 [66%] asymptomatic, 48 [12%] with prodromal Alzheimer's disease, and 83 [21%] with Alzheimer's disease dementia) and 242 euploid controls. CSF Aβ and plasma NFL values changed in individuals with Down syndrome as early as the third decade of life, and amyloid PET uptake changed in the fourth decade. 18 F-fluorodeoxyglucose PET and CSF p-tau changes occurred later in the fourth decade of life, followed by hippocampal atrophy and changes in cognition in the fifth decade of life. Prodromal Alzheimer's disease was diagnosed at a median age of 50·2 years (IQR 47·5-54·1), and Alzheimer's disease dementia at 53·7 years (49·5-57·2). Symptomatic Alzheimer's disease prevalence increased with age in individuals with Down syndrome, reaching 90-100% in the seventh decade of life. Alzheimer's disease in individuals with Down syndrome has a long preclinical phase in which biomarkers follow a predictable order of changes over more than two decades. The similarities with sporadic and autosomal dominant Alzheimer's disease and the prevalence of Down syndrome make this population a suitable target for Alzheimer's disease preventive treatments. Instituto de Salud Carlos III, Fundació Bancaria La Caixa, Fundació La Marató de TV3, Medical Research Council, and National Institutes of Health