Progressive Age-Associated Blood-Brain Barrier Leak/Dysfunction-Nexus of Neurodegenerative Disease Using MRI Markers to Identify Preclinical Disease and Potential New Targets for Future Treatments

This review article focuses on the upstream pertinent pathophysiology leading to neurodegenerative disease. Specifically, the nexus appears to be blood-brain barrier (BBB) leakiness resulting in a two-prong inflammatory disease spectrum damaging the microvasculature and corrupting protein synthesis and degradation with accumulating misfolded toxic proteins. The suboptimal results of removing misfolded proteins mean a new approach to disease in the preclinical state is required aimed at other targets. Validated noninvasive imaging and serologic biomarkers of early preclinical disease implemented in the high-risk patient cohort along with periodic surveillance once effective treatments are developed will be required. This review discusses the physiology and pathophysiology of the BBB, new MRI imaging techniques identifying the leak, and altered fluid dynamic effects in the preclinical state. The risk factors for disease development, preventative measures, and potential treatment targets are also discussed.

Identifying delay in glymphatic clearance of labeled protons post-acute head trauma utilizing 3D ASL MRI (arterial spin labeling): a pilot study

This study correlated mild traumatic brain injury (mTBI) cognitive changes with ASL-MRI glymphatic clearance rates (GCRs) and recovery with GCR improvement. mTBI disrupts the blood brain barrier (BBB), reducing capillary mean transit time and GCRs. mTBI is clinically diagnosed utilizing history/examination findings with no physiologic biomarkers. 3D TGSE (turbo-gradient spin-echo) pulsed arterial spin-labeling 3T MRI with 7 long inversion times (TIs) assessed the signal clearance of labeled protons 2800-4000 ms postlabeling in bifrontal, bitemporal, and biparietal regions within 7 days of mTBI and once clinically cleared to resume activities. The Sport Concussion Assessment Tool Version 5 (SKAT5) and Brief Oculomotor/Vestibular Assessment evaluated injured athletes' cognitive function prior to MRIs. The pilot study demonstrated significant GCRs improvement (95% CI - 0.06 to - 0.03 acute phase; to CI-recovery CI 0.0772 to - 0.0497; P < 0.001 in frontal lobes; and parietal lobes (95% CI - 0.0584 to - 0.0251 acute; CI - 0.0727 to - 0.0392 recovery; P = 0.024) in 9 mTBI athletes (8 female, 1 male). Six age/activity-matched controls (4 females, 2 males) were also compared. mTBI disrupts the BBB, reducing GCR measured using the 3D ASL MRI technique. ASL MRI is a potential noninvasive biomarker of mTBI and subsequent recovery.

Utilizing Reduced Labeled Proton Clearance to Identify Preclinical Alzheimer Disease with 3D ASL MRI

Addressing the seminal pathophysiology in Alzheimer disease (AD) is the next logical focus for effective intervention, given the initial disappointing and more recent possibly encouraging results of monoclonal antibody trials. Endothelial cell dysfunction-induced blood-brain barrier leak with associated prolonged capillary mean transit time (cMTT) and glymphatic outflow dysfunction is the most proximal events in the degeneration cascade. Sensitive and reproducible markers are required to both identify early disease and assess future treatment trial outcomes. Two participants, with mild cognitive impairment (MCI) and one with AD, were evaluated clinically prior to MRI in this small case series report. From seven 3D turbo gradient and spin echo (TGSE) pulsed arterial spin echo (PASL) MRI sequences six homologous region of interest in bitemporal, bifrontal, and biparietal lobes for each sequence were examined and plotted against time. By choosing late perfusion times during cMTT phase of perfusion linear analysis of signal decay could be utilized. A reference axial FLAIR sequence was also obtained. Slope of the linear analysis correlated to the rate of labeled proton clearance with reduced clearance occurring in AD participants compared to normal participants in our previous study. Whether similar differences in clearance rate extend to either MCI or early AD was investigated. Participants were categorized by clinical phenotype before MRI and compared to previously published phenotype cohorts: n = 18 normal/healthy, n = 6 AD, n = 3 MCI. Significant differences in labeled proton clearance rates between AD and MCI/control phenotypes within bilateral temporal lobes (left p = 0.004, right p = 0.002) and within bilateral frontal lobes AD versus controls (left p = 0.001, right p = 0.008) and AD versus MCI (left p = 0.001, right p = 0.001) were found. This noninvasive MRI technique has potential for identifying MCI transition to AD.

Utilizing timed categorical recall (naming US cities) for rapid bedside dementia screening

The availability of fast validated screening for dementia is a critical clinical need to improve neurologic examination time efficiency. This study validated a 1-minute timed categorical recall (TCR) method, naming as many US cities as possible and compared TCR to the Folstein Minimental Status Exam (MMSE) as a preliminary cognitive screening tool. Random uncompensated 349 volunteers were recruited ages 18 to 97 from local free clinics, retirement homes, university faculty, and students in Lynchburg, Virginia 2015 to 2020. Participants' demographic and medical information were collected. After 1 minute preparation, participants were rapidly named as many US cities as possible until they were told to stop (1 minute). The time limitation was withheld in advance. Number of cities and organizational strategies were recorded. Folstein MMSE administration immediately after TCR was administered to 122 subjects recruited in the final 2 study years as a comparison benchmark. A multiple linear regression model and a regression tree model were used to identify important variables for the number of cities named and determine subgroups and their thresholds. TCR resulted in accuracy rate (0.80), sensitivity (0.78), and specificity (0.81). The global TCR threshold (9 cities named) is superseded by 4 subgroup thresholds, categorized by statistically important variables (age, education level, and number of states visited) as follows: For those visiting ≥8 states and 1. 18 to 71 ages with a master's degree or above, the threshold was naming 20 cities; 2. 18 to 29 ages with a bachelor's degree or below, the threshold was naming 17 cities; 3. 30 to 71 ages with a bachelor's degree or below, the threshold was naming 10 cities. For those visiting <8 states or for ages 72 to 97 (regardless of education levels and number of states visited), the threshold was naming 8 cities. American cities are common knowledge across ages and backgrounds, making it a useful bedside screen for dementia. In clinical practice, patients who report fewer cities than the threshold of 9 cities should receive further cognitive testing. If the patient meets the criteria for a subgroup, then the higher subgroup thresholds apply. TCR is a more time-efficient preliminary dementia screening tool with improved sensitivity and similar specificity compared with MMSE.

Integrated Osteopathic-Neurologic Examinations With Musculoskeletal Treatment: The ONE Approach

The global burden of neurologic disorders is a leading cause of disability and death worldwide and has increased the demand for treatments and rehabilitation. Our proposed integrated osteopathic-neurologic examination (ONE) provides the physician with expanded diagnostic and point-of-care treatment modalities while allowing the physician to make a more tangible effect in patient care. By incorporating the osteopathic structural somatic examination with the complete neurologic evaluation, somatic dysfunction, occurring as a consequence or independent of neurologic injury, can be identified and treated using osteopathic manipulative techniques at time of visit. Using the proposed integrated examination, the physician can determine the interplay between structural and neurologic findings to identify patterns of change that coincide with more specific diagnoses and the chronicity of a condition. Tangible benefits from the ONE approach translate to more accurate clinical assessment and enhanced patient and physician satisfaction.

Novel MRI Techniques Identifying Vascular Leak and Paravascular Flow Reduction in Early Alzheimer Disease

With beta amyloid and tau antibody treatment trial failures, avenues directed to other facets of the disease pathophysiology are being explored to treat in the preclinical or early clinical state. Clear evidence of blood–brain barrier (BBB) breakdown occurring early in the AD process has recently been established. Likewise, the glymphatic system regulating water and solute inflow and outflow in parallel with the vascular system is affected causing delayed clearance of fluid waste. Its dysfunction as a component of AD along with BBB leak are reasonable candidates to explore for future treatments. Ideally, human medication trials require a minimally invasive method of quantifying both improvements in BBB integrity and glymphatic fluid clearance correlated with clinical outcomes. We will review the known physiology and anatomy of the BBB system, and its relationship to the glymphatic system and the microglial surveillance system. Dysfunction of this tripart system occurring in preclinical Alzheimer disease (AD) will be reviewed along with existing MRI tools for identifying altered flow dynamics useful for monitoring improved functionality with future treatments. High-resolution dynamic contrast enhanced MRI imaging demonstrating BBB leak and the recently reported non-invasive 3D PASL MRI pilot study demonstrating significant delay in glymphatic clearance in AD subjects appear to be the best candidates.

Rhinovirus 3C protease catalyzes efficient cleavage of a fluorescein-labeled peptide affording a rapid and robust assay

The 3C protease encoded by human rhinovirus type 2 catalyzes with equal efficiency cleavage of a peptide substrate with or without a fluorescein label attached to the amino acid at the P7' position. Substrates Ac-MEALFQGPLQYKDL-NH2 and MEALFQGPLQYKE(fluorescein)L are hydrolyzed with values of Vmax/KM of 970 M-1 s-1 and 1100 M-1 s-1, respectively. With the labeled substrate, HPLC achieves separation of substrate and product in 2.5 min. Separation in as little as 12 s is feasible. Fluorescein was derivatized so that it could be incorporated into peptides using automated solid-phase peptide synthesis.

Mitochondrial acetyl-CoA carboxylase. Time course of mobilization/activation in liver of refed rats

Fasted (48 h) rats were killed at 0, 2, 4, 6, 8, 12, 16, 20 and 24 h after they were refed on a high-carbohydrate diet. An increase in the maximal activity and quantity of cystolic acetyl-CoA carboxylase was found in liver of refed rats after a lag time of about 8 h. The increased quantity of cytosolic enzyme was attributable primarily to mobilization of mitochondrial storage forms and not to substantial increase in the rate of synthesis of acetyl-CoA carboxylase.

Sex effects on free recall of transforming orally and visually presented nouns into printed, picture, or imagery form

Two experiments using male and female college students studied the effects on free recall of transforming auditory and visual stimuli by imagination or penciling. Experiment 1 (N = 152) presented nouns either auditorily by a tape recorder or visually as printed words, and Ss either drew them as pictures or printed them as words. Significantly more items were recalled as a result of drawing pictures during the presentation of stimuli (p less than .001). Female Ss recalled significantly more items than male Ss (p less than .01). There was no significant difference found between auditory or visual presentation. The procedure in Experiment 2 (N = 112) was similar, except that Ss transformed the nouns by imagination or penciling. Results were similar to those of Experiment 1. There was no significant difference between imagery and penciling.

Effects on free recall and recognition of transforming visually presented words and pictures into trace or imagery form

The effects on free recall and recognition of transforming visually presented words and pictures was investigated. The Ss (n = 88) were asked to imagine or trace the words or pictures, and the number of item remembered was measured through free recall or recognition. There was no significant difference in items remembered as a result of tracing or imagining. Significantly more picture stimuli were remembered as opposed to words, and recognition of items was superior to free recall (p less than .01). A significant interaction (p less than .01) indicated that picture stimuli enhanced free recall, but when the method of recollection was recognition there was no difference in performance; words and pictures were remembered equally as well. The results support previous findings and also indicate that it is important to know the method of recollection, as well as the form of the presented stimuli.

Field study of the safety of abate for treating potable water and observations on the effectiveness of a control programme involving both abate and malathion

Abate is a larvicide for Aedes aegypti, a vector of yellow fever, dengue, and haemorrhagic fever. It is less toxic than malathion or DDT. Tests in human volunteers had previously indicated it would be safe to add to drinking-water where the mosquito often breeds.In a 19-month test in Puerto Rico, Abate was added to the drums and cisterns in which a community of about 2000 persons stored their drinking-water. This use of Abate and other insecticidal measures (malathion spraying) gradually achieved control of A. aegypti during the first 4 months of treatment and control was maintained thereafter although the test area was surrounded by active breeding-sites. There was no accumulation of Abate in the water in spite of monthly additions of the compound. With minor exceptions, residents readily accepted this use of Abate. Careful surveillance failed to reveal any illness or significant side-effects attributable to measures adopted in the control programme. Abate is considered safe for full-scale field use according to directions.