The Israel Registry for Alzheimer's Prevention (IRAP) Study: Design and Baseline Characteristics

BACKGROUND

Family history of Alzheimer's disease (AD) is associated with increased dementia-risk.

OBJECTIVE

The Israel Registry for Alzheimer's Prevention (IRAP) is a prospective longitudinal study of asymptomatic middle-aged offspring of AD patients (family history positive; FH+) and controls (whose parents have aged without dementia; FH-) aimed to unravel the contribution of midlife factors to future cognitive decline and dementia. Here we present the study design, methods, and baseline characteristics.

METHODS

Participants are members of the Maccabi Health Services, 40-65 years of age, with exquisitely detailed laboratory, medical diagnoses and medication data available in the Maccabi electronic medical records since 1998. Data collected through IRAP include genetic, sociodemographic, cognitive, brain imaging, lifestyle, and health-related characteristics at baseline and every three years thereafter.

RESULTS

Currently IRAP has 483 participants [mean age 54.95 (SD = 6.68) and 64.8% (n = 313) women], 379 (78.5%) FH+, and 104 (21.5%) FH-. Compared to FH-, FH+ participants were younger (p = 0.011), more often males (p = 0.003) and with a higher prevalence of the APOE E4 allele carriers (32.9% FH+, 22% FH-; p = 0.040). Adjusting for age, sex, and education, FH+ performed worse than FH-in global cognition (p = 0.027) and episodic memory (p = 0.022).

CONCLUSION

Lower cognitive scores and higher rates of the APOE E4 allele carriers among the FH+ group suggest that FH ascertainment is good. The combination of long-term historical health-related data available through Maccabi with the multifactorial information collected through IRAP will potentially enable development of dementia-prevention strategies already in midlife, a critical period in terms of risk factor exposure and initiation of AD-neuropathology.

Physiologic and hypermetabolic breast 18-F FDG uptake on PET/CT during lactation

OBJECTIVE

To investigate the patterns of breast cancer-related and lactation-related ¹⁸F-FDG uptake in breasts of lactating patients with pregnancy-associated breast cancer (PABC) and without breast cancer.

METHODS

¹⁸F-FDG-PET/CT datasets of 16 lactating patients with PABC and 16 non-breast cancer lactating patients (controls) were retrospectively evaluated. Uptake was assessed in the tumor and non-affected lactating tissue of the PABC group, and in healthy lactating breasts of the control group, using maximum and mean standardized uptake values (SUVmax and SUVmean, respectively), and breast-SUVmax/liver-SUVmean ratio. Statistical tests were used to evaluate differences and correlations between the groups.

RESULTS

Physiological uptake in non-breast cancer lactating patients' breasts was characteristically high regardless of active malignancy status other than breast cancer (SUVmax = 5.0 ± 1.7, n = 32 breasts). Uptake correlated highly between the two breasts (r = 0.61, p = 0.01), but was not correlated with age or lactation duration (p = 0.24 and p = 0.61, respectively). Among PABC patients, the tumors demonstrated high ¹⁸F-FDG uptake (SUVmax = 7.8 ± 7.2, n = 16), which was 326-643% higher than the mostly low physiological FDG uptake observed in the non-affected lactating parenchyma of these patients (SUVmax = 2.1 ± 1.1). Overall, ¹⁸F-FDG uptake in lactating breasts of PABC patients was significantly decreased by 59% (p < 0.0001) compared with that of lactating controls without breast cancer.

CONCLUSION

¹⁸F-FDG uptake in lactating tissue of PABC patients is markedly lower compared with the characteristically high physiological uptake among lactating patients without breast cancer. Consequently, breast tumors visualized by ¹⁸F-FDG uptake in PET/CT were comfortably depicted on top of the background ¹⁸F-FDG uptake in lactating tissue of PABC patients.

KEY POINTS

• FDG uptake in the breast is characteristically high among lactating patients regardless of the presence of an active malignancy other than breast cancer. • FDG uptake in non-affected lactating breast tissue is significantly lower among PABC patients compared with that in lactating women who do not have breast cancer. • In pregnancy-associated breast cancer patients, ¹⁸F-FDG uptake is markedly increased in the breast tumor compared with uptake in the non-affected lactating tissue, enabling its prompt visualization on PET/CT.

A Retrospective Analysis of the Safety and Activity of Lutetium-177-Prostate-Specific Membrane Antigen Radionuclide Treatment in Older Patients with Metastatic Castration-Resistant Prostate Cancer

BACKGROUND

Prostate cancer is a common malignancy of the elderly, and with the aging of the population, the need is growing for therapies suitable for this age group. Lutetium-177-prostate-specific membrane antigen (Lu-PSMA), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen, enabling beta particle therapy targeted to metastatic castration-resistant prostate cancer (mCRPC). In a recent single-arm phase II trial and a subsequent expansion cohort, a prostate-specific antigen (PSA) decline of ≥50% was observed in approximately 60% of patients receiving Lu-PSMA. Taking into account the specific challenges and potential toxicities of Lu-PSMA administration in elderly men, we sought to retrospectively analyze the safety and activity of Lu-PSMA in men aged older than 75 years with mCRPC.

PATIENTS AND METHODS

The electronic medical records of 24 patients aged older than 75 years treated with Lu-PSMA "off-trial" were reviewed, and clinical data were extracted. Clinical endpoints were toxicity and activity, defined as a PSA decline ≥50%. Descriptive statistics were performed using Excel.

RESULTS

The median age at treatment start was 81.7 years (range 75.1-91.9). The median number of previous treatment lines was four. The number of treatment cycles ranged from one to four; the mean administered radioactivity was 6 GBq per cycle. Treatment was generally tolerable; side effects included fatigue (n = 8, 33%), anemia (n = 7, 29%), thrombocytopenia (n = 5, 21%), and anorexia/nausea (n = 3, 13%). Clinical benefit was observed in 12 of 22 patients (54%); PSA decline above 50% was observed in 11 patients (48%) and was associated with significantly longer overall survival.

CONCLUSION

Our results indicate that Lu-PSMA is safe and active in elderly patients with mCRPC.

IMPLICATIONS FOR PRACTICE

Lutetium-177-prostate-specific membrane antigen (Lu-PSMA), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen, enabling beta particle therapy targeted to metastatic castration-resistant prostate cancer (mCRPC). The recently published single-arm phase II trial with Lu-PSMA, describing its safety and activity, did not include patients aged older than 75 years. In this study, Lu-PSMA activity was retrospectively analyzed in patients aged older than 75 years and results indicate that treatment was tolerable and similarly active in this age group, with no new emerging safety signals. Despite the small cohort size, this analysis suggests that Lu-PSMA can serve as an advanced palliative treatment line in mCRPC in elderly patients.

A double-blind placebo-controlled clinical trial testing the effect of hyperbaric oxygen therapy on brain and cognitive outcomes of mildly cognitively impaired elderly with type 2 diabetes: Study design

INTRODUCTION

Type 2 diabetes (T2D) is a risk factor for dementia. Ischemia due to vascular pathology is hypothesized to be an underlying mechanism for this association. Hyperbaric oxygen therapy (HBOT) is a treatment in which oxygen-enriched air (up to 100%) is administered to patients in a chamber at a pressure above one atmosphere absolute. HBOT is approved for the treatment of T2D ischemic non-healing wounds. Evidence from animal studies and small clinical trials suggests that HBOT improves hypoxic/ischemic brain injuries, consequently inducing brain angiogensis, leading to cognitive improvement.

METHODS

We present the design of the first double-blind, placebo-controlled, clinical trial on brain and cognitive outcomes in elderly (n = 154) with T2D and mild cognitive impairment to compare the effects of HBOT versus sham (normal air with 1.1 ATA pressure in the first and last 5 minutes of the session). Eligible candidates are randomized with equal probability to HBOT and sham. Outcomes are assessed before and after treatment, and at 6- and 12-month follow-up. The primary cognitive outcome is global cognitive change, indexed by a composite sum of z-scores of four executive functions and four episodic memory tests. The primary neurobiological outcome is cerebral blood flow (CBF; via arterial spin labeling magnetic resonance imaging [ASL-MRI]) and cerebral glucose utilization via fluorodeoxyglucose positron emission tomography (FDG-PET). Secondary outcome measures are specific cognitive domains (executive function and episodic memory) and functional measures (Clinical Dementia Rating sum of boxes, activities of daily living). Efficacy analyses will be performed for the intent-to-treat sample.

DISCUSSION

Recent studies suggest that HBOT induces neuroplasticity and improves cognition in post-stroke and traumatic brain injury patients. However, its effect on cognition, cerebral blood flow, and brain glucose utilization in T2D patients at high dementia risk is yet to be determined. If effective, this study may provide strong evidence for the brain and cognitive benefits of HBOT in this population.

Prospective Study of the Radiolabeled GRPR Antagonist BAY86-7548 for Positron Emission Tomography/Computed Tomography Imaging of Newly Diagnosed Prostate Cancer

BACKGROUND

Current imaging techniques may not detect all prostate cancer (PCa) lesions.

OBJECTIVE

To evaluate positron emission tomography (PET)/computed tomography (CT) using the radiolabeled GRPR antagonist probe BAY86-7548 (⁶⁸Ga-RM2) for localization of newly diagnosed PCa in comparison with multiparametric magnetic resonance imaging (mpMRI), histopathology, and immunohistochemistry (IHC).

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective study of 16 men with biopsy-proven PCa (2 low, 8 intermediate, and 6 high risk). ⁶⁸Ga-RM2 PET/CT was performed within 4 wk after mpMRI and within 2 wk before radical prostatectomy and extended bilateral pelvic lymph node dissection.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The presence of cancer was evaluated by blinded specialists using a 5-point Likert scale, with lesions scoring 4 or 5 considered positive, on ⁶⁸Ga-RM2 PET/CT, mpMRI, and ⁶⁸Ga-RM2 PET/CT-mpMRI fused images for each of 12 anatomic areas of the prostate. Whole-mount, step-section pathology served as the reference standard. Expression of GRPR and prostate-specific membrane antigen (PSMA) was analyzed via IHC of tumor paraffin sections.

RESULTS AND LIMITATIONS

Of 192 areas analyzed, 128 contained cancer. The sensitivity, specificity, and accuracy of ⁶⁸Ga-RM2 PET/CT imaging and mpMRI did not differ significantly; fusing the images maximized the sensitivity and accuracy (85.2% and 83.9%, respectively) and averaged the specificity (81.3%). The area under the receiver operating characteristic curve was 0.76 for PET visual analysis, 0.72 for PET quantitative analysis, 0.76 for mpMRI, and 0.85 for combined PET/CT and mpMRI analysis. ⁶⁸Ga-RM2 uptake did not correlate with Gleason score. IHC analysis revealed weaker staining for GRPR than for PSMA, and the expression of these markers was not correlated (r=0.3882). The major limitation is the small sample size.

CONCLUSIONS

⁶⁸Ga-RM2 PET/CT is promising for detection and localization of primary PCa, and complements mpMRI. GRPR expression appears to be independent from PSMA expression, suggesting that GRPR- and PSMA-targeted PET imaging may be complementary.

PATIENT SUMMARY

This pilot prospective study shows that a positron emission tomography probe that binds to a marker of prostate cancer, GRPR, improves the ability of magnetic resonance imaging to detect prostate cancer.

Modification of the Bu/Cy myeloablative regimen using daily parenteral busulfan: reduced toxicity without the need for pharmacokinetic monitoring

Pharmacokinetic and clinical outcome measures among three groups of patients undergoing hematopoietic transplant were assessed: group A: Parenteral busulfan (Bu) 3.2 mg/kg i.v. given qd, n=20; group B: parenteral Bu 0.8 mg/kg i.v. given every 6 h, n=11; group C: Bu 1 mg/kg p.o. given every 6 h, n=25. All groups received Bu over 4 days followed by Cy 60 mg/kg i.v. qd over 2 days; followed by an infusion of allogeneic stem cells. Median Bu clearance was 3.21 ml/min/kg and median daily AUC was 4071 micromol/min for the group A patients. The dosing formula for Bu i.v. qd was highly predictive of the AUC for patients whose mass < or =IBW+20%. For patients of greater mass, the dosing formula uniformly resulted in lower-than-predicted AUC. Neurologic toxicity, hepatic toxicity, hematologic engraftment, and relapse at 100 days were comparable across all three groups. Severe AGVHD was least among group A, followed by group B when compared with group C. Bu i.v. qd is a safe and effective regimen for allogeneic transplantation and is at least clinically equivalent to every 6 h dosing schemes using either oral or parenteral Bu.

Quality and ecology of adversity as common mechanisms of risk and resilience

This paper proposes common mechanisms to explain the effects of adversities and of resources that promote resilience. Adversities threaten the satisfaction of basic human needs and the acquisitions of competencies to carry out valued social roles. Adversities can also be characterized in terms of their ecological properties of occurrence in time, and place. Resilience resources at the individual, microsystem and macro levels reduce the negative effects of adversities through their effects on satisfaction of basic human needs and their effects on the occurrence of adversities. The effects of resilience resources are described as preventive, protective and promotive. Implications are presented for the development of interventions to promote resilience.

Appraisals of negative events by preadolescent children of divorce

This study investigated the appraisals of the significance of negative events made by 256 preadolescent children of divorce. Appraisals were assessed by a 24-item self-report scale. Confirmatory factor analysis of this scale found support for a 3-dimensional model: negative self-appraisal, negative other-appraisal, and material loss. Differentiation between the dimensions of appraisal increased with age in both cross-sectional and over-time data. Evidence for convergent and discriminant validity of the self-report measure of appraisals was found with scores derived from children's open-ended descriptions of their appraisals. Cross-sectional structural equation models found significant paths between negative appraisal and psychological symptoms, over and above the direct effects of the traditional life event measure of stress. Structural equation modeling of longitudinal (5.5 months) data found a significant path from Time 1 appraisal to Time 2 anxiety for the older children.

Major life events and minor stressors: identifying mediational links in the stress process

Whether the relationship between major life events and distress is mediated through minor stressors was examined in three stress groups: those who (a) experienced the death of a spouse, (b) divorced, or (c) were the parent of a child with asthma. Each of these major stress groups was compared with a control group. Path analyses conducted by aggregating the data cross major stress groups indicated that major life events exert both a direct influence on distress and an indirect influence through minor stressors. On the other hand, the nature of the mediational relation linking major life events with psychological distress through minor stressors was found to vary as a function of the major life stress situation under consideration. Methodological and theoretical implications for the study of stress processes are discussed.

Major life events and minor stressors: identifying mediational links in the stress process

Whether the relationship between major life events and distress is mediated through minor stressors was examined in three stress groups: those who (a) experienced the death of a spouse, (b) divorced, or (c) were the parent of a child with asthma. Each of these major stress groups was compared with a control group. Path analyses conducted by aggregating the data cross major stress groups indicated that major life events exert both a direct influence on distress and an indirect influence through minor stressors. On the other hand, the nature of the mediational relation linking major life events with psychological distress through minor stressors was found to vary as a function of the major life stress situation under consideration. Methodological and theoretical implications for the study of stress processes are discussed.

War-related stress. Addressing the stress of war and other traumatic events

A task force on war-related stress was convened to develop strategies for prevention and treatment of psychological, psychosocial, and psychosomatic disorders associated with the Persian Gulf War and other extreme stressors facing communities in general. The task force focused on the return home, reunion, and reintegration of service personnel with their families and work. Although the Persian Gulf War was won with relative ease, negative psychological sequelae may develop in some individuals because of the stress of war, family disruption, financial difficulty, and changes in family routines. Typical stress reactions and modes of coping that are usually unsuccessful or destructive were outlined, and suggestions were made for monitoring these. In addition, guidelines for successful coping were developed. Special attention was given to children's reactions and needs. Recommendations were made for outreach and intervention on the policy, systems (e.g., schools, businesses, governmental agencies), family, and individual levels.

War-related stress: Addressing the stress of war and other traumatic events

A task force on war-related stress was convened to develop strategies for prevention and treatment of psychological, psychosocial, and psychosomatic disorders associated with the Persian Gulf War and other extreme stressors facing communities in general. The task force focused on the return home, reunion, and reintegration of service personnel with their families and work. Although the Persian Gulf War was won with relative ease, negative psychological sequelae may develop in some individuals because of the stress of war, family disruption, financial difficulty, and changes in family routines. Typical stress reactions and modes of coping that are usually unsuccessful or destructive were outlined, and suggestions were made for monitoring these. In addition, guidelines for successful coping were developed. Special attention was given to children's reactions and needs. Recommendations were made for outreach and intervention on the policy, systems (e.g., schools, businesses, governmental agencies), family, and individual levels.

Coping and adjustment to genital herpes: the effects of time and social support

The current study investigated the relationship of the passage of time and membership in a self-help group with coping behaviors and distress among people with genital herpes. A comparison between 116 people in herpes support groups and 36 community volunteers on the use of coping and level of emotional adjustment was undertaken. Results of the study indicated that people employed fewer coping strategies with increasing time since the onset of the stressor. This pattern was particularly clear in non-support-group subjects. In comparison, support-group members did not exhibit as significant a decrease in the use of coping strategies or as great an improvement in the level of depression and degree bothered by herpes over time. Selection factors and effects of self-help group membership are discussed as alternative explanations for these differences. Future research in the area of group membership as well as helpful and nonhelpful processes in these groups is suggested.

Coping and adjustment to genital herpes

The current study examined how individuals deal with genital herpes, a recurrent, incurable disease with a great psychological impact. An assessment battery composed of cognitive and problem-focused coping, attribution, and social support mechanisms was employed. These coping mechanisms were correlated with measures of psychological adjustment: self-esteem, depression, sexual adjustment, and amount upset by herpes. Subjects were 152 people with herpes recruited from self-help groups and people from the community who volunteered to participate in the study. Results supported several hypotheses derived from previous research on coping with life stressors. Cognitive coping mechanisms, especially negative thoughts, along with wishful thinking and characterological self-blame, were significant predictors of poor psychological adjustment. In addition, the repeated use of disease management strategies was found to correlate with poor psychological adjustment. Further research in the area of coping with chronic illness is suggested.