Belief, Knowledge and Expertise. The emergence of the lay expert in medical sociology

The paper has three main aims. First, to trace – through the pages of the Journal – the changing ways in which lay understandings of health and illness have been represented during the 1979-2002 period. Second, to say something about the limits of lay knowledge (and particularly lay expertise) in matters of health and medicine. Third, to call for a re-assessment of what lay people can offer to a democratised and customer sensitive system of health care and to attempt to draw a boundary around the domain of expertise. In following through on those aims, the author calls upon data derived from three current projects. These latter concern the diagnosis of Alzheimer’s disease in people with Down’s syndrome; the development of an outcome measure for people who have suffered a traumatic brain injury; and a study of why older people might reject annual influenza vaccinations. Key words: Lay health beliefs, lay expertise, Alzheimer’s, Traumatic Brain Injury, Vaccinations

Pharmacological interventions for dementia in people with Down Syndrome (Protocol).

Background: People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer’s disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives: To assess the effectiveness of anti-dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria: Randomised controlled trials (RCTs) of anti-dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessaryMain results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl-L-carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow-up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) -0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI -0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI -0.43 to 0.52), behaviour (SMD -0.17, 95% CI -0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetylL-carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors’ conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome.

mRNA Levels of BACE1 and its interacting proteins, RTN3 and PPIL2, correlate in human post mortem brain tissue

β-Site amyloid precursor protein cleaving enzyme (BACE1) is the rate-limiting enzyme for production of Aβ peptides, proposed to drive the pathological changes found in Alzheimer’s disease (AD). Reticulon 3 (RTN3) is a negative modulator of BACE1 (β-secretase) proteolytic activity, while peptidylprolyl isomerase (cyclophilin)-like 2 (PPIL2) positively regulated BACE1 gene expression in a cell-based assay. This study aimed to analyze RTN3 and PPIL2 mRNA levels in four brain regions from individuals with AD and controls. BACE1 mRNA had been previously quantified in the samples, as had glial fibrillary acidic protein (GFAP) and neuron-specific enolase (NSE), to track changing cell populations in the tissue. mRNA levels in the human post mortem brain tissue were assayed using quantitative real-time polymerase chain reaction (qPCR) and qbasePLUS, employing validated stably expressed reference genes. No differences in RTN3 or PPIL2 mRNA levels were found in individuals with AD, compared to controls. Both RTN3 and PPIL2 mRNA levels correlated significantly with BACE1 mRNA and all three showed similar disease stage-dependent changes with respect to NSE and GFAP. These findings indicated that the in vitro data demonstrating an effect of PPIL2 on BACE1 expression have functional relevance in vivo. Further research into BACE1-interacting proteins could provide a fruitful approach to the modulation of this protease and consequently Aβ production.

Estágio em clínica de animais de companhia: síndrome de disfunção cognitiva canina

Este estágio foi realizado em clínica de animais de companhia. Observou e acompanhou-se tanto consultas com carácter preventivo como de clínica médica e cirúrgica. As consultas de medicina preventiva consistiram essencialmente em vacinações e desparasitações, enquanto outras foram meramente informativas. As consultas de clínica médica incidiram em diversas áreas, incluíndo dermatologia, gastroenterologia e cardiologia. As cirurgias efetuadas foram sobretudo eletivas, mas também se assistiu a cirurgias corretivas. Um dos casos observados foi um cão com disfunção cognitiva. Este foi o caso escolhido para ser alvo do estudo mais aprofundado que é apresentado na segunda secção deste relatório. A disfunção cognitiva canina é o equivalente à doença humana de Alzheimer. Esta condição é relativamente desconhecida e os seus sinais clínicos são frequentemente considerados normais da idade. No entanto, quando detetada e tratada atempadamente é possível abrandar a sua evolução, devendo os proprietários de cães afetados ser sensibilizados a procurar assistência profissional; Internship in small animal practice: canine cognitive dysfunction syndrome Abstract: This internship was conducted in small animal clinic. The attended appointments consisted mostly of cases of preventive and internal medicine and also surgical assistance. The appointments of preventive medicine included vaccinations, deworming and some merely informative sessions. The cases of internal medicine concerned areas such as dermatology, gastroenterology and cardiology. The surgical interventions were mainly optional but also corrective procedures. One of the observed cases was a dog with cognitive dysfunction. This case was elected to be the target of further study which is presented in the second section of this report. The canine cognitive dysfunction is the equivalent to the human Alzheimer’s disease. This condition is still largely unknown and its clinical presentation is often considered normal of aging. However, if detected and treated early it is possible to slow down its progress, thus the owners of affected dogs should be encouraged to seek professional assistance.

O sistema dois-hidrido de levedura para confirmação da sinalização de APP Tipo-Noth

Inúmeras potenciais funções foram sugeridas para a APP (Proteína Precursora de Amilóide de Alzheimer), contudo, fisiologicamente, a função precisa da APP não foi ainda desvendada. A APP tem características consistentes com a função de molécula-receptora, capaz de reconhecer sinais extracelulares. Também relevante para este trabalho, é o facto de que a sinalização através de RIP (Proteólise Intramembranar Regulada) tem consequências na expressão génica, como no caso da sinalização tipo-Notch. Tal como a proteína Notch, a APP é processada resultando num fragmento C-terminal designado por AICD (Domínio Intracelular da APP). Neste trabalho é focado o papel importante na sinalização nuclear desempenhado pelo fragmento AICD, especificamente através da interacção com proteínas adaptadoras, promovendo a transcrição. Com o objectivo de contribuir para uma melhor compreensão da base molecular da DA (Doença de Alzheimer), torna-se importante investigar as vias de localização nuclear do AICD e o seu envolvimento na transcrição génica, possivelmente afectando proteínas até agora não associadas à DA. Por estes motivos é fundamental a identificação de novas proteínas que interajam com a APP. Um rastreio foi efectuado, utilizando o sistema Dois-Híbrido em Levedura, para identificar interacções específicas do AICD no cérebro humano e, assim, caracterizar o interactoma do AICD. Foi feito o rastreio de aproximadamente 1.1x108 clones de uma biblioteca de cDNA de cérebro humano com o domínio C-terminal da APP com a mutação Y687E, que mimetiza o estado fosforilado. De experiências anteriores deste laboratório sabemos que a tirosina-687 afecta a localização subcelular da APP e é também consensual que a fosforilação é importante nos mecanismos de transdução de sinais, daí a utilização deste mutante parecer apropriada. O rastreio originou 55 clones positivos que foram analisados para identificar proteínas que interagem com a APP. Dois clones são particularmente importantes, a RanBPM e a Transportin-SR2, visto que estão associadas ao transporte de proteínas para o núcleo e confirmam a sinalização nuclear da APP. ABSTRACT: Many putative functions for APP (Alzheimer’s amyloid precursor protein) have been suggested, although the precise physiological function of APP remains to be elucidated. APP has characteristics consistent with it having a role as a receptor, capable of mediating extracellular signals. Also of relevance to the work described here is that RIP (Regulated Intramembrane Proteolysis) signalling can have consequences in gene expression, similar to Notch signalling. Like the latter, APP is processed by RIP resulting in a C-terminal fragment known as AICD. Here we test the hypothesis that the AICD fragment may play an important role in nuclear signalling, specifically by interacting with adaptor proteins potentiating transcription. Therefore, in order to contribute to our understanding of the molecular basis of AD (Alzheimer’s disease) it is important to investigate the pathways of AICD nuclear targeting and its involvement in gene transcription, possibly affecting other proteins hitherto not associated with AD. Thus, it is important to identify AICD binding proteins. A Yeast Two-Hybrid (YTH) screen was performed to identify human brainspecific AICD binding proteins, and thus characterize the AICD interactome. The screen of approximately 1.1 x108 clones from a human brain cDNA library was carried out using the AICD fragment with an Y687E mutation, which mimics phosphorylation on that residue. From previous work carried out in the laboratory we know that tyrosine-687 phosphorylation affects subcellular localization of APP, and it is also recognized that phosphorylation events are important in signal transduction mechanisms, hence the use of this mutant is appropriate. The YTH screen yielded 55 positive clones that were analysed and several novel brain-specific APP binding proteins were identified. Two clones were particularly important, RanBPM and Transportin-SR2, being that they are associated with the nuclear transport of proteins, and support the nuclear signalling for APP.

Genetic profiling of ApoE in dementia

A demência é uma das principais causas de incapacidade entre os idosos, afetando mais de 36 milhões de pessoas em todo o mundo. É caracterizada pela deterioração progressiva das funções cognitivas, resultando em dificuldades no desempenho das atividades diárias do indivíduo. A idade de aparecimento dos sintomas, bem como a sua taxa de progressão, são variáveis entre a maior parte das demências, sendo estas geralmente caracterizadas por uma natureza progressiva, aumentando de gravidade ao longo do tempo. Entre os tipos mais frequentes de demência encontram-se a Doença de Alzheimer (DA), Demência Vascular, Demência de Corpos de Lewy e Demência Frontotemporal. O diagnóstico diferencial das demências é realizado tipicamente por testes neuro-psicológicos (para a exclusão de outras demências) e por exames imagiológicos. Contudo, muitos dos sintomas clínicos característicos podem sobrepor-se entre os diversos tipos de demência, o que pode constituir um problema devido a falta de especificidade e erros de diagnóstico. A compreensão dos fatores de risco ambientais e genéticos que podem modular o aparecimento e/ou progressão de doenças abre novas perspetivas relativamente à gestão destas neuropatologias. O gene da apolipoproteína E (ApoE) é reconhecido como o maior fator de risco na demência, desempenhando um papel central em particular no desenvolvimento da DA, sendo que os portadores do alelo ε4 são mais suscetíveis para a doença. Além disso, possíveis associações foram também propostas entre este gene e outras doenças neurológicas, sendo no entanto estes dados ainda controversos. Assim, o objetivo principal deste trabalho consistiu em determinar as frequências alélicas e genotípicas do gene ApoE num grupo de estudo piloto de pacientes com demência na região de Aveiro. Este grupo foi subdividido com base no diagnóstico neuroquímico, no qual foram avaliados os níveis de Aβ1-42, Tau-total e fosfo-Tau 181 no líquido cefalorraquidiano dos pacientes. Como resultado, observou-se que o alelo ε3 foi o mais frequente no grupo total, independentemente do tipo de patologia, e que o alelo ε2 foi o menos comum. O alelo ε4 foi de facto mais frequente em pacientes com DA do que em pacientes com outras neuropatologias, o que está de acordo com a relação proposta por outros autores. Adicionalmente, foi possível verificar que a frequência deste alelo nos pacientes com patologia amilóide é semelhante à observada no grupo DA, sugerindo um papel relevante para o ApoE no metabolismo e acumulação cerebral do Aβ. Consequentemente, estes indivíduos podem ter uma maior suscetibilidade para o desenvolvimento de DA no futuro. Deste modo, os nossos dados corroboram a ideia de que o alelo ε4 é um forte fator de risco para a DA e que deve ser considerado como um teste genético relevante que pode contribuir para o diagnóstico clínico da demência.

Interrelation entre déficits métaboliques et neuropathologie associée à la maladie d’Alzheimer chez la souris 3xTg-AD

La maladie d’Alzheimer (MA) est la maladie neurodégénérative qui cause le plus important nombre de cas de démence. On estime que près de 15% des canadiens âgés de plus de 65 ans sont atteints de la MA. Avec le vieillissement de la population, le nombre de cas augmentera de manière substantielle dans les prochaines années. À l’heure actuelle, aucun traitement ne permet de ralentir la progression de la maladie. Pour plus de 99% des cas, ses causes exactes demeurent indéterminées. Toutefois, de nombreux facteurs de risque ont été identifiés. Parmi eux, on retrouve plusieurs facteurs liés au métabolisme énergétique dont l’obésité et le diabète de type 2 (DT2). De manière intéressante, des modifications du métabolisme, telles qu’une résistance à l’insuline centrale et périphérique, sont également observées chez les patients Alzheimer. Afin de mieux comprendre l’interaction entre le DT2 et la MA, nous avons d’abord étudié les altérations métaboliques chez la souris triple transgénique (3xTg-AD), un modèle murin de la MA. Nous avons, en premier lieu, observé une intolérance au glucose qui progresse avec l’âge, qui est plus importante chez les femelles et qui semble liée à l’accumulation du peptide beta-amyloïde (Aβ) humain dans le pancréas. Ensuite, nous avons nourri cette souris avec une diète riche en gras pour vérifier l’impact d’une aggravation des déficits métaboliques sur la pathologie Alzheimer. L’aggravation de l’intolérance au glucose chez les souris 3xTg-AD semblait liée à l’atrophie des îlots de Langerhans et, en conséquence, à une réduction de la production d’insuline en réponse à l’injection de glucose. En plus de l’aggravation des déficits métaboliques, la diète riche en gras a augmenté de manière drastique l’accumulation de la forme soluble du peptide Aβ dans le cortex et a déterioré la mémoire des souris 3xTg-AD. De manière intéressante, l’élévation du peptide Aβ et les troubles de la mémoire ont été rétablis par l’administration d’une seule dose d’insuline. Aussi, nous avons observé une augmentation du peptide Aβ dans le plasma 30 minutes à la suite de l’injection d’insuline, suggérant qu’il est possible que la baisse rapide du peptide soit en partie causée par une élévation de la clairance du peptide au cerveau. Ces résultats renforcent les évidences supportant le potentiel thérapeutique de l’insuline dans le traitement de la MA. Toutefois, les résultats chez les patients mettent en lumière l’inefficacité de l’administration intranasale d’insuline chez les porteurs de l’allèle 4 du gène de l’apolipoprotéine E (APOE4). Afin de comprendre les raisons qui expliquent cette différence de réponse à l’insuline chez les porteurs de l’APOE4, nous avons injecté des souris exprimant l’APOE3 et l’APOE4 humain avec de l’insuline dans le but de vérifier l’effet central et périphérique de l’insuline chez ces animaux. Les souris APOE4 montrent une plus importante élévation de la signalisation de l’insuline au cerveau comparativement aux souris APOE3. Cette plus haute réponse est aussi associée à une élévation plus importante de la phosphorylation de la protéine tau, un marqueur neuropathologique de la MA. En somme, ces résultats suggèrent qu’il existe un cercle vicieux entre la MA et le DT2. L’administration d’insuline a un potentiel thérapeutique intéressant pour la MA, malgré des effets limités chez les patients APOE4 en raison de son impact probable sur la phosphorylation de la protéine tau.

Brain-derived neurotrophic factor and adenosine signalling on amyloid-β peptide induced toxicity : impact on hippocampal function

Tese de doutoramento, Ciências Biomédicas (Neurociências), Universidade de Lisboa, Faculdade de Medicina, 2014

It has had quite a lot of reverberations through the family": reconfiguring relationships through parent with dementia care

In this chapter I explore the accounts of adult children caring for a parent with dementia. Dementia is typically understood to be an umbrella term for a large number of conditions, the most common of which are Alzheimer’s disease, vascular dementia and fronto-temporal dementia. These are progressive – ultimately terminal – conditions that affect memory, communication, mood and behaviour. I examine the accounts of interactions with parents with dementia that fracture and reconfigure normative familial relationships. In so doing I suggest that, in the absence of a primary spousal carer, caring for a person living with dementia can necessitate particular issues for adult children that trouble notions of how we understand familial roles, responsibilities and ‘duties’.

Are Premorbid Abnormal Personality Traits Associated with Behavioural and Psychological Symptoms in Dementia?

Objective: The study aims to investigate associations between behavioural and psychological symptoms of dementia (BPSD) and abnormal premorbid personality traits. Methods: Data were obtained from 217 patients with a diagnosis of probable Alzheimer’s disease. Behavioural and psychological symptoms of late-onset dementia were assessed with the Neuropsychiatric Inventory. Premorbid personality traits were assessed using the Standardised Assessment of Personality. Abnormal premorbid personality traits were categorised with Diagnostic and Statistical Manual of Mental Disorders fourth edition and International Statistical Classification of Diseases and Related Health Problems—10 diagnostic criteria for personality disorders. Results: Abnormal premorbid personality traits were associated with increased behavioural and psychological symptoms in dementia. Cluster A (solitary/paranoid) premorbid personality traits were associated with anxiety, depression and hallucinations. Cluster C (anxious/dependent) traits were associated with a syndrome of depression. Conclusions: The presence of Clusters A (solitary/paranoid) and C (anxious/dependent) abnormal premorbid personality traits seems to affect the expression of certain behavioural and psychological symptoms in dementia, depression in particular. Copyright # 2016 John Wiley & Sons, Ltd

Study the function of the newly discovered TrkB receptor fragment (TrkB-ICD) formed by calpain cleavage

Tese de mestrado, Neurociências, Faculdade de Medicina, Universidade de Lisboa, 2016