Impact of Differential Rates of Disease Progression in Amyloid-Positive Early Alzheimer's Disease: Findings from a Longitudinal Cohort Analysis

BACKGROUND

There is limited literature regarding the impact of differential rates of disease progression on longitudinal outcomes in individuals with early Alzheimer's disease (AD) and confirmed brain amyloid pathology.

OBJECTIVES

To describe the underlying characteristics and long-term outcomes associated with different rates of disease progression among amyloid-positive individuals with early symptomatic AD.

DESIGN

Retrospective observational study.

SETTING

Data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) in the United States (06/2005-11/2021).

PARTICIPANTS

Individuals with a clinical assessment of mild cognitive impairment or dementia and Clinical Dementia Rating® Dementia Staging Instrument Sum of Boxes (CDR-SB) score 0.5-9.0 (inclusive; first visit defined as the index date) and confirmed amyloid positivity. Participants were stratified into No Progression (change ≤0), Slower Progression (0< change <2.0 points), Median Progression (2.0-point change), and Faster Progression (change >2.0 points) cohorts based on the observed distribution of changes in CDR-SB score between the index and first subsequent visit.

MEASUREMENTS

For each cohort, the functional and neuropsychiatric outcomes were described at index and each subsequent visit for up to five years, and least-square (LS) mean changes from baseline were estimated using linear mixed-effects models adjusting for baseline demographic and clinical characteristics.

RESULTS

Among 1,263 participants included in the analysis, the mean±standard deviation (SD) age at index was 72.7±9.7 years and 55.3% were males. Demographic characteristics and comorbidity profiles at index were similar across cohorts. However, at index, the Faster Progression (N=279) cohort had higher CDR-SB and Functional Assessment Questionnaire (FAQ) scores compared with the No Progression (N=474), Slower Progression (N=297), and Median Progression (N=213) cohorts. Adjusting for baseline characteristics, at year 5 after index the FAQ score increased by 23.6 points for Faster Progression cohort and 10.4, 15.8, and 19.2 points for the No, Slower, and Median Progression cohorts, respectively. The corresponding increases in Neuropsychiatric Inventory Questionnaire (NPI-Q) scores were 6.7 points for the Faster Progression cohort, and by 1.3, 3.1, and 8.3 points, for the No, Slower, and Median Progression cohorts, respectively.

CONCLUSIONS

Despite similar demographic and clinical profiles at baseline, amyloid-positive individuals with greater deterioration based on CDR-SB early in the AD trajectory continue to experience worse functional and behavioral outcomes over time than those with more gradual deterioration in this metric.

Potential Implications of Slowing Disease Progression in Amyloid-Positive Early Alzheimer's Disease: Estimates from Real-World Data

BACKGROUND

Emerging therapies have shown promising results for slowing the progression of Alzheimer's disease (AD). However, the potential impact of these therapies on real-world outcomes remains to be explored.

OBJECTIVE

To examine the impact of slowing AD progression on functional abilities and behavioral symptoms.

DESIGN

Retrospective observational study.

SETTING

Data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) in the United States (06/2005-11/2021, primary analysis) and the Alzheimer's Disease Neuroimaging Initiative (ADNI) database (09/2005-03/2022, sensitivity analysis) were used.

PARTICIPANTS

Individuals with mild cognitive impairment (MCI) or mild dementia, Clinical Dementia Rating Scale Sum of Boxes (CDR-SB) score 0.5-9.0 (inclusive; first visit defined as the index date), and confirmed amyloid positivity were identified in NACC. In ADNI, individuals with at least one clinical center visit with a clinical assessment of MCI or mild dementia and confirmed amyloid positivity were identified.

MEASUREMENTS

Hypothetical effects of slowing disease progression as assessed by CDR-SB on functional and behavioral outcomes including the Functional Activities Questionnaire (FAQ) score, Neuropsychiatric Inventory Questionnaire (NPI-Q) score, and the probability of complete dependence over five years were evaluated using multivariable regression among NACC participants, separately for the subgroups with MCI and mild dementia at baseline, respectively. For the ADNI sensitivity analysis, the hypothetical effects of slowing disease progression were evaluated for FAQ score using multivariable regression among the MCI participants only.

RESULTS

Compared with natural disease progression, slowing progression by 20% over five years for NACC participants with MCI and mild dementia, respectively, would result in 1.7-point (10.8%) and 1.6-point (12.9%) less deterioration based on FAQ; 0.5-point (20.3%) and 0.5-point (19.3%) less deterioration based on NPI-Q; 4.7 percentage-point (22.2%) and 10.1 percentage-point (21.6%) lower probability of complete dependence. Among ADNI participants, delaying disease progression by 20% or 30% over 4 years would avert deterioration based on FAQ of 1.1 points (20.4%) and 1.6 points (29.6%), respectively, compared to natural disease progression.

CONCLUSIONS

Slowing early AD progression could result in preservation of functional and behavioral attributes and functional autonomy for longer.

A Clinical Case of COVID-19 Vaccine-Associated Guillain-Barré Syndrome

BACKGROUND Guillain-Barre syndrome (GBS) is an autoimmune condition that presents as weakness, numbness, paresthesia, and areflexia. GBS may occur following infection or vaccination. The pathogenesis of GBS is characterized by inflammatory infiltrates and segmental demyelination. The mechanism of GBS following COVID-19 vaccination is hypothesized to arise from an autoimmune-mediated mechanism leading to an increase in inflammatory cytokines. While there were no reported cases of GBS during the mRNA COVID-19 vaccination clinical trials, there have been a few case reports of GBS following COVID-19 vaccination. CASE REPORT We report a case of symmetric weakness and paresthesia that began 3 days after the patient received his first dose of the Moderna COVID-19 vaccine. Cerebrospinal fluid (CSF) studies demonstrated albuminocytologic dissociation. The combination of the patient's CSF findings and clinical symptoms was concerning for Guillain-Barre syndrome. Given the clinical findings 3 days following COVID-19 vaccination, there was a high concern for COVID-19 vaccine-induced GBS. The patient was treated with IVIG followed by plasmapheresis but failed to show significant improvement from either treatment. CONCLUSIONS Our case report demonstrates occurrence of GBS soon after the patient received the COVID-19 Moderna vaccine. Although rare, there is some evidence to support an association between COVID-19 vaccination and GBS, but this is generally limited to case reports and case series. Clinicians, however, should remain vigilant to mitigate potential risks, such as autonomic dysfunction, respiratory failure, permanent disability, and death in patients who develop GBS after vaccination.

Efficacy of Acupuncture and Moxibustion in Alopecia: A Narrative Review

Acupuncture is the practice of applying needles to target specific pressures points in the body. Since originating in China, acupuncture has been practiced for thousands of years to treat numerous conditions including chronic pain and mood disorders. Alopecia is a common dermatologic condition associated with psychological distress and decreased quality of life. Although it remains underexplored in western medicine, recent evidence suggests that acupuncture may be efficacious in the treatment of alopecia. In this review, we discuss the available evidence describing the efficacy of acupuncture or moxibustion alone (ACU) and in combination with other traditional and alternative interventions (ACU + TRAD) for hair loss. Additionally, the proposed physiologic mechanisms, targeted acupuncture points, and the benefits and barriers to treatment will be further described. An exploratory search using PubMed, EMBASE and Scopus databases was performed for studies that evaluated the effect of acupuncture and moxibustion on alopecia. In these studies, both ACU and ACU + TRAD were efficacious for numerous etiologies of hair loss including alopecia areata, androgenetic alopecia, and seborrheic alopecia. Given their ability to modulate the immune system, as well as neuronal networks associated with emotional cognition, the most frequently targeted acupoints were ST 36, GV 20, and LR 3. The proposed mechanistic effect is dependent upon disease etiology and is theorized to be twofold: reduction of inflammation and decrease in testosterone levels. The limited side effect profile of acupuncture makes it an advantageous treatment option, however, factors including cost, time, limited access, and aversion to needles may serve as barriers to treatment.

Cutaneous Periumbilical Fibroadenomas: A Rare Case of Ectopic Breast Tissue

Ectopic breast tissue is the presence of retained breast tissue along the embryologic mammary ridge, also known as the milk line. Accessory tissue can be located anywhere along or outside the anatomic milk line extending from the axilla to the groin. Ectopic breast tissue can undergo the same physiologic and pathologic changes seen in normal breast tissue, such as fibroadenomas, fibrocystic changes, and malignancy. The wide range of clinical presentations and symptomatology can pose a significant diagnostic challenge, and clinicopathologic correlation is key in establishing the diagnosis. In this report, we review the clinical and histopathologic findings in a rare case of cutaneous periumbilical fibroadenomas in a 25-year-old female.