A systems-biology clinical trial of a personalized multimodal lifestyle intervention for early Alzheimer's disease

INTRODUCTION

There is an urgent need to develop effective interventional treatments for people with Alzheimer's disease (AD). AD results from a complex multi-decade interplay of multiple interacting dysfunctional biological systems that have not yet been fully elucidated. Epidemiological studies have linked several modifiable lifestyle factors with increased incidence for AD. Because monotherapies have failed to prevent or ameliorate AD, interventional studies should deploy multiple, targeted interventions that address the dysfunctional systems that give rise to AD.

METHODS

This randomized controlled trial (RCT) will examine the efficacy of a 12-month personalized, multimodal, lifestyle intervention in 60 mild cognitive impairment (MCI) and early stage AD patients (aged 50+, amyloid positivity). Both groups receive data-driven, lifestyle recommendations designed to target multiple systemic pathways implicated in AD. One group receives these personalized recommendations without coaching. The other group receives personalized recommendations with health coaching, dietary counseling, exercise training, cognitive stimulation, and nutritional supplements. We collect clinical, proteomic, metabolomic, neuroimaging, and genetic data to fuel systems-biology analyses. We will examine effects on cognition and hippocampal volume. The overarching goal of the study is to longitudinally track biological systems implicated in AD to reveal the dynamics between these systems during the intervention to understand differences in treatment response.

RESULTS

We have developed and implemented a protocol for a personalized, multimodal intervention program for early AD patients. We began enrollment in September 2019; we have enrolled a third of our target (20 of 60) with a 95% retention and 86% compliance rate.

DISCUSSION

This study presents a paradigm shift in designing multimodal, lifestyle interventions to reduce cognitive decline, and how to elucidate the biological systems being targeted. Analytical efforts to explain mechanistic or causal underpinnings of individual trajectories and the interplay between multi-omic variables will inform the design of future hypotheses and development of effective precision medicine trials.

Ethanol embolization of arteriovenous fistulas: a primary mode of therapy

Arteriovenous fistulas (AVFs) can be posttraumatic or congenital vascular malformations. In the initial arteriographic evaluation, chronic AVFs potentially can be confused with arteriovenous malformations (AVMs). The authors studied five patients with a single AVF and one patient with numerous AVFs. Three patients had undergone surgery for treatment of their AVFs, one patient had undergone isobutyl-2-cyanoacrylate (IBCA) embolization, and two patients had undergone no prior therapy. The AVFs recurred in the three patients who had undergone surgery and in the patient who had undergone IBCA embolization. All patients underwent ethanol embolization of their AVFs. Angiograms obtained immediately after embolization documented closure of all AVFs. At follow-up, none of the embolized lesions have recurred. The authors conclude that ethanol embolotherapy can cure these problematic lesions. Extreme caution, however, must be employed with the use of intravascular ethanol because nontarget embolization can potentially result in tissue devitalization. In this study, two patients developed a small focal area of skin necrosis that did not require skin grafting and healed with conservative management.

Giant intracranial aneurysms: MR imaging

Fifteen patients with giant intracranial aneurysms were examined with magnetic resonance (MR) imaging, computed tomography (CT), and angiography. MR imaging revealed a rounded extraaxial mass with evidence of intraluminal blood flow in 12 of the 15 cases. Signal void within the lumen was seen in all 12 of these cases. Other flow effects, such as even-echo rephasing, were seen in some cases. Complete thrombosis was seen in three giant aneurysms in which high signal intensity on T1- and T2-weighted images filled the lumen, and no flow effects were seen. Partial thrombosis was detected in four aneurysms as persistent areas of medium to high signal intensity within the lumen on T1- and T2-weighted images. In five cases, the cause of the intraluminal signal that was present was difficult to determine. The ability of MR to indicate flow within the lumen in 12 of 15 cases provided for greater diagnostic confidence than with CT, which was strongly suggestive of an extraaxial tumor in nine patients. Calcification of the wall of the aneurysm was better detected with CT.