A European Academy of Neurology guideline on medical management issues in dementia

BACKGROUND AND PURPOSE

Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow-up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia.

METHODS

A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated.

RESULTS

Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk-benefit ratio should be performed at regular intervals. Regular, preplanned medical follow-up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non-pharmacological measures have been proven to be without benefit or in the case of severe self-harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first-line therapy (Good Practice statement).

CONCLUSION

This GRADE-based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas.

Predicted and measured disorder in peripherin/rds, a retinal tetraspanin

Vertebrate photoreceptor outer segment (OS) morphogenesis requires peripherin/rds (P/rds). We have characterized this protein's C-terminus and present evidence that suggests it is intrinsically disordered. We propose that structural flexibility may underlie the multifunctionality proposed for this domain previously. The extremely short C-termini present in other tetraspanin family members suggest that intrinsic disorder may also play a role for those proteins.

Ontogeny of ionotropic glutamate receptor expression in human fetal brain

Glutamate receptors have multiple roles in the central nervous system. Recent evidence suggests that the iontropic glutamate receptors are critical during brain development, particularly for corticogenesis, neuronal migration, and synaptogenesis. In this study, we examined subunit mRNA expression and binding sites of the NMDA, AMPA, and kainate receptors from gestational weeks 8-20 in human fetal brain. Expression of glutamate receptors was high during several periods in these brains. Different levels of expression of each NMDA, AMPA, and kainate receptor subunit transcripts were present during development, with a greater abundance of NR1, NR2B, NR2D, GluR7, and KA1 mRNA at most gestational ages. Binding sites for NMDA, AMPA, and kainate receptors were all detected, but each had a unique pattern of expression. These results demonstrate that glutamate receptors are expressed early in human brain development, and undergo complex changes over time consistent with their role in normal development.

Tissue inhibitor of metalloproteinases-1 (TIMP-1) binds to the cell surface and translocates to the nucleus of human MCF-7 breast carcinoma cells

To study cellular and subcellular localization of TIMP-1, we constructed a cDNA which would express a chimeric protein, TIMP-1-EGFP, having the enhanced green fluorescent protein of the jelly fish Aequorea victoria fused to the carboxyl-terminus of TIMP-1. Chinese Hamster Ovary (CHO) cells were stably transfected with the TIMP-1-EGFP expressing plasmid. The secreted chimera was processed through the endoplasmic reticulum and Golgi, as was shown by fluorescent confocal microscopy after incubations at temperatures which block processing at the intermediate compartment and the trans-Golgi network. In a co-culture system, secreted TIMP-1-EGFP could be visualized binding to the surface of MCF-7 breast carcinoma cells but not non-neoplastic HBL-100 breast epithelial cells. TIMP-1-EGFP localized to the nucleus of MCF-7 cells after 72 hrs in co-culture. These findings suggest that TIMP-1 may preferentially bind to and be taken up by malignant breast epithelial cells and that TIMP-1 may play a yet unidentified role in nuclear functions.

Biochemical characterization of MIP-1 alpha nuclear protein

A family of hematopoietic specific transcription factors, MIP-1 alpha nuclear protein (MNP) family, has recently been identified. They are intimately involved in regulating the transcription of the huMIP-1 alpha gene in monocytes, T-cells, and transformed B-cells. One member of the family (MNP-1) is essential for promoter activity in monocytes and B-cells, while another (MNP-2) is required for full promotor activity in T-cells. A third member of the family (MNP-3) is expressed in PMA induced HL60 cells and probably has a role in monocyte differentiation. In this communication we demonstrate by two techniques that MNP-1 and MNP-2 are distinct but related factors, and we present further evidence to show that MNP-1 acts as a heterodimer.

Stimulatory effect of endogenous tissue inhibitor of metalloproteinases-1 (TIMP-1) overexpression on type IV collagen and laminin gene expression in rat mammary carcinoma cells

We recently reported enhanced tumor growth and stimulation of vascular endothelial growth factor (VEGF) expression in rat mammary carcinoma cells transfected with a human tissue inhibitor of metalloproteinases-1 (hTIMP-1) cDNA (1). In the present study, we examined if the composition of the stroma was altered in the tumors with the highest hTIMP-1 production. Immunohistological examination revealed increased amounts of the basement membrane (BM) components, type IV collagen and laminin, in the hTIMP-1 overexpressing tumors compared to that of the control. In vitro studies also revealed upregulation of type IV collagen and laminin gene expression associated with the hTIMP-1 overexpression. Endogenous RNA levels of rat TIMP-1 and the rat matrix metalloproteinases (MMPs), MMP-2, MMP-3, and MMP-9, were not affected by the hTIMP-1 transfection, suggesting that the increase in BM deposition was not a result of decreased collagenolytic activity. This is the first report to show an association between overexpression of TIMP-1 and increased tumor BM matrix production through stimulation of type IV collagen and laminin gene expression.

Antipsychotic regulation of hippocampal dopamine receptor messenger RNA expression

Medial temporal lobe structures including the hippocampus and entorhinal cortex have been implicated in the pathophysiology of schizophrenia. Markers of dopaminergic neurotransmission indicate that these regions receive dopaminergic innervation. Accordingly, dysfunction of dopaminergic neurotransmission within the hippocampus and associated cortical areas may be associated with schizophrenia. Little is known, however, about the expression and regulation of dopamine receptors in these regions. We determined the effects of 14 days of clozapine or haloperidol treatment on dopamine receptor messenger RNA (mRNA) expression in medial temporal regions of the rat brain by in situ hybridization. These two drugs had different effects in the hippocampus and entorhinal cortex, particularly a dissociation of their effects on D2 and D3 receptor mRNA expression. There was a parallel down-regulation of D4 mRNA by both drugs. D1 and D5 transcripts were not regulated by either treatment. These results suggest a differential pattern of regulation of D2-like receptor expression by clozapine and haloperidol in some medial temporal lobe structures. These drugs also appear to cause changes in the expression of these transcripts that differ from what has been reported in the striatum, adding to a growing literature suggesting that hippocampal and striatal dopamine receptors are differentially regulated.

HIV-1 tat induces the expression of a new hematopoietic cell-specific transcription factor and downregulates MIP-1 alpha gene expression in activated T-cells

MIP-1 alpha is a secreted chemokine which can inhibit hematopoietic stem cells and modulate inflammatory responses. It is also an inhibitor of HIV replication in CD8+ T-cells. The expression of MIP-1 alpha is induced during cellular activation of CD4+ T-cells and monocytes. It is also expressed in transformed B-cells. We have previously identified a new transcription factor family (the MNP family) whose expression is crucial for the induction of MIP-1 alpha transcription during cellular activation and in transformed B cells. Monocytes and transformed B-cells normally express MNP-1 strongly and MNP-2 weakly, while T-cells strongly express only MNP-2. Recently, we reported that HIV-1 tat downregulates MIP-1 alpha expression in Jurkat T-cells. In this report we show induction of MNP-1 in Jurkat T-cells expressing HIV-1 tat. Expression of neither HTLV-1 tax in Jurkat T-cells nor EBV in B-cells had any effect on MNP-1 or MNP-2 expression, showing that the effect is specific for HIV-1 tat. We propose that HIV-1 tat may inhibit MIP-1 alpha expression by inducing MNP-1 expression in T-cells, probably by either competing with MNP-2 for binding to the MIP-1 alpha promoter or by sequestering it into inactive forms.

MIP1 alpha nuclear protein (MNP), a novel transcription factor expressed in hematopoietic cells that is crucial for transcription of the human MIP-1 alpha gene

Murine macrophage inflammatory protein 1 alpha (MIP-1 alpha) and its human equivalent (GOS19, LD78, or AT464) are members of the -C-C family of low-molecular-weight chemokines. Secreted from activated T cells and macrophages, bone marrow-derived MIP-1 alpha/GOS19 inhibits primitive hematopoietic stem cells and appears to be involved in the homeostatic control of stem cell proliferation. It also induces chemotaxis and inflammatory responses in mature cell types. Therefore, it is important to understand the mechanisms which control the expression of MIP-1 alpha/GOS19. Previous work has shown that in Jurkat T cells, a set of widely expressed transcription factors (the ICK-1 family) affect the GOS19 promoter. One member, ICK-1A, behaves as a strong negative regulator. In this communication, we provide evidence that the pathway of induction in the macrophage cell line U937 is different from that in Jurkat cells. Furthermore, we show that the ICK-1 binding site does not confer negative regulation in U937 cells. We provide evidence for an additional binding site, the MIP-1 alpha nuclear protein (MNP) site, which overlaps the ICK-1 site. Interaction of nuclear extracts from various cell lines and tissue with the MNP site leads to the formation of fast-migrating protein-DNA complexes with similar but distinct electrophoretic mobilities. A mutation of the MNP site which does not abrogate ICK-1 binding inactivates the GOS19.1 promoter in U937 cells and reduces its activity by fourfold in Jurkat cells. We propose that the MNP protein(s) binding at the MNP site constitutes a novel transcription factor(s) expressed in hematopoietic cells.