Personalized and Precision Medicine 2022

Anne-Marie Caminade

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Anne-Marie Caminade. Personalized and Precision Medicine 2022. MDPI, pp.272, 2023, 978-3-0365-7045-7. 10.3390/books978-3-0365-7044-0. hal-04058706

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Journal of
*Personalized*
*Medicine*

Personalized
and Precision
Medicine 2022

Edited by

Anne-Marie Caminade

Printed Edition of the Special Issue Published in
*Journal of Personalized Medicine*
Personalized and Precision Medicine
2022
<figure><img src="image_3.png" /></figure>
Personalized and Precision Medicine
2022

Editor

Anne-Marie Caminade

MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin

<figure><img src="image_4.png" /></figure>
Editor

Anne-Marie Caminade
Laboratoire de Chimie de
Coordination (LCC)
CNRS
Toulouse
France

Editorial Office

MDPI
St. Alban-Anlage 66
4052 Basel, Switzerland

This is a reprint of articles from the Special Issue published online in the open access journal *Journal of Personalized Medicine* (ISSN 2075-4426) (available at: www.mdpi.com/journal/jpm/special_issues/pemed_2021).

For citation purposes, cite each article independently as indicated on the article page online and as indicated below:

Last Name, A.A.; Last Name, B.B.; Last Name, C.C. Article Title. *Journal Name Year, Volume Number, Page Range*.

ISBN 978-3-0365-7045-7 (Hbk)

ISBN 978-3-0365-7044-0 (PDF)

© 2023 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications.

The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND.
# Contents

About the Editor ix

Preface to "Personalized and Precision Medicine 2022" xi

Anne-Marie Caminade
Personalized and Precision Medicine 2022
Reprinted from: J. Pers. Med. 2023, 13, 459, doi:10.3390/jpm13030459 1

Giulia Giacomucci, Cristina Polito, Valentina Berti, Sonia Padiglioni, Giulia Galdo and Salvatore Mazzeo et al.
Differences and Similarities in Empathy Deficit and Its Neural Basis between Logopenic and Amnesic Alzheimer's Disease
Reprinted from: J. Pers. Med. 2023, 13, 208, doi:10.3390/jpm13020208 5

Katarína Hubčíková, Tomáš Rakús, Alžbeta Mühlbäck, Ján Benetin, Lucia Bruncvik and Zuzana Petrášová et al.
Psychosocial Impact of Huntington's Disease and Incentives to Improve Care for Affected Families in the Underserved Region of the Slovak Republic
Reprinted from: J. Pers. Med. 2022, 12, 1941, doi:10.3390/jpm12121941 23

Viviana Nociti and Marina Romozzi
Multiple Sclerosis and Autoimmune Comorbidities
Reprinted from: J. Pers. Med. 2022, 12, 1828, doi:10.3390/jpm12111828 39

Karyn G. Robinson, Adam G. Marsh, Stephanie K. Lee, Jonathan Hicks, Brigette Romero and Mona Batish et al.
DNA Methylation Analysis Reveals Distinct Patterns in Satellite Cell-Derived Myogenic Progenitor Cells of Subjects with Spastic Cerebral Palsy
Reprinted from: J. Pers. Med. 2022, 12, 1978, doi:10.3390/jpm12121978 51

Sang-Cheol Im, Seong-Wook Seo, Na-Yeon Kang, Hoon Jo and Kyoung Kim
The Effect of Lumbar Belts with Different Extensibilities on Kinematic, Kinetic, and Muscle Activity of Sit-to-Stand Motions in Patients with Nonspecific Low Back Pain
Reprinted from: J. Pers. Med. 2022, 12, 1678, doi:10.3390/jpm12101678 69

Dominik Rak, Alexander J. Nedopil, Eric C. Sayre, Bassam A. Masri and Maximilian Rudert
Postoperative Inpatient Rehabilitation Does Not Increase Knee Function after Primary Total Knee Arthroplasty
Reprinted from: J. Pers. Med. 2022, 12, 1934, doi:10.3390/jpm12111934 83

Minji Kim, Jingwen Li, Sehyang Kim, Wonho Kim, Sun-Hyun Kim and Sung-Min Lee et al.
Individualized 3D-Printed Bone-Anchored Maxillary Protraction Device for Growth Modification in Skeletal Class III Malocclusion
Reprinted from: J. Pers. Med. 2021, 11, 1087, doi:10.3390/jpm11111087 91

Medi Kori, Gullu Elif Ozdemir, Kazim Yalcin Arga and Raghu Sinha
A Pan-Cancer Atlas of Differentially Interacting Hallmarks of Cancer Proteins
Reprinted from: J. Pers. Med. 2022, 12, 1919, doi:10.3390/jpm12111919 103

Arisa Djurian, Tomohiro Makino, Yeongjoo Lim, Shintaro Sengoku and Kota Kodama
Dynamic Collaborations for the Development of Immune Checkpoint Blockade Agents
Reprinted from: J. Pers. Med. 2021, 11, 460, doi:10.3390/jpm11060460 119
Victoria Eriksson, Oscar Holmkvist, Ylva Huge, Markus Johansson, Farhood Alamdari and Johan Svensson et al.

A Retrospective Analysis of the De Ritis Ratio in Muscle Invasive Bladder Cancer, with Focus on Tumor Response and Long-Term Survival in Patients Receiving Neoadjuvant Chemotherapy and in Chemo Naïve Cystectomy Patients—A Study of a Clinical Multicentre Database
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1769, doi:10.3390/jpm12111769
131

Harriet Rydell, Anna Ericson, Victoria Eriksson, Markus Johansson, Johan Svensson and Viqar Banday et al.

Thromboembolic Events in Patients Undergoing Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Study of Renal Impairment in Relation to Potential Thromboprophylaxis
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1961, doi:10.3390/jpm12121961
143

Ishika Mahajan, Aruni Ghose, Deepika Gupta, Manasi Manasvi, Saisha Bhandari and Aparimita Das et al.

COVID-19, Mucormycosis and Cancer: The Triple Threat—Hypothesis or Reality?
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1119, doi:10.3390/jpm12071119
153

Kostas Archontogeorgis, Athanasios Voulgaris, Evangelia Nena, Athanasios Zissimopoulos, Izolde Bouloukaki and Sophia E. Schiza et al.

Vitamin D Levels in Patients with Overlap Syndrome, Is It Associated with Disease Severity?
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1693, doi:10.3390/jpm12101693
169

Seung-Su Ha and Dong-Kyu Kim

Diagnostic Efficacy of Ultra-Short Term HRV Analysis in Obstructive Sleep Apnea
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1494, doi:10.3390/jpm12091494
179

Keh-Sen Liu, Yao-Shen Tong, Ming-Tsung Lee, Hung-Yu Lin and Min-Chi Lu

Risk Factors of 30-Day All-Cause Mortality in Patients with Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infection
Reprinted from: *J. Pers. Med.* **2021**, *11*, 616, doi:10.3390/jpm11070616
191

Heh-Shiang Sheu, Yi-Ming Chen, Yi-Ju Liao, Chia-Yi Wei, Jun-Peng Chen and Hsueh-Ju Lin et al.

Thiopurine S-Methyltransferase Polymorphisms Predict Hepatotoxicity in Azathioprine-Treated Patients with Autoimmune Diseases
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1399, doi:10.3390/jpm12091399
203

Simon Reider, Christina Watschinger, Julia Längle, Ulrike Pachmann, Nicole Przysiecki and Alexandra Pfister et al.

Short- and Long-Term Effects of a Prebiotic Intervention with Polyphenols Extracted from European Black Elderberry—Sustained Expansion of Akkermansia spp.
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1479, doi:10.3390/jpm12091479
213

Anna Russo, Alfonso Reginelli, Giorgia Viola Lacasella, Enrico Grassi, Michele Ahmed Antonio Karaboue and Tiziana Quarto et al.

Clinical Application of Ultra-High-Frequency Ultrasound
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1733, doi:10.3390/jpm12101733
229

Valerio Nardone, Emma D'Ippolito, Roberta Grassi, Angelo Sangiovanni, Federico Gagliardi and Giuseppina De Marco et al.

Non-Oncological Radiotherapy: A Review of Modern Approaches
Reprinted from: *J. Pers. Med.* **2022**, *12*, 1677, doi:10.3390/jpm12101677
241
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# About the Editor

## Anne-Marie Caminade

Anne-Marie Caminade is Director of Research Exceptional Class at the CNRS (Centre National de la Recherche Scientifique), Deputy Director of the Laboratoire de Chimie de Coordination (LCC) in Toulouse, and head of the "dendrimers and heterochemistry" team. She is co-author of about 510 publications and 18 patents, and previously Editor of two books (2011 and 2018). Her h-index is 77. She recently received Prizes from the French (SCF) and German (GDCh) Chemical Societies. She is a member of the Academia Europaea and of the European Academy of Sciences. Her current research interest is on the synthesis and study of properties of hyperbranched macromolecules named dendrimers, with an emphasis on their properties in nanomedicine.
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Preface to "Personalized and Precision Medicine
2022"

The origin of this Special Issue about "Personalized and Precision Medicine 2022" of the Journal of Personalized Medicine is the International Conference on Personalized and Precision Medicine PEMED 2021, which occurred online on 7-9 April 2021, after three editions organized in Paris (25-27 June 2018), Barcelona (15-17 May 2019), and Munich (19-21 February 2020). The diversity of studies carried out in connection with personalized and precision medicine was clearly emphasized during these International Conferences, and is also observed in the 20 papers of this Special Issue. The most represented topics concern brain diseases, cancers, lungs obstruction, and muscles and skeletal diseases. Other topics concern in particular the intestinal microbiome or COVID-19, emerging methods for imaging and using radiotherapy, and a promising new class of therapeutic molecules, the dendrimers.

Contributions by V. Bessi et al. (Alzheimer's disease), K. Hubčíková et al. (Huntington's disease), V. Nocity et al. (multiple sclerosis), R.E. Akins et al. (muscle dysfunction), K. Kim et al. (low back pain), D. Rak et al. (inpatient rehabilitation after knee surgery), J.-W. Kim et al. (3D titanium printing in orthodontics), K.Y. Arga, R. Sinha et al. (cancer hallmark proteins), K. Kodama et al. (interorganizational collaboration in cancer), A. Sherif et al. (2 papers about bladder cancers), S. Boussios et al. (COVID-19 in cancer patients), P. Steiropoulos et al. and D.-K. Kim et al. (two approaches of obstructive sleep apnea), M.-C. Lu et al. (blood-stream infection), W.-T. Hung et al. (auto-immune diseases), A.R. Moschen et al. (microbiome), D. Berritto et al. (ultra-high-frequency ultrasound), V. Nardone et al. (non-oncological radiotherapy), and A.-M. Caminade (dendrimers) illustrate the present and future impact of Personalized and Precision Medicine on all the therapeutic domains.

I wish to thank all the authors who contributed their work, and in so doing made this Special Issue a success. I also wish to thank the staff of JPM for their excellent support throughout the editorial process.

Anne-Marie Caminade

Editor
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Editorial

# Personalized and Precision Medicine 2022

Anne-Marie Caminade <fnref n="1" />,<fnref n="2" /> ID

This Special Issue, "Personalized and Precision Medicine 2022" (https://www.mdpi.com/journal/jpm/special_issues/pemed_2021 (accessed on 24 February 2023)), in the Journal of Personalized Medicine, was first proposed at the International Conference on Personalized and Precision Medicine PEMED 2021, which occurred online on 7-9 April 2021 (https://premc.org/conferences/pemed-personalized-precision-medicine/ (accessed on 24 February 2023)), after three editions organized in Paris (25-27 June 2018), Barcelona (15-17 May 2019), and Munich (19-21 February 2020). The diversity of studies carried out in connection with personalized and precision medicine was clearly emphasized during these international conferences, as also observed in the 20 papers of this Special Issue. The most represented topics concern brain diseases, cancers, lungs obstruction, muscles, and skeletal diseases. Other specific topics include the intestinal microbiome or COVID-19, emerging methods for imaging and using radiotherapy, and a promising new class of therapeutic molecules known as dendrimers.

Alzheimer's disease is the most prevalent brain disease and can take several clinical presentations. The article by V. Bessi et al. [1] compares the empathy deficit and its neural basis for Alzheimer's patients with either logopenic primary progressive aphasia or amnesia. Metabolic disfunctions were observed in different brain regions, depending on the type of the Alzheimer's disease, but they induce the same damage of cognitive empathy and personal distress over time. Contrary to Alzheimer's disease, Huntington's disease has a low prevalence, but it causes a long-lasting burden in affected families. The article by K. Hubčíková et al. [2] discusses the psychosocial impact of this disease on the affected families in the Slowak Republic. Comprehensive genetic counselling, including the possibility of preimplantation genetic diagnosis, can particularly mitigate the psychosocial effects and burden induced by Huntington's disease. Multiple sclerosis is a chronic inflammatory and neurodegenerative disease of the central nervous system, frequently associated with multisystem comorbidities. The review by V. Nocity et al. [3] summarizes the available data on the incidence and prevalence of autoimmune diseases in multiple sclerosis, their effect on the clinical course of the disease, and their impact on the treatment choice.

Spastic-type cerebral palsy is a brain disease that induces a complex neuromuscular disorder, involving altered skeletal muscle microanatomy and growth. The paper by R.E. Akins et al. [4] focuses on the poorly studied mechanisms that contribute to muscle pathophysiology and dysfunction. They examined whether a diagnosis of spastic cerebral palsy is associated with intrinsic DNA methylation differences in myoblasts and myotubes derived from muscle-resident stem cell populations. A comparison of the skeletal muscle biopsies obtained during orthopedic surgeries between patients with and without spastic cerebral palsy demonstrated fundamental differences in DNA methylation, which may reveal new targets for studies of mechanisms that contribute to muscle dysregulation. A very different paper concerning muscles is proposed by K. Kim et al. [5], which investigates the effect of different lumbar belts in patients with nonspecific low back pain. Measurements taken by a three-dimensional motion analysis device, force plate, and surface electromyography demonstrated the positive effect of extensible lumbar belts.

**Citation:** Caminade, A.-M.
Personalized and Precision Medicine
2022. *J. Pers. Med.* **2023**, *13*, 459.
https://doi.org/10.3390/jpm13030459

Received: 27 February 2023

Accepted: 28 February 2023

Published: 1 March 2023

<figure><img src="image_9.png" /></figure>

**Copyright:** © 2023 by the author.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

<footnote n="1">¹ Laboratoire de Chimie de Coordination (LCC), CNRS UPR8241, 205 Route de Narbonne, CEDEX 4, 31077 Toulouse, France; anne-marie.caminade@lcc-toulouse.fr</footnote>

<footnote n="2">² LCC-CNRS, Université de Toulouse, CNRS, Toulouse, France</footnote>
Orthopedic surgeries are frequently followed by inpatient rehabilitation. The paper by D. Rak et al. [6] posed the question of comparing the efficiency between “classical” and expensive rehabilitation or fast-track rehabilitation for inpatients after total knee replacement. It is shown that one year after surgery, impatient rehabilitation does not provide long-term benefits over fast-track rehabilitation. In some cases, orthodontic malocclusion necessitates bone-anchored maxillary protraction, which induces infection or device failures that occur with conventional plates. The paper by J.-W. Kim et al. [7] displays a pilot prospective study using preoperative simulation and the 3D titanium printing of customized plates. Better results were obtained with these customized plates after two years, showing that this method is effective in treating skeletal malocclusion.

Four papers in this Special Issue are based on cancer, which is one of the leading causes of death. The paper by K.Y. Arga and R. Sinha et al. [8] explores cancer hallmark proteins in different cancer types, studied with the aim of discovering measurable indicators. A pan-cancer analysis to map differentially interacting hallmarks of cancer proteins associated with 12 common cancers was carried out. The study presents candidate systems' biomarkers that may be valuable for improving personalized treatment strategies for various cancers. The review by K. Kodama et al. [9] proposes a large overview of the discovery and development of 107 anticancer drugs, in connection with interorganizational collaboration, from 1998 to 2018. It is shown that immune checkpoint blockade agents are a significantly active area in interorganizational transactions, suggesting that such types of agents are a paradigm for cancer treatment, resulting in huge product sales and continuous indication expansion.

Two papers from the same group focus on the treatment of bladder cancers. The first of the two, by A. Sherif et al. [10], uses a clinical multicenter database to demonstrate that a high aspartate transaminase–alanine aminotransferase ratio (De Ritis ratio) before treatment of muscle invasive bladder cancer is associated with increased mortality. However, this ratio cannot be used for downstaging prediction. The second paper by A. Sherif et al. [11] investigates thromboembolic events in patients with muscle-invasive bladder cancer undergoing neoadjuvant chemotherapy. It was suggested that low-molecular-weight heparin is a possible prophylaxis, but a high incidence of decreased renal function was observed in these patients. Amongst the neoadjuvant-chemotherapy-administered patients with thromboembolic events, 41% of patients had decreased renal function, thus, reducing the likelihood of them benefitting from low-molecular-weight heparin prophylaxis.

The review by S. Boussios et al. [12] focuses on three massive healthcare threats (cancer, mucormycosis, and COVID-19), and the danger of one of these diseases becoming predisposed to another. The conclusion was that COVID-19 and mucormycosis pose a larger risk in cancer patients.

Besides the COVID-19 virus, various other obstructive lung diseases are known. The paper by P. Steiropoulos et al. [13] evaluates vitamin D serum levels in patients with obstructive sleep apnea, eventually associated with chronic obstructive pulmonary disease (such an association is defined as the overlap syndrome). Lower vitamin D levels have been observed in patients with overlap syndrome compared with obstructive sleep apnea patients and non-apneic controls, which might be associated with disease severity. Another paper by D.-K. Kim et al. [14] on patients with obstructive sleep apnea proposes an ultra-short-term analysis to detect the balance of autonomic nervous system activity. The overall heart rate variability feature alterations obtained by this method indicated sympathetic overactivity dependent on obstructive sleep apnea severity. The risk factors of mortality in patients with carbapenem-resistant *Klebsiella pneumoniae* bloodstream infection are analyzed in the paper by M.-C. Lu et al. [15]. No effective antimicrobial regimen could be identified, but diverse risk factors were identified, such as lower platelet count and a higher Pitt bacteremia score.

For instance, miscellaneous topics concern the prediction of hepatotoxicity in azathioprine-treated patients with auto-immune diseases. The paper by W.T. Hung et al. [16] studies in Asian patients with thiopurine methyltransferase, which is a rate-limiting enzyme in
azathioprine metabolization. Genetic variants in the thiopurine methyltransferase were analyzed, showing that the non-normal metabolizers were associated with hepatotoxicity. Another example discusses the intestinal microbiome. The paper by A.R. Moschen et al. [17] focuses on the short- and long-term effects of capsules of a purified extract from the European black elderberries on the microbiome composition. The supplementation was well tolerated, and changes in species abundance were observed over time. In particular, the relative abundance of *Akkermansia* spp., which may have beneficial effects on inflammation and metabolism, continued to increase in a subset of participants, even beyond the supplementation period.

Two different physical techniques are presented. The clinical applications of ultra-high-frequency ultrasound are proposed by D. Berritto et al. [18] for the study of many superficial targets, within the first 3 cm of skin surface. The high spatial resolution of this technic is especially suitable for innovations to diagnostic imaging of hands, wrists, and feet. A review of the modern approaches of non-oncological radiotherapy is proposed by V. Nardone et al. [19]. Different disorders such as heart tachycardia, soft tissue disorders, muscle-skeletal disorders, osteoarthritis and osteoarthrosis, neurological disorders, and Graves' ophthalmopathy are considered.

Finally, an emerging family of macromolecules with potential therapeutic properties, known as dendrimers, are reviewed by A.-M. Caminade [20], with emphasis on their clinical trials. Many of these clinical trials have recently been reported (2020–2022), with the aim of treating essentially bacterial vaginosis, cancers, and COVID-19.

Overall, the twenty papers in this Special Issue constitute an impressionist overview of the state-of-the-art research in the field of personalized and precision medicine, with some perspectives on the future of this topic.

**Acknowledgments:** I wish to thank all the authors who contributed their work and made the Special Issue a success in doing so. I also wish to thank the staff of JPM for their excellent support throughout the editorial process.

**Conflicts of Interest:** The author declares no conflict of interest.

## References

1. Giacomucci, G.; Polito, C.; Berti, V.; Padiglioni, S.; Galdo, G.; Mazzeo, S.; Bergamin, E.; Moschini, V.; Morinelli, C.; Nuti, C.; et al. Differences and Similarities in Empathy Deficit and Its Neural Basis between Logopenic and Amnesic Alzheimer's Disease. *J. Pers. Med.* **2023**, *13*, 208. [CrossRef] [PubMed]

2. Hubčíková, K.; Rakús, T.; Mühlbäck, A.; Benetin, J.; Bruncvik, L.; Petrášová, Z.; Bušková, J.; Brunovský, M. Psychosocial Impact of Huntington's Disease and Incentives to Improve Care for Affected Families in the Underserved Region of the Slovak Republic. *J. Pers. Med.* **2022**, *12*, 1941. [CrossRef] [PubMed]

3. Nociti, V.; Romozzi, M. Multiple Sclerosis and Autoimmune Comorbidities. *J. Pers. Med.* **2022**, *12*, 1828. [CrossRef] [PubMed]

4. Robinson, K.G.; Marsh, A.G.; Lee, S.K.; Hicks, J.; Romero, B.; Batish, M.; Crowgey, E.L.; Shrader, M.W.; Akins, R.E. DNA Methylation Analysis Reveals Distinct Patterns in Satellite Cell-Derived Myogenic Progenitor Cells of Subjects with Spastic Cerebral Palsy. *J. Pers. Med.* **2022**, *12*, 1978. [CrossRef] [PubMed]

5. Im, S.-C.; Seo, S.-W.; Kang, N.-Y.; Jo, H.; Kim, K. The Effect of Lumbar Belts with Different Extensibilities on Kinematic, Kinetic, and Muscle Activity of Sit-to-Stand Motions in Patients with Nonspecific Low Back Pain. *J. Pers. Med.* **2022**, *12*, 1678. [CrossRef] [PubMed]

6. Rak, D.; Nedopil, A.J.; Sayre, E.C.; Masri, B.A.; Rudert, M. Postoperative Inpatient Rehabilitation Does Not Increase Knee Function after Primary Total Knee Arthroplasty. *J. Pers. Med.* **2022**, *12*, 1934. [CrossRef] [PubMed]

7. Kim, M.; Li, J.; Kim, S.; Kim, W.; Kim, S.-H.; Lee, S.-M.; Park, Y.L.; Yang, S.; Kim, J.-W. Individualized 3D-Printed Bone-Anchored Maxillary Protraction Device for Growth Modification in Skeletal Class III Malocclusion. *J. Pers. Med.* **2021**, *11*, 1087. [CrossRef] [PubMed]

8. Kori, M.; Ozdemir, G.E.; Arga, K.Y.; Sinha, R. A Pan-Cancer Atlas of Differentially Interacting Hallmarks of Cancer Proteins. *J. Pers. Med.* **2022**, *12*, 1919. [CrossRef] [PubMed]

9. Djurian, A.; Makino, T.; Lim, Y.; Sengoku, S.; Kodama, K. Dynamic Collaborations for the Development of Immune Checkpoint Blockade Agents. *J. Pers. Med.* **2021**, *11*, 460. [CrossRef] [PubMed]
10. Eriksson, V.; Holmkvist, O.; Huge, Y.; Johansson, M.; Alamdari, F.; Svensson, J.; Aljabery, F.; Sherif, A. A Retrospective Analysis of the De Ritis Ratio in Muscle Invasive Bladder Cancer, with Focus on Tumor Response and Long-Term Survival in Patients Receiving Neoadjuvant Chemotherapy and in Chemo Naïve Cystectomy Patients—A Study of a Clinical Multicentre Database. *J. Pers. Med.* **2022**, *12*, 1769. [CrossRef] [PubMed]

11. Rydell, H.; Ericson, A.; Eriksson, V.; Johansson, M.; Svensson, J.; Banday, V.; Sherif, A. Thromboembolic Events in Patients Undergoing Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Study of Renal Impairment in Relation to Potential Thromboprophylaxis. *J. Pers. Med.* **2022**, *12*, 1961. [CrossRef] [PubMed]

12. Mahajan, I.; Ghose, A.; Gupta, D.; Manasvi, M.; Bhandari, S.; Das, A.; Sanchez, E.; Boussios, S. COVID-19, Mucormycosis and Cancer: The Triple Threat—Hypothesis or Reality? *J. Pers. Med.* **2022**, *12*, 1119. [CrossRef] [PubMed]

13. Archontogeorgis, K.; Voulgaris, A.; Nena, E.; Zissimopoulos, A.; Bouloukaki, I.; Schiza, S.E.; Steiropoulos, P. Vitamin D Levels in Patients with Overlap Syndrome, Is It Associated with Disease Severity? *J. Pers. Med.* **2022**, *12*, 1693. [CrossRef] [PubMed]

14. Ha, S.-S.; Kim, D.-K. Diagnostic Efficacy of Ultra-Short Term HRV Analysis in Obstructive Sleep Apnea. *J. Pers. Med.* **2022**, *12*, 1494. [CrossRef] [PubMed]

15. Liu, K.-S.; Tong, Y.-S.; Lee, M.-T.; Lin, H.-Y.; Lu, M.-C. Risk Factors of 30-Day All-Cause Mortality in Patients with Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infection. *J. Pers. Med.* **2021**, *11*, 616. [CrossRef] [PubMed]

16. Sheu, H.-S.; Chen, Y.-M.; Liao, Y.-J.; Wei, C.-Y.; Chen, J.-P.; Lin, H.-J.; Hung, W.-T.; Huang, W.-N.; Chen, Y.-H. Thiopurine S-Methyltransferase Polymorphisms Predict Hepatotoxicity in Azathioprine-Treated Patients with Autoimmune Diseases. *J. Pers. Med.* **2022**, *12*, 1399. [CrossRef] [PubMed]

17. Reider, S.; Watschinger, C.; Längle, J.; Pachmann, U.; Przysiecki, N.; Pfister, A.; Zollner, A.; Tilg, H.; Plattner, S.; Moschen, A.R. Short- and Long-Term Effects of a Prebiotic Intervention with Polyphenols Extracted from European Black Elderberry—Sustained Expansion of Akkermansia spp. *J. Pers. Med.* **2022**, *12*, 1479. [CrossRef] [PubMed]

18. Russo, A.; Reginelli, A.; Lacasella, G.V.; Grassi, E.; Karaboue, M.A.A.; Quarto, T.; Busetto, G.M.; Aliprandi, A.; Grassi, R.; Berritto, D. Clinical Application of Ultra-High-Frequency Ultrasound. *J. Pers. Med.* **2022**, *12*, 1733. [CrossRef] [PubMed]

19. Nardone, V.; D'Ippolito, E.; Grassi, R.; Sangiovanni, A.; Gagliardi, F.; De Marco, G.; Menditti, V.S.; D'Ambrosio, L.; Cioce, F.; Boldrini, L.; et al. Non-Oncological Radiotherapy: A Review of Modern Approaches. *J. Pers. Med.* **2022**, *12*, 1677. [CrossRef] [PubMed]

20. Caminade, A.-M. Dendrimers, an Emerging Opportunity in Personalized Medicine? *J. Pers. Med.* **2022**, *12*, 1334. [CrossRef] [PubMed]

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Article

# Differences and Similarities in Empathy Deficit and Its Neural Basis between Logopenic and Amnesic Alzheimer's Disease

Giulia Giacomucci<sup>1,†</sup>, Cristina Polito<sup>2</sup>, Valentina Berti<sup>3,4 †</sup>, Sonia Padiglioni<sup>5,6</sup>, Giulia Galdo<sup>1</sup>, Salvatore Mazzeo<sup>1,2 †</sup>, Enrico Bergamin<sup>7</sup>, Valentina Moschini<sup>8</sup>, Carmen Morinelli<sup>8</sup>, Claudia Nuti<sup>7</sup>, Maria Teresa De Cristofaro<sup>4</sup>, Assunta Ingannato<sup>1 ‡</sup>, Silvia Bagnoli<sup>1</sup>, Benedetta Nacmias<sup>1,2 ‡</sup>, Sandro Sorbi<sup>1,2</sup> and Valentina Bessi<sup>1,* ‡</sup>

**Abstract:** The aims of the study were to assess empathy deficit and neuronal correlates in logopenic primary progressive aphasia (lv-PPA) and compare these data with those deriving from amnesic Alzheimer's disease (AD). Eighteen lv-PPA and thirty-eight amnesic AD patients were included. Empathy in both cognitive and affective domains was assessed by Informer-rated Interpersonal Reactivity Index (perspective taking, PT, and fantasy, FT, for cognitive empathy; empathic concern, EC, and personal distress, PD, for affective empathy) before (T0) and after (T1) cognitive symptoms' onset. Emotion recognition was explored through the Ekman 60 Faces Test. Cerebral FDG-PET was used to explore neural correlates underlying empathy deficits. From T0 to T1, PT scores decreased, and PD scores increased in both lv-PPA (PT z = -3.43, *p* = 0.001; PD z = -3.62, *p* < 0.001) and in amnesic AD (PT z = -4.57, *p* < 0.001; PD z = -5.20, *p* < 0.001). Delta PT (T0-T1) negatively correlated with metabolic disfunction of the right superior temporal gyrus, fusiform gyrus, and middle frontal gyrus (MFG) in amnesic AD and of the left inferior parietal lobule (IPL), insula, MFG, and bilateral superior frontal gyrus (SFG) in lv-PPA (*p* < 0.005). Delta PD (T0-T1) positively correlated with metabolic disfunction of the right inferior frontal gyrus in amnesic AD (*p* < 0.001) and of the left IPL, insula, and bilateral SFG in lv-PPA (*p* < 0.005). Lv-PPA and amnesic AD share the same empathic changes, with a damage of cognitive empathy and a heightening of personal distress over time. The differences in metabolic disfunctions correlated with empathy deficits might be due to a different vulnerability of specific brain regions in the two AD clinical presentations.

**Keywords:** Alzheimer's disease; logopenic variant primary progressive aphasia; empathy

**Citation:** Giacomucci, G.; Polito, C.; Berti, V.; Padiglioni, S.; Galdo, G.; Mazzeo, S.; Bergamin, E.; Moschini, V.; Morinelli, C.; Nuti, C.; et al. Differences and Similarities in Empathy Deficit and Its Neural Basis between Logopenic and Amnesic Alzheimer's Disease. *J. Pers. Med.* **2023**, *13*, 208. https://doi.org/10.3390/jpm13020208

Academic Editor: Anne-Marie Caminade

Received: 23 November 2022

Revised: 17 January 2023

Accepted: 18 January 2023

Published: 25 January 2023

<figure><img src="image_11.png" /></figure>

Copyright: © 2023 by the authors.
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## 1. Introduction

Empathy is widely recognized as the capacity to “put oneself in another’s shoes”, and it can be defined as the crucial ability to both feel and comprehend what others feel [1]. Empathy is conceptualized as a multidimensional construct regulated by unconscious affective and conscious cognitive processes [2]. Indeed, Decety and Jackson proposed the current model of empathy and suggested that empathy may be divided into two major components: affective empathy is the capacity to experience affective reactions to the

<footnote n="1">¹ Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, 50134 Florence, Italy</footnote>

<footnote n="2">² IRCCS Fondazione Don Carlo Gnocchi, 50143 Florence, Italy</footnote>

<footnote n="3">³ Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy</footnote>

<footnote n="4">⁴ Nuclear Medicine Unit, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy</footnote>

<footnote n="5">⁵ Regional Referral Centre for Relational Criticalities—Tuscany Region, 50134 Florence, Italy</footnote>

<footnote n="6">⁶ Research and Innovation Centre for Dementia-CRIDEM, AOU Careggi, 50134 Florence, Italy</footnote>

<footnote n="7">⁷ University of Florence, 50134 Florence, Italy</footnote>

<footnote n="8">⁸ SOD Neurologia I, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, 50134 Florence, Italy</footnote>

<footnote>* Correspondence: valentina.bessi@unifi.it; Tel.: +39-05-7948660; Fax: +39-05-7947484</footnote>
observed experiences of others, while cognitive empathy is the capacity to recognize and understand another’s emotional state in order to enable the observer to adopt the other’s point of view [3].

Empathy seems to be impaired in several neurodegenerative diseases. Severe loss of empathy has been widely described as a diagnostic criterion of the behavioral variant of frontotemporal dementia (bv-FTD) [4–6]. On the other hand, despite studies that explored empathy deficit in Alzheimer’s disease (AD) not showing conclusive results [7], at the state of the art, researchers agree that empathy is impaired in AD, with a predominant loss of cognitive empathy, while the affective domain seems to be spared. Recently, it has been shown that there is a peculiar involvement of brain regions related to empathy in the AD continuum: the impairment of cognitive empathy seems to start at the mild cognitive impairment (MCI) stage and may be related to a progressive involvement starting from right middle frontal gyrus in the prodromal stage, extending to the insula and superior temporal gyrus in the dementia stage. On the other hand, an increase of emotional contagion (part of affective empathy) was already found in preclinical phases, and this alteration might be related to the derangement of mirror neurons systems in parietal regions in prodromal stages and to impairment of the temporal emotion inhibition system in advanced phases [8].

Despite the growing interest in empathy and social cognition in bv-FTD and A, little is known about the potential impairment of empathy in primary progressive aphasia (PPA). The term PPA defines a group of neurodegenerative syndromes characterized by progressive, selective decline in speech and language functions [9]. According to the current classification, three main clinical variants have been identified on the basis of specific linguistic features: non-fluent/agrammatic (nfv-PPA) and semantic (sv-PPA) variants, which are considered as part of the fronto-temporal lobar degeneration (FTLD) spectrum, and logopenic variant primary progressive aphasia (lv-PPA), which is considered as an atypical presentation of AD [9]. Interestingly, compromised brain regions across variants extend beyond classical language areas, and none of them is exclusively devoted to linguistic functions [10–12]. Deficits in both cognitive and affective empathy have been described in sv-PPA and may be independent from language dysfunction [13,14]. On the other hand, while affective empathy seems to be spared in nfv-PPA, findings about cognitive empathy are far from conclusive [15]. Finally, only few reports explore empathy and emotion recognition in lv-PPA, showing a decrease in cognitive empathy outcomes when compared to the pre-morbid results alongside a marginal reduction of affective empathy [15,16]. Evidence regarding empathy in lv-PPA is still sparse and inconclusive, and the neural correlates of empathy impairment have never been explored before.

In this scenario, the aims of our study were: (1) to investigate possible empathy deficits in lv-PPA; (2) to explore the metabolic pattern associated with empathy deficit in lv-PPA by means of [18F]fluorodeoxyglucose positron emission tomography ([18F]FDG-PET); and (3) to compare empathy and its neural correlates in lv-PPA and in prototypical amnesic AD.

## 2. Materials and Methods

### 2.1. Participants

Eighteen patients with a clinical diagnosis of lv-PPA [9] and thirty-eight patients with a diagnosis of amnesic AD [17] were longitudinally included in this study. All participants underwent a comprehensive family and clinical history, general and neurological examination, extensive neuropsychological assessment, and evaluation of empathy through the Interpersonal Reactivity Index (IRI) [18,19]. Facial emotion recognition ability was assessed through the Ekman 60 Faces (EK-60 F) Test in 47 patients (34 AD and 13 lv-PPA) [20,21]. IRI and EK-60 F data of AD and lv-PPA patients were compared to those obtained in 31 subjects with subjective cognitive decline (SCD) [22]. Age at empathy assessment was defined as the age of the subject when the IRI and/or EK-60 F tests were administered. Age at onset was defined as age at the onset of complaints of cognitive symptoms. Seventy-one subjects underwent APOE genotyping.
## 2.2. Neuropsychological Evaluation, Empathy, and Facial Emotion Recognition Assessment

All subjects were evaluated by means of an extensive neuropsychological battery standardized and described in further detail elsewhere [23]. Mini-Mental State Examination was used as global measurement. Short-term verbal and spatial memory were explored through Digit Span and Corsi Tapping Test and verbal long-term memory through Rey Auditory Verbal Learning Test, Immediate Recall RVLT-I and Delayed Recall RVLT-D, and Babcock Short Story Immediate and Delayed Recall. Token Test and Category Fluency Task were used to evaluate language [23–25]. Rey–Osterrieth Complex Figure copy and recall of Rey–Osterrieth Complex Figure test were used to explore visual-spatial abilities and visuo-spatial long-term memory, respectively [26]. Dual Task [27], Phonemic Fluency Test [25], Trail Making Test (TMT) [28], and Visual Search [29] were used to explore attention/executive function. Everyday memory was assessed by means of Rivermead Behavioral Memory Test (RBMT) [30]. All raw test scores were adjusted for age, education, and gender according to the correction factor reported in validation studies for the Italian population [23,24,26–30]. Language was further assessed by SAND (Screening for Aphasia in NeuroDegeneration) [31] or ENPA (Neuropsychological Evaluation for Aphasia) [32]. The presence and severity of depressive symptoms were evaluated by means of the 22-item Hamilton Depression Rating Scale (HRSD) [33].

Empathy was evaluated by Interpersonal Reactivity Index (IRI) [18,19], which consists of a 28-item questionnaire divided in four different 7-item subscales: perspective taking (PT), fantasy (FT), empathic concern (EC), and personal distress (PD). Perspective taking and fantasy subscales explore cognitive empathy, while empathic concern and personal distress subscales are used to assess affective empathy. In. more details, PD subscale is a measure of emotional contagion [34], which is a primitive structure of affective empathy and defined as the automatic, total identification with another’s behavior in order to encourage altruistic behavior [3]. Each item of IRI consists of an affirmation, and the individual has to express the degree of agreement on a 5-point Likert scale from 1 (does not describe me/the patient at all) to 5 (describes me/the patient very well). IRI was administered to the informants [35]. Caregivers had to rate patients’ empathy before (T0) and after (T1) cognitive symptoms’ onset. The differences from T0 to T1 of the scores of each scale were quantified as Delta (Δ): ΔFT, ΔPT, ΔEC, and ΔPD.

Facial emotion recognition was assessed by Ekman 60 Faces (EK-60 F) Test, which consists of 60 black and white pictures of the Ekman and Friesen series of Pictures of Facial Affect [20], representing the faces of ten actors (six women and four men), each of which shows one of six basic emotions (anger, sadness, happiness, fear, disgust, or surprise). A global score (EK-60 F global score) of 60 indicates the best possible performance. Each basic emotion has a sub-score of a maximum of 10 points. Images were shown each for 5 s according to the Ekman and Friesen procedure [20] via Power Point presentation on a computer. Patients were asked to indicate which of the basic emotions better represents the facial emotion shown on the display [21].

## 2.3. Apolipoprotein E (APOE) Genotyping

Patients’ DNA was extracted from peripheral blood samples by use of a standard automated method (QIAcube, QIAGEN Hilden, Germany). APOE genotypes were investigated by HRMA [36]. Two sets of PCR primers were designed to amplify the regions encompassing rs7412 (NC_000019.9:g.45412079C > T) and rs429358 (NC_000019.9:g.45411941T > C). The APOE genotype was coded as APOE ε4– (no APOE ε4 alleles) and APOE ε4+ (presence of one or two APOE ε4 alleles).

## 2.4. Amyloidosis and Neurodegeneration Biomarkers Analysis

Amyloidosis biomarkers analysis was performed in 69 patients. Sixty-four patients (27 amnesic AD, 17 lv-PPA, 20 SCD) underwent cerebrospinal fluid (CSF) biomarkers analysis.

The CSF samples were collected at 8 a.m. by lumbar puncture, immediately centrifuged, and stored at –80 °C until performing the analysis. Aβ1-42, Aβ1-42/1-40 ratio,
t-tau, and p-tau were measured using a chemiluminescent enzyme immunoassay (CLEIA) analyzer LUMIPULSE G600 (Fujirebio). Fujirebio guidelines determined cut-off values (Diagnostic sensitivity and specificity using clinical diagnosis and follow-up golden standard. 19 November 2018), which were Aβ1-42 > 670 pg/mL, Aβ42/40 ratio > 0.062, t-tau < 400 pg/mL, and p-tau < 60 pg/mL [37].

Twenty-three patients (7 amnesic AD, 6 lv-PPA, 10 SCD) underwent cerebral amyloid PET. Amyloid PET imaging was performed according to national and international guidelines [38], with any of the available fluorine18-labeled tracers (18Florbetaben (FBB)—Bayer-Pyramal, 18Flutemetamol (FMM)—General Electric). Images were rated as either positive or negative according to criteria defined by the manufacturers.

According to ATN classification [39], patients were classified as A+ if at least one of the amyloid biomarkers (CSF or amyloid PET) revealed the presence of Aβ pathology and as A- if none of the biomarkers revealed the presence of Aβ pathology. All amnesic AD and lv-PPA patients were A+.

## 2.5. FDG-PET Brain Imaging

All amnesic AD and lv-PPA patients underwent brain [18F]FDG-PET. Scans were performed using advanced hybrid PET-CT scanner in 3D list mode. Patients were instructed to fast for 6 h before the study, and blood sugar level was tested to be lower than 120 mg/dL. Patients were injected with 185 MBq of [18F]-FDG via a venous cannula. After the injection, patients were left in a dimly lit, quiet room and told to keep their eyes closed. All [18F]FDG-PET scans were acquired following the EANM guidelines [40]. All PET images were corrected for photon attenuation, scatter, and radioactive decay and reconstructed using 3D iterative algorithm. [18F]FDG-PET scans pre-processing and statistical analysis are described in Section 2.6.

## 2.6. Statistical Analysis

IBM SPSS Statistics Software Version 25 (SPSS Inc., Chicago, IL, USA) and computing environment R 4.0.3 (R Foundation for Statistical Computing, Vienna, 2013) were used to perform all statistical analysis. All p-values were two-tailed, and the significance level for all analyses was set at $\alpha = 5\%$, corresponding to a threshold *p* of 0.05. All variables are described as mean and standard deviation. Shapiro-Wilk test was used to assess the distribution of all variables. Chi-square test was used to compare categorical data. One-way ANOVA followed by Bonferroni post hoc test was used to evaluate differences among groups in continuous variables. Variation of IRI scores over time, from before to after the onset of cognitive symptoms (T0-T1), was explored through Wilcoxon signed-rank test. The influence of demographic variables and neuropsychological scores on current empathy and on facial emotion recognition ability was investigated through Spearman's correlation. Bonferroni correction for multiple comparisons was applied for correlations between each IRI subscales and demographic features (*p* = 0.0019), neuropsychological measures (*p* = 0.0019), and SAND scores (*p* = 0.0016); similarly, it was applied for correlations between facial emotion recognition ability and demographic features (*p* = 0.002), neuropsychological measures (*p* = 0.002), and SAND scores (*p* = 0.0017).

## 2.7. SPM Analysis

In order to assess the metabolic pattern related to empathy changes in lv-PPA and how it differs between prototypical amnesic AD and lv-PPA, a total of 42 patients were considered (26 amnesic AD and 16 lv-PPA patients). Each patient had positive amyloid biomarkers. [18F]FDG-PET images were normalized to the MNI space using a validated procedure. Images were smoothed with an isotropic 3D Gaussian kernel with a FWHM of 8 mm in each direction and then were used for a single-subject SPM-based routine for diagnostic purposes [41]. Age was included as a covariate in the two-sample *t*-test analysis. The correlation between IRI subscales, resulting from behavioral data analysis, and brain hypometabolism in the amnesic AD and lv-PPA groups was explored using the
SPM multiple regression design, including age and MMSE as nuisance variables in the linear model. The threshold was set at *p*-value < 0.001, uncorrected, to test for correlations also in the small subsamples of amnesic AD and lv-PPA. Only clusters containing more than 50 voxels were considered significant.

## 2.8. Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

# 3. Results

## 3.1. Demographic Features and Biomarkers Analysis

Table 1 shows the demographic variables of the cohort. Considering the whole sample, 57 patients were females and 30 males. Age at onset was significantly different among the three groups (F [2, 82] = 17.527, *p* < 0.001): indeed, SCD (54.40 ± 10.08, *p* < 0.001) were younger than amnesic AD (66.53 ± 6.708, *p* < 0.001) and lv-PPA (64.50 ± 7.60, *p* < 0.001) patients. Age at empathy assessment was significantly different among groups (F [2, 83] = 3.739, *p* = 0.028): in detail, at empathy evaluation, SCD were younger (65.61 ± 9.48) than amnesic AD (71.04 ± 7.33, *p* < 0.024) but not younger than lv-PPA (68.65 ± 7.02, *p* = 1.000) patients. Mini Mental State Examination (MMSE) was different among the groups (F [2, 81] = 48.897 *p* < 0.001), with lower scores in amnesic AD (17.03 ± 5.28) as compared to SCD (27.73 ± 2.04, *p* < 0.001) but not to lv-PPA (16.69 ± 6.37, *p* = 1.000) patients. Considering the subsample who underwent APOE genotype analysis, 36.62% resulted to be APOE ε4 carriers.

<table><caption>**Table 1.** Demographic features in Alzheimer's disease (AD) and logopenic variant primary progressive aphasia (lv-PPA) groups.</caption><thead><tr><th></th><th>SCD<br>n = 31</th><th>AD<br>n = 38</th><th>lv-PPA<br>n = 18</th></tr></thead><tbody><tr><td>Gender (M/F)</td><td>4/27 *α</td><td>17/21 *</td><td>9/9 α</td></tr><tr><td>Age at onset (years)</td><td>54.94 ± 10.08 βγ</td><td>66.53 ± 6.71 β</td><td>64.50 ± 7.60 γ</td></tr><tr><td>Age at empathy (years)</td><td>65.61 ± 9.48 δ</td><td>71.04 ± 7.33 δ</td><td>68.65 ± 7.02</td></tr><tr><td>Disease duration (years)</td><td>9.62 ± 7.51 εη</td><td>4.44 ± 3.59 ε</td><td>2.87 ± 1.54 η</td></tr><tr><td>Family history of dementia</td><td>22/6 θ</td><td>16/17 θ</td><td>6/11</td></tr><tr><td>Years of education</td><td>12.58 ± 3.40 ι</td><td>9.80 ± 4.65 ικ</td><td>13.22 ± 4.45 κ</td></tr><tr><td>MMSE</td><td>27.43 ± 2.04 λμ</td><td>17.03 ± 5.28 λ</td><td>16.69 ± 6.37 μ</td></tr><tr><td>APOE ε4+</td><td>30.77%</td><td>50.00%</td><td>50.00%</td></tr><tr><td>A+/A-</td><td>8/12 (40%) γ°</td><td>30/0 (100%) γ</td><td>18/0 (100%) °</td></tr></tbody></table>

Values are reported as mean and standard deviation for continuous variables and as frequencies or percentages for categorical variables. Statistical differences among groups are *underlined*. M, males; F, females; MMSE, Mini Mental State Examination. *χ² = 8.172, *p* = 0.008; αχ² = 6.126, *p* = 0.019; β *p* < 0.001; γ *p* = 0.001; δ *p* = 0.024; ε *p* < 0.001; η *p* < 0.001; θχ² = 5.838, *p* = 0.019; ι *p* = 0.025; κ *p* = 0.018; λ *p* < 0.001; μ *p* < 0.001; νχ² = 24.92, *p* < 0.001; °χ² = 16.71, *p* < 0.001.

Sixty-four patients (27 amnesic AD, 17 lv-PPA, 20 SCD) underwent CSF biomarkers analysis. Twenty-three patients (7 amnesic AD, 6 lv-PPA, 10 SCD) were subjected to cerebral amyloid PET, which was positive in 17 patients (6 amnesic AD, 6 lv-PPA, 5 SCD). Based on the positivity for at least one cerebral amyloidosis biomarker, 30 amnesic AD and 18 lv-PPA patients and 8 subjects with SCD were classified as A+ (56 out of 69, 82.35%).

## 3.2. IRI Empathy Results

Significant differences were detected neither in premorbid empathy, in IRI total score T0 (F [2, 79] = 0.397, *p* = 0.674), nor in any subscale FT-T0 (F [2, 79] = 1.599, *p* = 0.209), PT-T0
(F [2, 79] = 1.945, *p* = 0.150), EC-T0 (F [2, 79] = 0.530, *p* = 0.590), and PD-T0 (F [2, 79] = 1.014, *p* = 0.368) among the three groups.

As regards current empathy, one-way ANOVA showed significant differences in FT-T1 (F [2, 79] = 5.046, *p* = 0.008) and PD-T1 (F [2, 79] = 10.004, *p* < 0.001) among groups. At Bonferroni post hoc test, amnesic AD patients' FT-T1 scores were significantly lower than those of SCD (14.91 ± 6.50 vs. 19.54 ± 4.45, *p* = 0.009). Both lv-PPA (28.62 ± 6.03, *p* < 0.001) and amnesic AD (26.09 ± 6.00, *p* = 0.003) presented higher scores than SCD (21.04 ± 5.51) on the PD-T1 subscale, while no differences were found between lv-PPA and amnesic AD patients (*p* = 0.481). No significant differences were found in PT-T1 and EC-T1 scores among groups (Figure 1).

<figure><img src="image_12.png" /><figcaption>**Figure 1.** Empathy assessed by Interpersonal Reactivity Index (IRI) in subjective cognitive decline (SCD), Alzheimer's disease (AD) and logopenic variant primary progressive aphasia (lv-PPA).
\* *p* < 0.05, \*\* *p* < 0.005, \*\*\* *p* < 0.001.</figcaption></figure>

To estimate changes of empathy from before to after the onset of cognitive symptoms in amnesic AD and lv-PPA, Wilcoxon signed-rank test was used (Table 2). A significant decrease of FT (17.11 ± 5.09 vs. 15.05 ± 6.21, *z* = -2.464, *p* = 0.014) was detected in amnesic AD subgroup. A decrease in PT scores was found both in amnesic AD (21.08 ± 6.15 vs. 15.42 ± 6.66, *z* = -4.753, *p* < 0.001) and in lv-PPA patients (23.94 ± 6.40 vs. 15.82 ± 6.61, *z* = -3.435, *p* < 0.001). Finally, a significant increase of PD was found both in amnesic AD (17.08 ± 4.99 vs. 26.03 ± 5.72, *z* = -5.204, *p* < 0.001) and in lv-PPA patients (15.76 ± 5.47 vs. 28.35 ± 6.07, *z* = -3.623, *p* < 0.001).
<table><caption>**Table 2.** Change of empathy capacity from before to after the onset of cognitive symptoms in Alzheimer's disease (AD) and logopenic variant primary progressive aphasia (lv-PPA) groups.</caption><thead><tr><th rowspan="2"></th><th colspan="3">AD</th><th colspan="3">lv-PPA</th></tr><tr><th>Mean ± SD</th><th>z</th><th>p</th><th>Mean ± SD</th><th>z</th><th>p</th></tr></thead><tbody><tr><td>IRI 0</td><td>81.26 ± 13.31</td><td rowspan="2">-0.828</td><td rowspan="2">0.408</td><td>83.41 ± 11.12</td><td rowspan="2">-0.166</td><td rowspan="2">0.868</td></tr><tr><td>IRI 1</td><td>81.95 ± 13.35</td><td>83.76 ± 14.90</td></tr><tr><td>FT 0</td><td>17.11 ± 5.09</td><td rowspan="2">-2.464</td><td rowspan="2"><strong>0.014</strong></td><td>17.18 ± 5.89</td><td rowspan="2">-1.574</td><td rowspan="2">0.115</td></tr><tr><td>FT 1</td><td>15.05 ± 6.21</td><td>15.24 ± 6.21</td></tr><tr><td>PT 0</td><td>21.08 ± 6.15</td><td rowspan="2">-4.752</td><td rowspan="2"><strong>&lt;0.001</strong></td><td>23.94 ± 6.40</td><td rowspan="2">-3.435</td><td rowspan="2"><strong>0.001</strong></td></tr><tr><td>PT 1</td><td>15.42 ± 6.66</td><td>15.82 ± 6.61</td></tr><tr><td>EC 0</td><td>26.39 ± 4.45</td><td rowspan="2">-1.185</td><td rowspan="2">0.236</td><td>25.94 ± 5.12</td><td rowspan="2">-1.250</td><td rowspan="2">0.211</td></tr><tr><td>EC 1</td><td>25.76 ± 5.70</td><td>24.35 ± 6.47</td></tr><tr><td>PD 0</td><td>17.08 ± 4.99</td><td rowspan="2">-5.204</td><td rowspan="2"><strong>&lt;0.001</strong></td><td>15.76 ± 5.47</td><td rowspan="2">-3.623</td><td rowspan="2"><strong>&lt;0.001</strong></td></tr><tr><td>PD 1</td><td>26.03 ± 5.72</td><td>28.35 ± 6.07</td></tr></tbody></table>

Values are reported as mean and standard deviation. Statistical differences between groups are in **bold**.

### 3.3. EK-60 F Emotion Recognition Results

Considering emotion recognition ability assessed by EK-60F test, all the variables were significantly different among the three groups (Table 3). At EK-60F global score, lv-PPA and amnesic AD patients performed significantly poorer than SCD (32.25 ± 8.09 vs. 33.29 ± 7.56 vs. 47.58 ± 5.14, respectively, *p* < 0.001). Concerning the single emotions' recognition, lv-PPA and amnesic AD had worse performances in the recognition of anger, disgust, sadness, surprise, and happiness detection as compared to SCD (Table 3).

<table><caption>**Table 3.** Facial emotion recognition ability in subjective cognitive decline (SCD), Alzheimer's disease (AD), and logopenic variant primary progressive aphasia (lv-PPA) as assessed by the Ekman 60 Faces Test (EK-60 F).</caption><thead><tr><th></th><th>SCD</th><th>AD</th><th>lv-PPA</th><th>F</th><th>p</th><th>p between SCD and AD</th><th>p between SCD and lv-PPA</th><th>p between AD and lv-PPA</th></tr></thead><tbody><tr><td>EK-60 F total score</td><td>47.58 ± 5.14</td><td>33.29 ± 7.56</td><td>32.25 ± 8.09</td><td>42.863</td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Execution time (seconds)</td><td>290 ± 56.19</td><td>445.74 ± 124.03</td><td>425.08 ± 103.60</td><td>21.427</td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Anger</td><td>7.35 ± 1.80</td><td>5.29 ± 2.33</td><td>5.08 ± 2.11</td><td>9.480</td><td><strong>p < 0.001</strong></td><td><strong>p = 0.001</strong></td><td><strong>p = 0.006</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Disgust</td><td>8.10 ± 1.45</td><td>5.26 ± 2.49</td><td>5.25 ± 2.60</td><td>16.134</td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p = 0.001</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Fear</td><td>5.10 ± 2.68</td><td>2.94 ± 2.00</td><td>3.67 ± 2.43</td><td>6.862</td><td><strong>p = 0.002</strong></td><td><strong>p = 0.001</strong></td><td><strong>p = 0.235</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Happiness</td><td>9.84 ± 0.45</td><td>8.94 ± 1.043</td><td>7.33 ± 2.15</td><td>21.962</td><td><strong>p < 0.001</strong></td><td><strong>p = 0.006</strong></td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td></tr><tr><td>Sadness</td><td>7.97 ± 2.01</td><td>4.71 ± 2.51</td><td>4.75 ± 2.80</td><td>17.476</td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p = 1.000</strong></td></tr><tr><td>Surprise</td><td>9.48 ± 1.03</td><td>6.24 ± 2.75</td><td>6.17 ± 2.25</td><td>21.666</td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p < 0.001</strong></td><td><strong>p = 1.000</strong></td></tr></tbody></table>

Values are reported as mean and standard deviation. Statistical differences between groups are in **bold**.

SCD scores for fear recognition were higher than those obtained by amnesic AD patients (5.10 ± 2.68 vs. 2.94 ± 2.00, *p* = 0.001) but not higher than those obtained by lv-PPA (3.67 ± 2.43, *p* = 0.235). On the other hand, no differences were detected between lv-PPA and amnesic AD patients except for happiness, with lower scores found in the lv-PPA subgroup as compared to the amnesic AD one (7.33 ± 2.15 vs. 8.94 ± 1.04 vs., *p* = 0.01) (Figure 2).
<figure><img src="image_13.png" /><figcaption>**Figure 2.** Emotional recognition ability as assessed by Ekman 60 Faces Test in subjective cognitive decline (SCD), Alzheimer's disease (AD), and logopenic variant primary progressive aphasia (lv-PPA).
\* *p* < 0.05, \*\* *p* < 0.005, \*\*\* *p* < 0.001.</figcaption></figure>

### 3.4. Correlations between Demographic Data, Neuropsychological Variables, Empathy, and Emotion Recognition

Correlations were found neither between each IRI subscales, age at empathy evaluation, years of education, and HDRS scores; nor in the whole cohort; nor in lv-PPA; nor in amnesic AD subgroups. On the other hand, significant differences between women and men in the whole group were found: women had higher scores than men in IRI-T0 (84.02 ± 11.69 vs. 78.46 ± 10.71, *p* = 0.034), IRI-T1 (86.67 ± 11.88 vs. 79.79 ± 13.94, *p* = 0.044), FT-T0 (18.45 ± 4.74 vs. 16.54 ± 4.85, *p* = 0.031), FT-T1 (17.86 ± 5.56 vs. 14.29 ± 6.79, *p* = 0.004), and PD-T0 (21.16 ± 6.29 vs. 20.92 ± 5.36, *p* = 0.024). These gender differences were not found when we analyzed lv-PPA and amnesic AD except for IRI-T1 scores, which were higher in amnesic AD women as compared to men (84.29 ± 14.04 vs. 77.53 ± 11.69, *p* = 0.021). We also analyzed correlations between neuropsychological tests, SAND evaluation, and each IRI subscale: correlations were found neither in the whole cohort, nor in lv-PPA, nor in amnesic AD subgroups.

Correlations were found between each EK-60 F scores, age at empathy evaluation, and years of education neither in the whole cohort, nor in lv-PPA, nor in amnesic AD subgroups. Similar to IRI subscales, we found significant difference between women and men in the whole group: in more detail, women obtained higher scores as compared to men in EK-60 F total (40.16 ± 9.92 vs. 34.75 ± 8.40, *p* = 0.012), disgust (6.20 ± 2.50 vs. 5.17 ± 2.46, *p* = 0.004), sadness (6.45 ± 2.65 vs. 4.71 ± 2.88, *p* = 0.011), and surprise (7.86 ± 2.53 vs. 6.50 ± 2.80, *p* = 0.017). Moreover, EK-60 F execution time was lower in women as compared to men (361.69 ± 121.13 vs. 438.13 ± 110.53, *p* = 0.001). These gender differences were not found when we analyzed lv-PPA and amnesic AD subgroups. Moreover, no correlations were found between neuropsychological tests, SAND evaluation, and emotion recognition ability (both EK-60 F total score and single emotion recognition scores) in the whole cohort, in logopenic, or in amnesic Alzheimer's disease subgroups.

### 3.5. SPM Results

Significant correlations between IRI subscales and brain metabolism in amnesic AD and lv-PPA groups were found through the SPM multiple regression analysis.

In detail, a negative correlation between ΔPT and brain metabolism was found:

* In amnesic AD in the right superior temporal gyrus, fusiform gyrus, and middle frontal gyrus (*p* < 0.005);
* In lv-PPA in the left inferior parietal lobule, left insula, left middle frontal gyrus, right posterior paracentral lobule, and bilateral superior frontal gyrus (*p* < 0.005) (Table 4 and Figure 3).

<table><caption>**Table 4.** Correlation between changes in empathy over time and cerebral hypometabolism in in logopenic primary progressive aphasia and amnesic Alzheimer's disease patients at 18F-FDG-PET SPM analysis.</caption><thead><tr><th colspan="6">Negative Correlation between ΔPT (PT-T0 - PT-T1) and Brain Metabolism</th></tr><tr><th rowspan="2"></th><th rowspan="2">Cluster Extent</th><th colspan="3">Talairach Coordinates (mm)</th><th rowspan="2">T Score</th></tr><tr><th>x</th><th>y</th><th>z</th></tr></thead><tbody><tr><td colspan="6"><strong>Amnesic AD</strong></td></tr><tr><td>R Superior Temporal Gyrus</td><td>130</td><td>32.0</td><td>16.0</td><td>-24.0</td><td>4.90</td></tr><tr><td>R Middle Frontal Gyrus</td><td>90</td><td>24.0</td><td>18.0</td><td>43.0</td><td>3.69</td></tr><tr><td>R Fusiform Gyrus</td><td>67</td><td>57.0</td><td>-43.0</td><td>-8.0</td><td>3.38</td></tr><tr><td colspan="6"><strong>lv-PPA</strong></td></tr><tr><td>L Inferior Parietal Lobule</td><td>138</td><td>-30.0</td><td>-50.0</td><td>45.0</td><td>4.95</td></tr><tr><td>L Superior Frontal Gyrus</td><td>125</td><td>-8.0</td><td>-1.0</td><td>66.0</td><td>4.83</td></tr><tr><td>L Middle Frontal Gyrus</td><td></td><td>-10.0</td><td>-11.0</td><td>58.0</td><td>3.15</td></tr><tr><td>R Posterior Paracentral Lobule</td><td>156</td><td>20.0</td><td>-42.0</td><td>56.0</td><td>4.74</td></tr><tr><td>R Superior Frontal Gyrus</td><td>68</td><td>10.0</td><td>24.0</td><td>52.0</td><td>4.48</td></tr><tr><td>L Insula</td><td>64</td><td>-38.0</td><td>14.0</td><td>10.0</td><td>4.13</td></tr><tr><td>L Insula</td><td></td><td>-38.0</td><td>22.0</td><td>12.0</td><td>4.11</td></tr></tbody></table><table><thead><tr><th colspan="6">Positive Correlation between ΔPD (PD-T0 - PD-T1) and Brain Metabolism</th></tr><tr><th rowspan="2"></th><th rowspan="2">Cluster Extent</th><th colspan="3">Talairach Coordinates (mm)</th><th rowspan="2">T Score</th></tr><tr><th>x</th><th>y</th><th>z</th></tr></thead><tbody><tr><td colspan="6"><strong>Amnesic AD</strong></td></tr><tr><td>R Inferior Frontal Gyrus</td><td>121</td><td>42.0</td><td>7.0</td><td>33.0</td><td>5.43</td></tr><tr><td colspan="6"><strong>lv-PPA</strong></td></tr><tr><td>L Inferior Parietal Lobule</td><td>85</td><td>-50.0</td><td>-31.0</td><td>33.0</td><td>6.77</td></tr><tr><td>R Superior Frontal Gyrus</td><td>68</td><td>14.0</td><td>-12.0</td><td>67.0</td><td>4.94</td></tr><tr><td>L Insula</td><td>168</td><td>-44.0</td><td>4.0</td><td>5.0</td><td>4.93</td></tr><tr><td>R Precuneus</td><td>158</td><td>14.0</td><td>-48.0</td><td>56.0</td><td>4.51</td></tr><tr><td>L Superior Frontal Gyrus</td><td>77</td><td>-12.0</td><td>-14.0</td><td>67.0</td><td>4.42</td></tr><tr><td>L Superior Frontal Gyrus</td><td></td><td>-6.0</td><td>-6.0</td><td>67.0</td><td>3.36</td></tr></tbody></table>

Abbreviations: AD, Alzheimer's disease; lv-PPA, logopenic primary progressive aphasia; L, left; R, right. Significant differences at *p* < 0.005 in both amnesic AD and in lv-PPA for negative correlation with ΔPT. Significant differences at *p* < 0.001 in amnesic AD and *p* < 0.005 in lv-PPA for positive correlation with ΔPD.
<figure><img src="image_14.png" /><figcaption>**Figure 3.** Negative correlation between changes in perspective taking ability over time assessed by ΔPT (PT-T0 - PT-T1) and brain metabolism in logopenic primary progressive aphasia and amnesic Alzheimer's disease patients at 18F-FDG-PET SPM analysis. Significant clusters projected on the standardized Montreal Neurological Institute (MNI) magnetic resonance imaging (MRI) render surface. Color grading: cyan, lv-PPA; violet, amnesic AD.</figcaption></figure>

A positive correlation between ΔPD and brain metabolism was found:

* In amnesic AD in the right inferior frontal gyrus (*p* < 0.001);

* In lv-PPA in the left inferior parietal lobule, insula, and superior frontal gyrus and in the right precuneus and superior frontal gyrus (*p* < 0.005) (Table 4 and Figure 4).
<figure><img src="image_15.png" /><figcaption>**Figure 4.** Positive correlation between changes in emotional contagion over time assessed by ΔPD (PD-T0 - PD-T1) and brain metabolism in logopenic primary progressive aphasia and amnesic Alzheimer's disease patients at 18F-FDG-PET SPM analysis. Significant clusters projected on the standardized Montreal Neurological Institute (MNI) magnetic resonance imaging (MRI) render surface. Color grading: cyan, lv-PPA; violet, amnesic AD.</figcaption></figure>

**4. Discussion**

Our study is the first that deeply explored empathy in lv-PPA while also trying to define the neural correlates of empathy impairment in this variant of PPA, which is considered as an atypical presentation of Alzheimer's disease. Moreover, for the first time, we compared the behavioral and metabolic data of empathy between lv-PPA and prototypical amnesic AD in order to define similarities and differences between these two presentations of Alzheimer's disease.

Our study showed several similarities in empathic impairment between lv-PPA and amnesic AD. In more detail, both lv-PPA and amnesic AD patients presented a decrease in PT over time, suggesting a significant damage to cognitive empathy. On the other hand, a relative sparing of EC (part of affective empathy) was found in both subgroups.
In particular, a significant decline in PT was found in both logopenic and in amnesic AD, suggesting that both clinical phenotypes of AD present a significant change of cognitive empathy from before to after the onset of cognitive symptoms. Although results about empathy deficits in AD are far from conclusive, recent studies suggested a selective impairment of cognitive empathy [35,42–44]. Moreover, a decrease of perspective taking ability from before to after the onset of cognitive disturbance has been recently described in AD, and this change seems to be present also in the prodromal stage of the disease [8]. Considering lv-PPA, Hazelton et al. already reported a disruption of cognitive empathy, showing a decrease of perspective taking ability by comparing premorbid and present scores of the PT subscale [15].

Affective empathy seems to be spared both in lv-PPA and in amnesic AD patients since no significant changes were found in EC scores from before to after the onset of cognitive symptoms. Moreover, no differences were found in EC-T1 among lv-PPA, amnesic AD, and also SCD patients, which may be considered as the preclinical phase of cognitive decline [45]. However, we found changes in PD in both lv-PPA and in amnesic AD. Personal distress has been widely defined as a measure of emotional contagion, which could be considered as a primitive structure of emotional empathy and indicates the tendency to automatically adopt the behavior of another person [2]. Both lv-PPA and amnesic AD patients presented higher PD scores as compared to SCD. When we analyzed the trend of each component of empathy over time, we found a significant increase in PD from before to after the onset of cognitive disturbs both in amnesic AD and in lv-PPA patients, leading to the further hypothesis that emotional contagion heightens with the development of cognitive decline.

Concerning amnesic AD, our results are in line with some studies that previously described a higher emotional contagion as compared to healthy controls [7,34]: Sturm et al. hypothesized that emotional contagion might increase linearly from healthy controls to MCI and AD patients, who presented the highest degree of emotional contagion [34]. Moreover, a previous work of our group has already shown a significant increase of PD scores from before to after the onset of cognitive disturbance [8], suggesting that this change in emotional contagion might be a peculiar feature of AD patients.

Changes in PD scores in PPA have also been previously described by Hazelton et al., who explored empathy deficit in lv-PPA and nfv-PPA, showing an increase in personal distress in both variants following the disease onset [15].

We also explored emotion recognition ability through the EK-60 F test. According to our results, both lv-PPA and amnesic AD patients presented difficulties in facial emotion recognition, showing lower scores in recognition of almost all six basic emotions as compared to SCD subjects. The only exception was the recognition of fear since no differences were detected between lv-PPA and SCD subgroups, while amnesic AD patients performed more poorly than SCD. Our results are in line with the current literature reporting severe difficulties in identification of facial emotions in AD patients [46–49]. On the other hand, emotion recognition has been only recently studied in lv-PPA, and results are far too few to be clearly conclusive. A previous study reported spared performance in this variant through a task requiring identification of emotional expressions in static faces [16]. On the other hand, another work reported better performance in an emotion recognition task involving naturalistic scenes (i.e., TASIT) in lv-PPA than nfv-PPA, in which emotion recognition seems to be impaired [15,16,50]. Nevertheless, this difference was not statistically significant. Moreover, it has been shown that lv-PPA significantly outperforms those with semantic variant [51]. Thus, considering these findings, it has been hypothesized that emotion recognition deficits in lv-PPA (if present) may be milder than in other variants [10]. However, considering our results, we might suggest that emotion recognition ability may be impaired in lv-PPA. However, these data need to be confirmed.

Globally, no clear differences were detected in emotion recognition ability between lv-PPA and amnesic AD. Although several studies reported incongruent results, emotion recognition ability seems to be impaired in AD [8,47,48]. Indeed, it has been suggested that the recognition of specific emotions (i.e., disgust) may be spared in AD probably
due to the relative sparing of basal ganglia [52]. However, these findings have not been confirmed in other works [8]. To the best of our knowledge, no previous studies have analyzed this aspect by comparing these two presentations of Alzheimer's disease. Our results lead to the hypothesis that this emotion processing function is similarly impaired in the two presentation of the disease. Notably, the only difference was found in the recognition of happiness, with more difficulties found in lv-PPA as compared to amnesic AD patients. This result is challenging to discuss. In fact, this finding has never been previously described. Piguet et al. analyzed emotion recognition ability through the EK 60-F test by comparing healthy controls, nfv-PPA, and lv-PPA patients, showing significant group differences for the negative (anger, disgust, fear, and sadness) but not the positive (surprise and happiness) emotions due to the low performance of the non-fluent (but not logopenic) group compared to healthy controls. In addition, non-fluent patients also performed worse than logopenic patients for the emotion fear, which is considered as a negative emotion [16]. Such difficulties in happiness recognition in our lv-PPA patients have never been described so far: this subtle difference may be highlighted in our work through the comparison between the two presentation of AD. However, this result needs to be confirmed in further studies with larger cohorts.

Interestingly, we did not find any correlation between demographic data, neuropsychological tests, language evaluation, IRI subscale, and emotion recognition in either lv-PPA or in amnesic AD patients. This is partially in contrast with a previous report according to which the reduction of PT scores in lv-PPA was correlated with visuospatial abilities [15]. However, no further studies have explored this topic yet as well as correlations between emotion recognition ability and neuropsychological evaluation. Moreover, it has been recently highlighted that PD positively correlates with depression in healthy subjects [53]: indeed, no correlations were found between HDRS and PD in our cohort either in lv-PPA or in amnesic AD patients. Although our work is a preliminary study, our results might suggest that the empathic impairment and difficulties in emotion recognition might not be correlated with cognitive decline, with depressive symptoms, and in particular with language impairment in lv-PPA patients. Nevertheless, further studies are needed to confirm this hypothesis.

The further aims of our study were to explore the metabolic pattern associated with empathy changes in lv-PPA and to compare empathy and its neural correlates in logopenic and in prototypical amnesic AD. First of all, to the best of our knowledge, this is the first study that explored the neural bases of empathy deficits in lv-PPA. Surprisingly, despite the similar empathy impairment, the metabolic correlates of empathy deficits were different between lv-PPA and amnesic AD patients.

Indeed, while in amnesic AD patients, the empathic dysfunction was related to hypometabolism of specific brain regions mainly located on the right hemisphere, in lv-PPA, it was correlated with hypometabolism of both hemispheres. This involvement of both hemispheres in lv-PPA might be explained by the fact of the presence of a specific and peculiar left lateralization of neurodegeneration in this disease [9].

Cognitive empathy changes over time were correlated with the involvement of the right superior temporal gyrus, middle frontal gyrus, and fusiform gyrus in amnesic AD and with involvement of the left inferior parietal lobule, insula, middle frontal gyrus, and bilateral superior frontal gyrus in lv-PPA.

Previous works have already described the correlation between cognitive empathy deficits and the involvement of superior temporal and middle frontal gyri in AD patients [8]. This correlation might be explained by the fact that superior temporal gyrus plays a role in mentalizing activity and perspective-taking tasks [54,55] through its connections with the temporal poles and medial prefrontal cortex [56]. Similarly, the middle frontal gyrus, as part of the dorsolateral prefrontal cortex (DLPFC), is involved perspective-taking tasks [55,57]. Moreover, it seems to intentionally inhibit self-perspective in order to consider the other's point of view [35] and to be involved in emotion evaluation [58]. Interestingly, we also found an involvement of the fusiform gyrus: Rankin et al. already described the role of the
fusiform gyrus in cognitive empathy, in particular in perspective-taking ability, probably related to its direct involvement in facial perception and recognition [35].

On the other hand, loss of perspective taking over time in lv-PPA has been related to the impairment of the inferior parietal lobule, insula, middle frontal gyrus, and superior frontal gyrus. As regards the inferior parietal lobule, although it has been described as directly involved in the network of emotional contagion, it has been clearly stated that perspective-taking tasks engage several brain regions that also include the inferior parietal lobule [55]. Similarly, the superior frontal gyrus, in particular the supplementary motor area, seems to be involved in cognitive empathy tasks [55]. Concerning the insula, it is well-known that this brain region plays a major role in generating forward models of feeling states for others in order to predict and understand the social and affective behavior of other people [2,55,59].

Such neurophysiological bases might explain the association of the impairment of these brain regions and the perspective-taking deficits over time. Nevertheless, our findings might suggest that loss of perspective-taking ability over time might be related to the selective impairment of different empathy-related brain regions in the two clinical presentation of Alzheimer's disease.

We also found that the amplification of emotional contagion over time was correlated with the involvement of the inferior parietal lobule, insula, superior frontal gyrus, and precuneus in lv-PPA and with the involvement of the right inferior frontal gyrus in prototypical amnesic AD. The involvement of frontal and parietal regions (in particular of the inferior frontal gyrus and inferior parietal lobule) may be explained by the fact that these areas are part of the mirror neurons system (MNS) network [2]. Emotional contagion is rooted in the MNS, which transforms sensory representations of others' behavior into one's own visceromotor representations and allows understanding others' actions according to the perception-action model [59]. In more detail, it has been suggested that the inferior frontal gyrus identifies the goals or intentions of actions by their resemblance to stored representations for these actions [60]. Despite the unquestioned involvement in cognitive empathy, several studies have also described a putative role of the insula in the mirror mechanism of emotions: in fact, it has been demonstrated that there is a clear overlap between insular activation elicited by one's own and others' emotions, such as disgust [59,61,62]. Similarly, the insula is also involved in the empathic process of "shared pain": in fact, empathizing with people in pain is associated with hemodynamic activity in the brain that is similar to the activity that occurs when people feel pain themselves, leading to the activation of the "empathy to pain network", which involves the anterior cingulate cortex and insula [63]. It has been suggested that empathy for pain of others may be considered, at least in part, as an automatic, primitive, bottom-up process of affective empathy since it may aid in the immediate perception and avoidance of a threat to oneself [64]. The superior frontal gyrus and supplementary motor area also seem to be involved not only in cognitive empathy tasks but also in affective empathy [55].

The most interesting data show that similar changes in empathy correspond to the involvement of different brain regions in the two phenotypes of Alzheimer's disease. This may be explained by the fact that empathy is a complex construct: a cognitive function that implies several interconnected brain regions [3]. On the other hand, it is well-known that neurodegeneration in lv-PPA and in prototypical amnesic AD involve different brain regions due to the selectivity of vulnerability of these two presentations [65,66]. Considering these premises, we might hypothesize that the selective neurodegeneration of the two clinical subtypes of Alzheimer's disease might damage different brain regions and networks related to empathy, leading to the same impairment.

Our study has some remarkable strengths. First of all, this is one of the first studies deeply analyzing empathy changes in lv-PPA and comparing empathy impairment with that found in amnesic AD patients in order to detect differences and similarities between these two clinical presentations of the disease. Another strength is the research of the neural
correlates of empathy deficits in lv-PPA, which have never been explored before, by means of FDG-PET.

The main limitation of our study is the relatively small sample size and thus the lack of corrections for multiple comparisons in the correlation analysis between empathy deficits and hypometabolism in FDG PET analysis. Indeed, we chose to use a more exploratory threshold in order to explore the metabolic correlates of empathy also in the small subsamples of the lv-PPA and amnesic AD patients individually considered. Another limitation of the study is the use of a caregiver-report questionnaire even though the IRI is the most used, validated instrument for the evaluation of empathy. In fact, even if observer-based measures are more ecologically valid and have yielded valuable data previously [67], they are nevertheless limited by their dependence on informants' varying reliability [68]. On the other hand, the scores attributed by the informants present the advantage of capturing real-life empathic behavior independently from the patients' anosognosia [10]. The last limitation is the absence of healthy controls and the need to use SCD to compare the behavioral data although despite this category of subjects has been already used in previous work exploring empathy in AD [69].

**5. Conclusions**

In conclusion, to the best of our knowledge, our study analyzed for the first time differences and similarities between lv-PPA and amnesic AD, which are two clinical presentations of this neurodegenerative disease. We described a peculiar involvement of specific brain areas in empathy changes in lv-PPA, comparing them with that found in amnesic AD.

Interestingly, lv-PPA and amnesic AD presented the same changes in empathy, showing a damage of perspective-taking ability (part of cognitive domain) together with a heightening of emotional contagion (the most primitive structure of affective empathy) over time. Nevertheless, these similar changes in empathy correspond to the involvement of different brain regions in the two phenotypes of Alzheimer's disease. This could be explained by the fact that neurodegeneration might damage different brain regions and networks related to empathy in these two presentations of Alzheimer's disease due to the selectivity of vulnerability of the brain areas of these variants.

Moreover, our study described empathy changes and difficulties in emotion recognition in lv-PPA. In fact, while clinical diagnosis of PPA is basically anchored in linguistic disturbances, a proportion of cases cannot be easily classified based solely on language tests. In this scenario, emerging experimental works are revealing impairments in several socio-cognitive processes in these patients in association with brain measures. While some studies have already described deficits in emotion recognition, the theory of mind, and empathy in nfv-PPA and sv-PPA, evidence about lv-PPA are sparse and far from conclusive. Our work showed for the first time that lv-PPA patients presented deficits in empathy and in emotion recognition, too. Further studies are needed to confirm our results and better explore these socio-cognitive aspects of PPA, which might be very helpful in improving early diagnostic accuracy.

**Author Contributions:** Conceptualization, G.G. (Giulia Giacomucci), S.S. and V.B. (Valentina Bessi); methodology, G.G. (Giulia Giacomucci) and S.M.; software, C.P.; validation, G.G. (Giulia Giacomucci), C.P., V.B. (Valentina Berti), S.P., G.G. (Giulia Galdo), S.M., E.B., V.M., C.M., C.N., M.T.D.C., A.I., S.B., B.N., S.S. and V.B. (Valentina Bessi); formal analysis, G.G. (Giulia Giacomucci) and C.P.; investigation, G.G. (Giulia Giacomucci) and C.P.; resources, V.B. (Valentina Berti), S.P., S.M., E.B., V.M., C.M., C.N., M.T.D.C., A.I., S.B., B.N. and S.S.; data curation, G.G. (Giulia Giacomucci), C.P., V.B. (Valentina Berti), S.P. and G.G. (Giulia Galdo); writing—original draft preparation, G.G. (Giulia Giacomucci) and C.P.; writing—review and editing, G.G. (Giulia Giacomucci) and V.B. (Valentina Bessi); visualization, G.G. (Giulia Giacomucci), C.P., V.B. (Valentina Berti), S.P., G.G. (Giulia Galdo), S.M., E.B., V.M., C.M., C.N., M.T.D.C., A.I., S.B., B.N., S.S. and V.B. (Valentina Bessi); supervision, S.S. and V.B. (Valentina Bessi); project administration, V.B. (Valentina Bessi); funding acquisition, B.N. All authors have read and agreed to the published version of the manuscript.
**Funding:** This study was funded by RICATEN22 (Ateneo Università di Firenze, fondi Ateneo 2022). The funding source had no such involvement in the study design.

**Institutional Review Board Statement:** The ethics committee of the Azienda Ospedaliero-Universitaria Careggi approved the protocol of the study. All procedures involving experiments on human subjects have been done in accordance with the ethical standards of the Committee on Human Experimentation of the institution and with the Helsinki Declaration of 1975. Specific national laws have been observed.

**Informed Consent Statement:** All participants gave informed consent to participate in the study.

**Data Availability Statement:** The data that support the findings of this study are available from the corresponding author upon reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.

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<figure><img src="image_16.png" /></figure>

Article

# Psychosocial Impact of Huntington's Disease and Incentives to Improve Care for Affected Families in the Underserved Region of the Slovak Republic

Katarína Hubčíková ¹,²,*, Tomáš Rakús ¹,²,³, Alžbeta Mühlbäck ⁴,⁵,⁶ ID, Ján Benetin ¹, Lucia Bruncvik ²,⁷,
Zuzana Petrášová ¹,², Jitka Bušková ²,⁸ and Martin Brunovský ²,⁸ ID

¹ Neuropsychiatric Department, Psychiatric Hospital of Philipp Pinel in Pezinok, 90201 Pezinok, Slovakia

² Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic

³ Department of Psychiatry, Slovac Medical University, 83303 Bratislava, Slovakia

⁴ Department of Neuropsychiatry, kbo-Isar-Amper-Klinikum, 84416 Taufkirchen (Vils), Germany

⁵ Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12821 Prague, Czech Republic

⁶ Department of Neurology, University Hospital of Ulm, 89081 Ulm, Germany

⁷ Landesklinikum Hainburg, 2410 Hainburg an der Donau, Austria

⁸ National Institute of Mental Health, 25067 Klecany, Czech Republic

* Correspondence: k.hubcikova@gmail.com; Tel.: +421917111575; Fax: +421336482121

**Abstract:** Introduction: Huntington's disease (HD) is often on the margin of standard medical practice due to its low prevalence, the lack of causal treatment, and the typically long premanifest window prior to the onset of the symptoms, which contrasts with the long-lasting burden that the disease causes in affected families. Methods: To capture these socio-psychological aspects of HD and map the experiences of affected individuals, persons at risk of HD, and caregivers, we created a questionnaire using a qualitative research approach. The questionnaire containing 16 questions was conducted online for a period of three months through patient associations in Slovakia and their infrastructures. Results: In total, we received 30 responses. The survey results, in particular, indicate insufficient counselling by physicians with explicitly missing information about the possibility of preimplantation genetic diagnostic. There was also a necessity to improve comprehensive social and health care in the later stages of the disease, raise awareness of the disease in the general health community, and provide more information on ongoing clinical trials. Conclusion: The psychosocial effects, as well as the burden, can be mitigated by comprehensive genetic counselling as well as reproductive and financial guidelines and subsequent therapeutic programs to actively support patients, caregivers, children, and adolescents growing up in affected families, preferably with the help of local HD community association. Limitations: We have used online data collection to reach a wider HD community, but at the same time, we are aware that the quality of the data we would obtain through face-to-face interviews would be considerably better. Therefore, future studies need to be conducted to obtain more detailed information.

**Keywords:** Huntington's disease; psychosocial effects; underserved region; disease burden; genetic counselling; genetic testing

**Citation:** Hubčíková, K.; Rakús, T.; Mühlbäck, A.; Benetin, J.; Bruncvik, L.; Petrášová, Z.; Bušková, J.; Brunovský, M. Psychosocial Impact of Huntington's Disease and Incentives to Improve Care for Affected Families in the Underserved Region of the Slovak Republic. *J. Pers. Med.* **2022**, *12*, 1941. https://doi.org/10.3390/jpm12121941

Academic Editor: Anne-Marie Caminade

Received: 17 August 2022
Accepted: 14 November 2022
Published: 22 November 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

<figure><img src="image_17.png" /></figure>

Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
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Attribution (CC BY) license (https://
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4.0/).

## 1. Introduction

Huntington's disease (HD) is an autosomal dominant, neurodegenerative disorder leading to the progressive impairment of motor skills, cognitive function, and psychiatric disorders [1]. HD is caused by the expansion mutation of the cytosine, adenine, and guanine (CAG) triplet on chromosome 4, as identified in 1983 [2]. The huntingtin gene (*HTT*, OMIM 613004), formerly IT-15, was then identified in 1993 [3] Huntington's disease Collaborative Research. The *HTT* gene is responsible for coding the Huntingtin (*HTT*) protein. The expansion mutation of the *HTT* gene leads to the production of mutant *HTT* (mHTT)
protein accumulating in the striatum of the basal ganglia, leading to progressive neuronal dysfunction and death, usually within a few decades after the onset of symptoms [4]. The number of CAG repeats in *HTT* is inversely associated with disease onset; the greater the CAG number, the earlier the onset of HD [5]. The onset of the disease is defined as a manifestation of significant motor or neurological symptoms and occurs on average around the age of 40 [6].

The number of CAG repeats within the HTT gene varies from 6 to 35 in the general population [7]. CAG repeats in the range of 36 to 39 refer to reduced penetrance repeat length [8]. CAG repeats with less than 27 present a stable transmission, and no manifestation is expected. The CAG repeat lengths of 27 to 35 refer to the intermediate allele and are also not associated with HD development. However, there is the possibility of expansion upon transmission, resulting in genetic anticipation [9].

Especially in paternal transmission, the number of repetitions in sperm increases due to the meiotic instability of the abnormal CAG repeat, often leading to Juvenile Huntington's Disease (JHD) with a presence of more than 60 CAG repeats and occurs before the age of 21, which comprises about 5% of all HD cases [10,11]. For this reason, the children of an affected parent (common father) may be at risk of developing the disease earlier than their parent with HD [12].

Current HD management focuses on symptomatic treatment in terms of pharmacological and non-pharmacological interventions, such as psychotherapy, physiotherapy, and speech and occupation therapies by a multidisciplinary team [13]. Several promising methods are designed to modify the natural history of HD and are currently under investigation in research studies and clinical trials aiming to reduce the reproduction of mutant *HTT* gene products [14]. The natural history of HD with the progression of symptoms in individual stages of HD about disability and life milestones, including suicidal tendencies, is illustrated in Figure 1.

Caring for patients with HD represents a gradually increasing burden for their caregivers, involving family members, partners, and other relatives lasting several decades [17]. The situation is further complicated due to the reconciliation with a 50% risk of disease in their offspring, which significantly increases emotional burden and suffering compared to other non-hereditary conditions. The genetic nature of HD means that it is not uncommon for children to care for their parents before they develop symptoms, or for a parent to care for a partner and then for the child, and sometimes for several generations to care for them at the same time. Such a chronic and widespread role of care in families with HD can deepen isolation, feelings of loss of their family members and their future, feelings of guilt, anger, burden, and helplessness [18]. The diagnosis of HD also affects the wider blood relatives.

Physicians and healthcare professionals consulting families with HD should do their utmost to ensure that all family members obtain the necessary information to make an informed decision about genetic testing, reproduction, and future financial and life plans [19,20]. Appropriate genetic counselling plays an important role in HD management. The requirements for genetic counselling differ on the condition of a client or patient, depending on the type of consultation. Two types of procedures are available: differential diagnostic and presymptomatic (predictive) testing. The predictive genetic test allows for measuring CAG repeat length in a blood laboratory sample and predicting whether an at-risk individual will develop HD later in life [19]. Predictive testing should be reserved for adults who have participated in a thorough consultation with a genetic counsellor or other trained professional or HD expert about their genetic risks and the potential risks and benefits of the test itself, as well as post-test support [21,22]. The participant needs to prepare for an unfavourable result by receiving information about the disease and the social consequences of the genetic test [22]. The most important predictive and diagnostic genetic testing procedure is appropriate counselling; informed consent from the patient must be obtained before testing [19,21]. The implications of a positive result for the patient and their family must be clearly outlined. Both the nature of HD itself and its autosomal dominant
inheritance must be explained to make it clear that if the test is positive for HD, any of their
children would have a 50% chance of inheriting it [20,23,24]. The usual standard process of
genetic counselling and testing is summarised in Table 1.

<figure><img src="image_18.png" /><figcaption>**Figure 1.** Progression of symptoms and disability in a typical person with HD, adapted from A Physician Guide to Management of HD [15] and onset of cognitive impairment adjusted by Langley et al., 2021 [16].</figcaption></figure>
<table><caption>**Table 1.** The process of genetic counselling and testing for HD, adapted from [21]. Abbreviations: CAG—cytosine, adenine, guanine.</caption><thead><tr><th colspan="2">The Process of Genetic Counselling and Testing for HD</th></tr></thead><tbody><tr><td>Initial session</td><td><ul><li>Providing details of family history to the doctor or genetic counsellor at the session, who then attempts to confirm the diagnosis history</li><li>A doctor or genetic counsellor provides information about Huntington's disease, the genetic test process and possible results</li><li>Discussion on reasons for requesting a test at this stage and their approach to the possible outcomes. There will also be a chance to discuss, if wanted, the reproductive options available if the person wants to avoid the possibility of passing the disease on to the next generation</li><li>Allowing identifying someone who will support them through the process</li><li>Encourages them to consider the impact of any result on life, family or friends. This can be particularly important concerning family members who may not wish to be tested, but the test could also reveal their status</li><li>Encouraging to consider financial implications and other issues such as life insurance and employment</li><li>The initial session is followed by a summary letter and a reflection period</li></ul></td></tr><tr><td>Reflection period</td><td><ul><li>If the person wants to continue with the process, a second session is arranged</li><li>A review of the information discussed at the first session is undertaken.</li></ul></td></tr><tr><td>Second/third session</td><td><ul><li>The doctor/genetic counsellor, by genetic testing guidelines, may consider a neurological and psychologicaö examination to evaluate the person. However, it is not a requirement for participation in predictive testing.</li><li>Discussion about preparing for genetic tests and results</li><li>The date is arranged for a blood sample to be taken</li><li>The results will not be provided on that day</li></ul></td></tr><tr><td>Genetic test</td><td><ul><li>The results will not be provided on that day</li></ul></td></tr><tr><td>The results</td><td><ul><li>At a follow-up appointment (usually a month after), there will be a face-to-face discussion concerning the test results.</li></ul></td></tr><tr><td>Follow-up sessions</td><td><ul><li>Relevant follow-up sessions are arranged as required after results are given</li><li>Regardless of the result, the person must have access to support and advice available.</li></ul></td></tr><tr><td>Advice and support</td><td><ul><li>It is appropriated to referral to local associations for HD, thus ensuring contact with others who are going through the same situation; there are mostly support groups and online communities</li></ul></td></tr></tbody></table>

In addition, it is appropriate to enrich the education with knowledge about the expression of HD within an intermediate allele of 27–35 CAG repeats and the impact of reduced penetration between 36–39 CAG repeats [25]. At the same time, information about technological advances in preimplantation genetic diagnostic testing (PGD) and prenatal testing improved collaborative research networks need to be discussed. A better understanding of the psychosocial aspect of living with HD needs to be provided. The HD expansion mutation carrier, manifest patients and persons at risk of HD need to be informed of their reproductive potential in preference to planned pregnancy according to the regulation of the respective countries [26]. Determining genetic status confronts people with new dilemmas in their reproductive decisions.

It is important to highlight the HD community's local peer support. Anyone affected by HD can benefit from participating in the activities of local HD associations, such as support group seminars on the latest information, and thus be in touch with others experiencing the same situation. In our European area is the European Huntington Association (EHA), an umbrella organisation that provides an extensive network of people coping with the disease—either in person or professionally. It accelerates the information flow and support
to people with HD in their country and builds cross-border relationships [27]. The patient community comprises people personally affected by HD (with a local presence in most European countries), and the research community includes experts working with HD. The situation of affected patients and their relatives was unsatisfactory in the Slovak Republic for a long time. Although the Slovak self-help group was officially active from 1994 to 2016, it was founded and maintained by only a few volunteers in Slovakia who, despite their heroic efforts, did not receive enough support from the government and health professionals and burnt out over time. A functioning infrastructure was not developed, and even such simple things as a functioning website and communication channels with members were not established and were only based on personal contacts. This was in great contrast to the situation in the Czech Republic, with which Slovakia was a common state until 1993, so the issue of the HD community had practically the same starting point at that time. Furthermore, due to the cultural and linguistic proximity of the two countries, the affected families in Slovakia had the opportunity to compare the situation and were understandably frustrated. The Czech Huntington's Association quickly became a member of the EHA, and at the same time, several specialised centres and/or several EHDN clinics were established in the country. Comprehensive care with options such as in vitro fertilisation (IVF), including preimplantation diagnostics, is covered by statutory health insurance for patients with Huntington's disease. At the time of conducting this survey, there was no EHDN clinic in Slovakia and IVF, including preimplantation genetic diagnosis, has to be paid for by the patients themselves. At the end of 2019, the Slovak HD Society resumed its activities at the request of patients and their families and shortly afterwards became a member of the EHA. The support group created a dynamic exchange platform to promote and provide better access to the needs of those affected. Work began on building an infrastructure with a website. The main goal is to provide support and information about the nature of the disease, its inheritance, the possibilities of genetic diagnosis, treatment and care for patients and family members, and the establishment of support groups [28].

This survey was the first opportunity to officially express experiences and suggestions for improving the situation of the until then unheard HD community. It was the starting point for defining the first and next steps for the restoration of the Slovak HD association. The presented paper aims to explore and evaluate the psychosocial impacts of HD and incentives to improve the care of affected patients and families in the underserved region of Slovakia.

## 2. Material and Methods

### 2.1. *Study Assessment*

The project was set up to map the situation of patients and families affected by HD in the Slovak Republic (SR). This project is part of a larger national initiative to improve the care of affected patients and families. For this purpose, two types of questionnaires with 16 questions were designed to explore the main psychological aspects and domains. The questionnaire was implemented and accessible via the online platform www.survio.com accessed on 1 November 2022. The first questionnaire was aimed at people who have tested positive for Huntington's disease, regardless of the stage of the disease. The second questionnaire focused on people at risk, not affected by HD and caregivers and partners of affected individuals. Each questionnaire consisted of 13 open questions and three multiple-choice questions with the possibility to answer in the text. The questionnaire covered the main domains of genetic counselling about Huntington's disease knowledge (initial information, main source of information, reproductive counselling, experimental treatment, lack of knowledge), genetic testing (reasons for testing or not), the possibility of psychological counselling, the impact of Huntington's disease (the most burdensome symptom, financial burden, impact on relationships) and social and health services in Slovakia. The questionnaire was available online for three months in the year 2020. The questionnaire was designed by an expert group of representatives of the patient HD community and health care professionals, such as the neurologist, the psychiatrist, and the psychologist and
was reviewed to ensure proper understanding and clear language. This survey, including a questionnaire, has been approved by a constituted Ethics Committee of the Psychiatric Hospital of Philipp Pinel in Pezinok, Slovakia (Approval Date: 30 September 2020) and conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh in 2000).

## 2.2. *Study Participants*

The regular members of the Slovak HD Society—specifically patients, persons at risk and their relatives have received the possibility to participate in this project. Membership in the newly renewed Slovak HD society was obtained through online form through the newly opened website huntington.sk in the course of 2020, while information about Slovak HD society and the possibility of membership was also sent in the form of a leaflet to all genetic clinics and all neurological, psychiatric and neuropsychiatric inpatient facilities in the Slovak Republic at the beginning of 2020. As part of filling out the membership application form, it was possible, among other things, to voluntarily choose whether the applicant for membership is a patient, a person at risk, a relative, or a medical professional or write his or her other motivation to join verbally. The links to the questionnaire were sent to the regular members of the Slovak HD Patient Society, who stated that they are patients, persons at risk or relatives when applying for membership. They previously provided an email address and consent to participate in the research project to the patient's network administrator.

In total, 60 regular members have been contacted and received an email with an explanation text and a questionnaire link. The connection to the patient questionnaire was sent on two occasions to the members to participate in the project. It was possible to fill out two questionnaires per family by repeatedly accessing the link. In the questionnaire for patients, it was possible to indicate in the opening multiple questions that the answers were recorded by another close person since the patient was no longer able to fill them in himself. Three patients used this option. The data have been proceeding anonymously, without any identifiable parameters.

## 3. Results

In this project, the qualitative methodological approach was used to evaluate the finding of two questionnaires with 13 open-ended questions and as well the quantitative analysis to evaluate three multiple-choice questions. The survey data from the open-ended questions were analysed based on the grounded theory approach [29,30]. Repeated reading and coding of the results of the open-ended questions resulted in several themes related to the questions, and the answers were clustered into the four main domains covering:

(I) Knowledge about HD, including initial information about HD, the main source of information, reproductive options, information on experimental treatment, and additional information.

(II) Genetic testing and counselling, including the process of testing and psychological support and reasons why an individual decided to take a genetic test or not to be tested.

(III) Impact of HD on the relationships, financial burden and burden to HD (symptoms).

(IV) Social and health care services in Slovakia, including experience and proposal for improvement.

In total, 60 links to access the questionnaire were sent to the regular members of the Slovak HD Society. The responsiveness rate was 50% (30 answers). In this study, we obtained responses from the following individuals: nine individuals tested positive for HD, four of whom were asymptomatic and five of whom had the manifest disease, five individuals at risk for HD, and 16 responses from caregivers and partners of asymptomatic and manifest patients, as summarised in the first line of Table 2.
<table><caption>**Table 2.** Questions and answers of the respondents on the questionnaire administered via the Slovak HD association to patients, persons at risk, their relatives and partners, including their experiences and suggestions for improving the situation for the HD community in SR. The questions have been administered as multiple-choice or as open questions. The table shows an overview and a summary of the available answers. Abbreviations: GT—Genetic Testing; HD—Huntington Disease; N- number of participants; n.n. not known. PGD—Preimplantation genetic diagnosis; SSE—social services establishment; SR—Slovak Republic.</caption><thead><tr><th rowspan="2">Questions in Individual Categories of the Questionnaire</th><th colspan="3">Answers and Particular Groups of Respondents (Number of Participants)</th></tr><tr><th>Patients with HD (N = 5)/Asymptomatic HD Carriers (N = 4)</th><th>Individuals at Risk (N = 5)</th><th>Partners of Asymptomatic Persons (N = 6)/Partners of Manifest HD Patients (N = 10)</th></tr></thead><tbody><tr><td><strong>Knowledge about HD</strong></td><td></td><td></td><td></td></tr><tr><td><strong>Initial information</strong><br>How and when did you first learn about the risk or presence of HD in your family or partner?<br><br><strong>The main source of information</strong><br>Where did you mainly get information about HD? How did your doctor teach you about HD? (open question)<br><br><strong>Reproductive options</strong><br>Has a doctor provided information on reproductive options, including PGD (your child would be healthy even if you/your partner is affected)?<br><br><strong>Experimantal treatment</strong><br>Did you receive information on ongoing clinical trials for HD? How do you get any updated information?<br><br><strong>Lack of knowledge</strong><br>What information do you think a person at risk for HD should receive? What did you find out over time, and would you appreciate it if you knew it before? (open questions)</td><td>At the age: 14, 38, 42, 39, 50/15, 35, 50, n.n.<br>From family: 6,<br>From doctor: 3<br><br>From the family: 3;<br>From doctor: 1,<br>Internet: 7<br><br>Yes: 2<br>No, I am not interested anyway: 2<br>No, I searched by myself: 2<br>No, first time to hear: 3<br><br>Yes: 1 (doctor), 3 (Internet), family (2)<br>No: 2<br>I am interested /I am not interested in updates: 8/0<br>PGD: 3<br>Consulting HD expert: 1<br>Early knowledge of HD risk (early diagnosis of parent/myself/not hiding HD in the family): 3;<br>I don't know: 2</td><td>At the age: 0, 14, 20, 38, n.n.<br><br>From the family: 2,<br>From doctor: 0,<br>Internet: 3<br><br>Yes: 2<br>No, I am not interested anyway: 2<br>No, I searched by myself: 1<br>No, first time to hear: 0<br><br>Yes: 4 (Internet)<br>No: 1<br>I am interested /I am not interested in updates: 5/0<br>Reprod. options, PGD: 1<br>Better awareness among health professionals: 1<br>Entitlement to a disability pension: 1;<br>I don't know: 2</td><td>At the age: 7, 15, 25, 34, 39, n.n/25, 26, 30, 35, 38, 40, 46, 58, n.n, n.n<br>From family: 5/1,<br>From doctor: 1/5,<br>From partner:0/4<br><br>From family:1,<br>From doctor: 1,<br>internet: 16<br><br>Yes: 2<br>No, I am not interested anyway: 2<br>No, I searched by myself: 7<br>No, first time to hear: 3<br><br>Yes: 1 (doctor), 14 (Internet)<br>No: 1<br>I am interested /I am not interested in updates: 15/1<br>PGD: 3<br>Information on research: 4<br>More support for HD community: 2<br>Consulting HD expert: 1;<br>I don't know: 6</td></tr><tr><td><strong>Genetic testing (GT)</strong></td><td></td><td></td><td></td></tr><tr><td><strong>Reasons for (not) being tested</strong><br>Please write down why you decided/consider being tested, resp. not to be tested? (open question)<br><br><strong>Psychologist Consultation</strong><br>Have you talked to a psychologist during genetic testing? Was it/was it not beneficial for you?</td><td>For GT: know the truth: 2<br>Emerging symptoms: 3<br>Disability pension: 1<br>Future planning: 3<br><br>Yes: 2 (beneficial), 1 (not helpful)<br>No: 7</td><td>For GT: because of the children: 1<br>Against GT:<br>live a fulfilled life: 1<br>I don't know: 2<br><br>Yes: 1 (beneficial), 1 (not beneficial)<br>No: 3</td><td>For GT: know the truth: 3<br>Future planning: 7<br>Disability pension: 1<br>Emerging symptoms: 3;<br>I don't know: 2<br><br>Yes: 3 (beneficial), 2 (not beneficial)<br>No: 11</td></tr><tr><td><strong>Impact of HD</strong></td><td></td><td></td><td></td></tr><tr><td><strong>Most aggravating symptom</strong><br>Which symptoms of HD are/were the most burdensome for you? (open question)<br><br><strong>Financial burden</strong><br>How has HD affected your family budget? Was the help of the state sufficient for you? (open question)<br><br><strong>Impact on relationships</strong><br>(answers resulted from other open-ended questions)</td><td>Positive test: 2<br>Motor skills (chorea): 5<br>Psychiatric (nervousness, cognitive decline): 2<br><br>Higher financial burden: 7 State support limited: 4, we are modest: 2, family help: 2.<br>I don't know: 2<br><br>Blaming parents for hiding HD: 1<br>Fear of transmitting HD: 1<br>Hesitation/anxiety to say a positive result to the family: 2<br>Suspicion of alcoholism due to chorea: 2<br>Criminal prosecution: 2</td><td>Motor skills (chorea): 2<br>Psychiatric (depression, cognitive decline, aggression): 4<br>I don't know: 1<br><br>Higher financial burden: 4 State support limited: we are modest 2, family help: 1<br>Any support yet: 1<br>I don't know: 1<br><br>Decision with the partner to ignore the fears of the HD and live the life that will come: 1</td><td>Positive test: 1<br>Motor skills (chorea): 3<br>Psychiatric (cognitive decline, aggression): 7<br>Dysphagia: 3<br>Independence loss: 4<br>Higher financial burden: 13 State support limited: we are modest 3, family help: 5, extra job:1 Any support yet: 3<br>I don't know: 3<br>Anxiety about the gradual loss of a partner: 1<br>Fear of destroying the life of my healthy partner: 1<br>Fear of divorce: 2<br>Feeling my life is ruined due to illness of relatives: 1</td></tr></tbody></table>
<table><caption>Table 2. *Cont.*</caption><thead><tr><th rowspan="2">Questions in Individual Categories of the Questionnaire</th><th colspan="3">Answers and Particular Groups of Respondents (Number of Participants)</th></tr><tr><th>Patients with HD (N = 5)/Asymptomatic HD Carriers (N = 4)</th><th>Individuals at Risk (N = 5)</th><th>Partners of Asymptomatic Persons (N = 6)/Partners of Manifest HD Patients (N = 10)</th></tr></thead><tbody><tr><td><strong>Social and health care services in SR</strong></td><td></td><td></td><td></td></tr><tr><td><strong>Experiences</strong><br>How do you evaluate social and nursing services for patients with HD in SR?</td><td>Insufficient—SSE staff and paramedics do not know HD: 5<br>I don't know: 4</td><td>Insufficient—SSE staff and paramedics do not know HD: 2<br>I don't know: 3</td><td>Insufficient—SSE staff and paramedics do not know HD: 9<br>Sufficient: 1; I don't know: 6</td></tr><tr><td><strong>Suggestions for improvement</strong><br>What do you think should be improved in social/health services for patients with HD? (open questions)</td><td>Better awareness among health professionals: 3<br>Support home care of HD patients: 1<br>Experts/Psychologists for HD: 1<br>I don't know: 4</td><td>Awareness among health professionals and the public: 2<br>I don't know: 3</td><td>Aids for later stages: 2<br>Special SSE for HD: 3<br>Better awareness: 5<br>Preferential appointment: 2<br>Support groups for both carriers and patients:<br>Acceptance of the HD in the context of disability 1</td></tr></tbody></table>

For individual categories of questions, we also present citations of selected answers that authentically illustrate the situation and care of affected individuals with HD and its psychosocial effects. As stated above, the categories were clustered into domains I-IV to ease the overview.

### 3.1. First Information on HD

Only three out of thirty respondents mentioned receiving a good source of initial information about the HD from their physician. However, all participants lacked information on reproductive options, instruction on preimplantation testing in in vitro fertilisation, and a generally more empathic approach. Seven participants even learned about the possibility and accessibility of the PID in Slovakia for the first time only from our questionnaire. Moreover, all respondents would better appreciate at least some information on the ongoing clinical trials.

To the question 'How did your physician approach you?' we provide some examples: "There was no information ... I searched for everything on the internet myself". "The neurologist didn't pay attention and immediately wrote us off as an incurable diagnosis". "The neurologist told me not to make a 'big head' out of it". "I even had to actively explain to the general practitioner what the disease was and what it was causing". "It was told me that I will die".

We addressed the questions about the information that a person at risk for HD should receive and what to know earlier upon the genetic testing or disease onset. We received a detailed answer stating that "greater emphasis should be placed on possible symptomatic treatment so that one does not take it for final." The participants would also appreciate information on support possibilities for caregivers, "we have to unite to help each other; there is no other support for us." The participants were missing information on how to approach the affected person: "I have often heard from a husband that I am healthy and do not understand him".

### 3.2. Genetic Counselling and Testing

In the section about genetic testing, we explore the reasons for testing and experience with genetic counselling. The participants stated they mainly sought this information as they needed to know the truth about planning for the future and emerging symptoms.

Of particular interest are the answers of persons at risk who either did not yet know their genetic status, as they either did not take the genetic test or were waiting for the test results at the time of participating in the survey. Some answers pointed out the option not to know about the genetic status, "We decided not to know" on the other hand, some participants stated in more detail, "when planning the future, we chose the path of PGD with prenatal diagnosis, but without success. Subsequently, we decided to ignore the fear of the disease and live life as it is and as it will come. I don't want to be tested; I know what awaits me in the case of a positive test, and I don't want to wrap my life in the gloom of Huntington's disease". This
questionnaire could also see the burden of the COVID-19 pandemic and how it affects families. "My husband and I are waiting for test results. Although I went to the tests with him, the doctor did not let me into the office or tell me anything—allegedly for the corona reason. At the same time, she was not wearing a face mask. I was sorry because it is difficult for both my husband and me".

It is important to understand why the persons decide to take a test and disclose their genetic status; we also respond to individuals who have witnessed HD in their relatives since childhood/adolescence. "When I discovered that there was a 50% chance I could inherit this stuttering gene, I was determined to know what I was up to. Everything stopped making sense, and my only goal was to find out if I was sick or not". "So that I wouldn't ruin my partner's life ... And I would be ready for the institution and that I would be insane" "To stop it in our family".

### 3.3. The Impact of HD

We divide this section into three subcategories to better understand the burden for caregivers, the effect on relationships in general, and the impact on families' financial situation with HD.

#### 3.3.1. Burden for Caregivers

The results present the high burden of caregivers, showing higher burdens when coping with the mental symptoms rather than the motoric ones of their affected family members; "My father and sister were HD patients. I saw aggression, the desire to kill, they ruined my life, nobody will bring me back my youth ages". It also affects the partnership "The hardest thought is that my beloved husband, who is very wise, rational, just, will become someone who cannot take care of himself and lose his identity". The partners and caregivers at the same time are often overwhelmed with the care of the affected person in the family, and sometimes the care of the rest family comes short: "I had a mother-in-law who was affected, and same time I have a husband and a son. I was caring for all; I would welcome any help".

#### 3.3.2. Relationships

The relationships are mostly affected within the family and involve different levels. The communication between parents and children can be damaged at different levels, as communication about HD implies a lot of challenges. Some respondents stated: "My parents didn't tell me anything about HD, although they knew about it. I blame them". The affected members experience problems communicating their genetic status in their own family and experience the feeling of guilt, "Knowing about the HD is good when young people plan to start a family; I went to test myself for the kids, and now I don't know how to tell them, that I am affected, I feel guilty".

The own perspective of the positive genetic result plays a role and reflects further in the relationship: "The positive result destroyed me, my partnership; I don't want to do it to them either". some even stated, "everything about this disease puts me in depression so far ... I try not to think about it and live. Still, every encounter with such a person takes away my zest for life".

#### 3.3.3. Impact on the Financial Situation of Families with HD

The impact on families' financial situation with HD is very important, as most respondents describe it as unsatisfactory. It is very difficult as the partner or family needs to compensate for an affected member, "I had to work full-time at retirement age, to be able to pay for my husband's private caring facility". Most caregivers experience a difficult time as they have a full-time job and care for an affected individual and the rest of the family. "My husband was left without a job; the disability pension is so small. I have to go to work, and we don't know what will happen next". The affected families need to rely on the help of further family members and wider relatives. "We wouldn't have been able to manage it without the help of our relatives". The situation is even more complicated for the early-manifest respondents who experience the problems due to the symptoms of HD: "I haven't been able to find a job for a long time, I act like I'm an alcoholic with my involuntary movements. And once I got a job,
> I almost everywhere had an accident at work. Currently, I am at the unemployment office, and I receive benefits, which, of course, are not even enough to cover the basic living costs like household and food; my family helps me".

### 3.4. Social and Health Services in the Slovak Republic

The emerging fact is the lack of support for social and health services in the Slovak Republic. Most respondents consider them to be insufficient, with the most common blame regarding inadequate knowledge about HD among the health professionals and staff working in the social services and nursing facilities. The respondents summarise their perspectives in the following strong statements:

* "The patient is just waiting to die".

* "No support in the system".

* "Psychiatrists know nothing about it".

* "Inadequate, no one knows what to do".

* "Doctors and staff have minimal knowledge. Rather they take the disease as a sensation".

The participants were asked what could improve the health care and social systems. The majority of participants proposed rational and possibly easy solutions to enable better maintenance of affected individuals, such as *Better prescription of medical devices, prioritisation during the doctor visits, advice on how to deal with the dentist; insurance companies should also pay for the recreational stays for caregivers as well (not only affected person)*. It became clear that all respondents wish for more information and education about HD.

## 4. Discussion

This is the first survey of its kind to examine the needs and problems of the Huntington's landscape in the underserved region of Slovakia. Our survey results on the psychosocial impact of Huntington's suggest similar conclusions to other studies in this field [18,31,32]. For overview purposes, we will discuss the different themes, which were clustered into subthemes based on responses.

### 4.1. Genetic Counselling and Testing

This survey highlighted the importance of proper guidelines for genetic testing and counselling [21], as implemented in many European countries. Physicians conducting the genetic test need to provide information about HD in a timely, private, and sensitive manner to those who wish to do so while respecting the interests of those who do not want the test [33]. The liberty of choice for the patient and the possibility to opt-out of the procedure at any step and re-enter the protocol if the patients wish so at the later stage of life [22,34]. The respondents at risk were determined not to undergo predictive genetic testing. They are afraid to receive irreversible information for the future and are worried about possible stigma [35]. However, higher importance should be given to genetic counselling on reproductive options as the option is regularly available in Slovakia. Consultation on reproductive options should be public for all interested persons, regardless of whether they have previously had to undergo predictive testing, or it should usefully be included in consultations on genetic testing if the person so wishes [20,36].

In addition, it should not be forgotten that individuals who learn that they will develop HD in the future needs to be offered support not only in a short time post-testing but even from the long time perspective [35]. An earlier survey of attitudes to predictive testing suggested that 11–15% of people at risk would consider suicide if given an unfavourable test result [35]. In contrast, Quaid et al. report that only four (2.1%) of the 189 individuals in the US predictive test sample were hospitalised after receiving unfavourable results [37]. The study of Almquist et al. even described only 0.97% of all participants who experienced a catastrophic response to predictive testing [38]. In summary, all reported frequencies are still high and require attention.
However, rather rare negative reactions and impacts after the predictive testing should be compared to thousands of individuals who have been relieved of the anxiety of not knowing whether HD will develop [34,39]. Furthermore, in preventing fatal reactions after predictive testing, it is necessary to emphasise the importance of ongoing counselling regardless of the test result, identifying problematic reconciliation techniques and active support in reconciliation strategies [21]. Despite all recommendations about the appropriate psychological interviews as a part of predictive genetic testing, only a few respondents stated that they had attended an interview with a psychologist during this process.

Moreover, in our survey, we specifically process the responses of individuals who have witnessed HD in their relatives since early childhood and adolescence.

## 4.2. Family Relationships

HD has a major impact on family systems; impairments shape caregiver roles in the affected family member and change in time upon disease progression [40]. Our results confirmed the earlier findings of the role shifts in many HD families, including parenting (children overtaking the role of a parent in a family partly) [40]. In almost all areas, teenagers growing up in a family with HD actively assist in complex nursing care for a parent with HD. The topics that concern them include responsibilities and early decision-making, personal exposure and burden due to individual risk for HD. [41]. Some of our respondents describe their early experience with HD as negative; *my father and sister were HD patients. I saw aggression and desire to kill; they ruined my life, and nobody will bring me back to my youth.* Our findings are in line with interviews conducted with 32 young people living in a family with HD, where the following main problems were mentioned: the possibility of starting a family as a distressing decision; feelings of loneliness in the family and among peers, the experience of the affected parent being unable to have more reasonable conversations, and the non-affected parent being mostly described as absent and unreachable because they are taking care of a partner and often has several jobs for financial reasons; family life is so difficult and marked by the conflicts [42].

Our results are in line with numerous other studies highlighting the most affected domains in the family system involving family functioning, emotions and reactions, social functioning, and state and social services [41–45].

The respondents experience negative and traumatic experiences (witnesses of domestic violence, aggression, suicide and suicide attempts), causing long-term impacts on their own lives [42].

The hereditary aspect is also important as some respondents were, for a long time, not aware of their own risk as proper communication did not take place in the family [46] as also stated in our interviews: "*my parents didn't tell me anything about HD*", "*we did not talk about it*", "*I went to test me for the kids, and now I don't know how to tell them, that I am affected, I feel guilty*".

Overall, the respondents also reported feelings of being overburdened and feeling alone without any support and, at the same time, caring for multiple jobs and households.

## 4.3. Future and Family Planning

Future and family planning is one of the most important topics and reasons for undergoing predictive testing in clinical practice [47]. There is significant distress already when considering the predictive testing, and multiple factors, such as parenteral experience with disease and risk perception, play a role in decision-making [48]. Decruyenaere et al. observed that more than the majority of HD expansion mutation carriers, after undergoing predictive genetic testing, had chosen to have children with a prenatal or preimplantation genetic diagnosis. About one in three (35%) decided to have no children anymore. A minority (7%) was undecided or had no children for other reasons [49]. The factors impacting the decision not to have children were the personal experience of growing up in a family with HD and the ethical issues related to prenatal and preimplantation genetic diagnoses [49]. The factors associated with the non-use of prenatal testing and
the preimplantation genetic diagnosis were aversion to terminating the pregnancy and optimism associated with treatment options and ongoing clinical trials for HD [50]. As we have already assumed, several factors play a role in the decision-making process, such as gender, knowledge and ethical issues about PD and PGD, the availability of these methods, the strength of the desire to have children, and personal experiences with HD in the family [45,49,50]. The results illustrate the complexity of the decision-making process and the necessity of in-depth genetic counselling. A group of those who knew about the risk and decided to have children had their decision mostly based on the hope of a cure that would come in time to help their children if needed; a certain role played the “wish thinking”, in which they believe that their children will not develop HD [49]. Findings similar to our responses were presented in the group of those who had children before they knew about the risk. They reflected the lack of information about HD and inheritance patterns [51]. In the group of those who choose not to have children because of the risk, the main reason was their own experience, how they saw the decline and death of family members for HD in generations [51].

### 4.4. Social and Health Care System Support

Our findings also highlight the central role of the physician or general practitioner who might consider working with families on strategies to improve emotional engagement, communication, and problem-solving and ensure better care for affected members [52]. The findings of studies point out the importance of support needed for families with HD facing different problems. There is an urgent need to develop strategies to help and support genetic counsellors, healthcare providers, and school workers [53]. Our respondents reported major complaints about the problematic and lacking support for patients with HD in the presymptomatic and especially advanced stage of the disease and reflecting the need for a multidisciplinary approach—the key role in helping build and develop the infrastructure played here patients and lay organisations. There is an urgent need for an interdisciplinary approach to HD management to ensure adequate systematic care during all stages of the disease. It is important to provide appropriate care at all stages of Huntington's disease. Starting in the period before predictive testing with psychological support, involving the general practitioner, the specialist and the family, to balance early between fatalism (“I already have HD, and there is nothing I can do about it”) and denial (“These symptoms are not HD” or “I have no symptoms”) [21,23]. Available supports should include educational materials, home health care or skilled nursing support, respite care, advocacy organisations, and local or online support groups. Educating patients and caregivers about the availability of these services and providing access to them is imperative for neurologists and other healthcare providers [54].

## 5. Limitations

Although there are so far no epidemiological studies available in Slovakia, the prevalence of the HD is expected to be as in other European regions 6–15: 100,000 [55,56], with an anticipated increase of another 17% by 2030 [57]. Based on this information by the population of five million inhabitants in Slovakia, we emphasise that there are more affected families and individuals that we could not reach with our survey and would need to be identified in future.

The one limitation, especially from the perspective of the qualitative research approach, was the online form of data collection. We preferred the questionnaire form with the possibility of answers in their own words to an interview via phone call or zoom, mainly to preserve the anonymity of the respondents and obtain answers with a lower degree of self-censorship. However, we are aware that the optimal way to obtain information would be a personal interview with the trained local HD medical specialist, who already knows the respondent and has a therapeutic relationship with them. However, this was not possible due to the lack of HD specialists in Slovakia and non-existent HD centres where patients would naturally concentrate. The number and type of participants could also be
significantly influenced by the necessity of sufficient cognitive ability of patients to use
the Internet, which we tried to cover with the possibility that the family could fill in the
questionnaire on behalf of the patient. Another source of influence on the number and
type of respondents could be the lack of access to the Internet, which according to data
from Eurostat for the year 2020 [58]—at the time of data collection, on the level of access of
households to the Internet represented only 14% of households in Slovakia that did not
have access to the Internet.

In addition, the COVID-19-related isolation periods and restrictive measures may
influence some responses. It should also be noted that the survey took place between the
first two COVID-19 pandemic waves, although the first wave in Slovakia was very mild,
and the measures were considered mild compared to other European countries. All of the
responses were received within four weeks of publication in early October 2020, so the
survey was completed quickly.

**6. Conclusions**

In summary, Huntington´s disease requires a multidisciplinary approach due to the
different needs of those affected at different stages, which is still scarce in Slovakia. In
routine clinical practice, health professionals often assume that after informing the patient
and his/her blood relatives about the possibility of diagnosis by genetic testing and the
real limitations of currently available treatment, no other kind of support is possible than
symptomatic control of motor and psychiatric symptoms. The results of our survey on
the experiences and suggestions for improvement of the HD community in Slovakia point
mainly to the lack of basic education of doctors and the explicit absence of information
about the possibility of prenatal and preimplantation genetic testing. Strategies are needed
to improve the knowledge of health professionals and to provide better counselling. Fur-
thermore, information on ongoing clinical trials, as well as research progress, is seen as
important. The results also show that comprehensive social and health services need to be
provided for the later stages of the disease. Experts and multidisciplinary teams should be
formed, and public awareness of the disease should be raised to improve the situation in
any underserved region.

**Author Contributions:** Conceptualization, K.H.; Data curation, A.M.; Formal analysis, J.B. (Ján Benetin) and Z.P.; Methodology, K.H., L.B. and Z.P.; Resources, K.H. and A.M.; Supervision, J.B. (Ján Benetin), J.B. (Jitka Bušková) and M.B.; Validation, Z.P.; Visualization, T.R. and L.B.; Writing—original draft, K.H., T.R. and L.B.; Writing—review & editing, A.M. and M.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by MSMT CR programme Cooperatio 38—Neuroscience, Charles University.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Psychiatric Hospital of Philipp Pinel in Pezinok, Slovakia (Approval Date: 30 September 2020).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

**Data Availability Statement:** The data presented in this study are available upon request from the corresponding author. The data are not publicly available because the database contains patient personal data.

**Acknowledgments:** We would like to thank all patients, partners, caregivers and families for par-
ticipating in the project. We also thank all persons involved in the restoration process of the Slovak
Society for Help in Huntington's Disease and acknowledge Vladimir Vaclavik, Bea de Shepper, and
Astri Arnesen for their support to the Slovak HD community.

**Conflicts of Interest:** The authors declare no conflict of interest.
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<figure><img src="image_19.png" /></figure>

Review

# Multiple Sclerosis and Autoimmune Comorbidities

Viviana Nociti<fnref n="1" />,<fnref n="2" />,* and Marina Romozzi <fnref n="1" /> ID

**Abstract:** Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterized by broad inter- and intraindividual heterogeneity and different prognoses. Multisystem comorbidities are frequent features in people with MS (PwMS) and can affect treatment choices, quality of life, disability and mortality. In this scenario, autoimmune comorbidities play a cardinal role for several reasons, such as the implication on MS pathogenesis, diagnostic delay, disease activity, disability progression, brain atrophy, and treatment choice. However, the impact of an autoimmune comorbid condition on MS is not fully elucidated. This review aims to summarize the currently available data on the incidence and prevalence of autoimmune diseases in PwMS, the possible effect of this association on clinical and neuroradiological MS course and its impact on treatment choice.

**Keywords:** multiple sclerosis; personalized medicine; autoimmune; comorbidities

## 1. Introduction

Multiple sclerosis (MS) is a chronic, inflammatory and degenerative demyelinating disease of the central nervous system (CNS), of unknown etiology, affecting individuals in early adulthood [1]. The disease is characterized by broad inter- and intraindividual heterogeneity with various clinical presentations, different subtypes and prognoses and consequently variable responses to treatments [1]. MS treatment guidelines have changed significantly over the past decades due to the growing number of approved disease-modifying therapies (DMTs), which can influence the disease course by preventing relapses and disability progression in people with MS (PwMS) [2].

Although the etiology and pathogenesis of MS remain unclear, it is believed to be an immune-mediated disease. The pathophysiology of MS seems to be characterized by an aberrant immune activation [3]. This immune dysregulation leads to neuroinflammation in which both immune cells from the periphery and resident cells of the CNS (e.g., microglia and astrocytes) are involved [3].

MS may share similar underlying pathogenesis with certain comorbidities, particularly autoimmune pathologies, which may arise from genetic susceptibility to autoimmunity and overlapping pathogenetic mechanisms [4].

Comorbidity is defined as the co-existence of multiple diseases or medical conditions in a patient, which may share similar overlapping pathophysiology and affect the course of the disease itself [5].

Multisystem comorbidities are frequent features in PwMS, particularly neurological disturbance, other comorbidity autoimmune conditions, psychiatric comorbidities, cardiovascular diseases, chronic lung diseases and metabolic disorders. Among neurological disturbances, epilepsy, migraine and restless leg syndrome are more frequent in patients with MS compared with the general population [6].

Psychiatric comorbidities (i.e., depression, anxiety, and bipolar disorder) have been associated with poor quality of life (QoL), reduced adherence to DMTs and fatigue [7].

**Citation:** Nociti, V.; Romozzi, M. Multiple Sclerosis and Autoimmune Comorbidities. *J. Pers. Med.* **2022**, *12*, 1828. https://doi.org/10.3390/jpm12111828

Academic Editor: Anne-Marie Caminade

Received: 1 October 2022
Accepted: 29 October 2022

Published: 3 November 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

<figure><img src="image_20.png" /></figure>

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

<footnote n="1">¹ Centro Sclerosi Multipla, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, 00168 Rome, Italy</footnote>

<footnote n="2">² Università Cattolica del Sacro Cuore, 00168 Rome, Italy</footnote>

<footnote>* Correspondence: viviana.nociti@policlinicogemelli.it</footnote>
Cardiovascular comorbidities such as abnormalities in blood pressure, heart rate, heart rhythm, and left ventricular systolic function are common in PwMS, and a diagnosis of MS increases the risk of myocardial infarction, stroke and heart failure [8,9].

Many comorbidities are present before or at MS symptom onset, but it seems that the prevalence increases over time [10]. For example, some comorbidities such as depression and anxiety may represent preclinical symptoms of MS resulting from immunological and inflammatory changes in the CNS [7].

Over the last decades, the average age of the MS population has increased correlating with increasing general life expectancy, advances in DMTs, the adoption and subsequent widespread use of magnetic resonance imaging (MRI) and improved health and social care for these patients. Further, MS has become a lifelong condition. The risk of multi-morbidity increases with age and in patients with a chronic disease such as MS [11]. However, over time, the accrual of comorbidities can be explained by several other factors such as physical invalidity, a background of common risk factors and the use of DMTs [4].

Several studies have shown that the presence of comorbidities can delay diagnosis. Furthermore, comorbidities can affect treatment choices, QoL, disability and mortality [12].

Marrie et al., using the North American Research Committee on Multiple Sclerosis Registry, evaluated the association between comorbidities and both the diagnostic delay and severity of the disability at MS diagnosis. They found that the presence of comorbidities was associated with greater diagnostic delays and increased disability at diagnosis [13]. The presence of comorbid conditions increases the complexity of patient management and bears important clinical and socioeconomic implications for PwMS [12].

This review aims to describe the current evidence regarding the range of comorbidities in PwMS, focusing on autoimmune comorbidities, and widen the current knowledge about the influence of these comorbidities on the clinical features and therapeutic choices in MS.

## 2. Neurological Comorbidities and MS

Several studies have suggested that comorbid neurological conditions such as epilepsy and migraine are more frequent in PwMS [6].

### 2.1. Epilepsy

Epileptic seizures are more common in PwMS than in the general population. A systematic review found that the incidence of seizure disorders (18 studies) ranged from 0.6% to 6% after MS onset, and the prevalence (24 studies) ranged from 0.9% to 8%, both higher than reported in the general population. However, heterogeneity among these studies was substantial [14].

Seizures may occur at any point during the course of MS and have also been described as the presenting symptom of MS [15–17]. Seizures have been observed in patients with relapsing-remitting MS (RRMS) as well as in progressive forms [15,18].

Several studies suggested that focal onset seizures are more common than generalized seizures and secondary generalization of focal seizures is also frequent [19,20].

A systematic review demonstrated that patients with MS who had seizures are more likely to have a younger age of onset compared to MS patients without seizures, and there was also a trend demonstrating higher disability scores in patients with epilepsy [18]. A longitudinal study by Calabrese et al. showed an association between the severity of cortical pathology, namely the number and volume of cortical lesions evaluated by double-inversion recovery (DIR) imaging, and the occurrence of epilepsy in PwMS. Moreover, in patients with RRMS and epilepsy, cognitive dysfunction was four-times higher than in the RRMS group without epilepsy [21].

In a study by Martinez-Lapiscina et al., MS patients with seizures had a higher mean number of cortico-juxta cortical lesions on T2-weighted/fluid attenuation inversion recovery magnetic resonance imaging as compared to MS controls [22].
The pathologic substrate of epilepsy in MS is not fully elucidated. Still, the involvement of grey matter, along with brain inflammation, are presumably the reasons behind the increased incidence of epilepsy [23].

## 2.2. Migraine

Migraine affects up to 50% of PwMS with a significantly higher prevalence than in the general population [24].

PwMS are more than twice as likely to report migraine than controls, with a significant association for migraine without aura [25]. Migraine can precede MS onset, be associated with relapses, or manifest during the disease course [26,27]. However, the prevalence of comorbid migraine seems to be higher in patients with RRMS compared to those with progressive forms [28].

The mechanism explaining the association between MS and migraine remains to be clarified, but several hypotheses have been postulated. The inflammatory demyelinating MS lesions may induce migraine by disrupting the pathways involved in the pathogenesis of migraine, deputed to pain stimuli processing. It was observed that lesions within the midbrain, especially in the periaqueductal grey matter, were frequently associated with comorbid migraine in PwMS [29,30].

Furthermore, a study on rodent models of autoimmune-induced cortical demyelination showed that cortical demyelination was associated with accelerated cortical spreading depression (CSD), which has been implicated in migraine pathophysiology, both with and without aura [31,32].

Only a few pieces of evidence support the hypothesis that CSD may lead to a subtle increase in permeability of the blood-brain-barrier and neuroinflammation, thereby exposing antigens in the CNS to circulating T cells [33]. Graziano et al. found an increased frequency of contrast-enhancing lesions in MS patients with migraine, specifically within the RRMS disease subtype, and postulated that having migraine comorbidity may increase the level of blood-brain-barrier disruption in these patients [27].

Regarding the overall impact on MS severity, some studies have found no significant correlation between the level of disability and the presence of migraine [28], while the presence of comorbid migraine negatively affects some aspects of QoL in these patients [34].

# 3. Autoimmune Comorbidities and MS

The coexistence of autoimmune/inflammatory comorbidities has recently engendered significant interest in the MS research field. First, MS and specific comorbidities may have underlying pathogenesis. Second, the association between autoimmune comorbidities and MS may reveal common genetic and environmental risk factors [4].

For example, smokers with multiple sclerosis had an increased risk of developing comorbid autoimmune disease after MS onset [35].

Several articles describe the association between autoimmune/inflammatory conditions and MS, but the results are still inconsistent. A population-based case-control study on autoimmune comorbidities and MS showed that before MS diagnosis, uveitis occurred 3-fold more often, and inflammatory bowel disease (IBD) occurred 1.7-fold more often in patients with MS [36]. A nationwide cohort study in Denmark found that PwMS were at an increased risk of developing ulcerative colitis and pemphigoid [37]. Nevertheless, other studies, including a recent multicentric population-based study, did not find any increased risk of autoimmune diseases among MS patients [38].

A systematic review of the incidence and prevalence of autoimmune disease in PwMS found that psoriasis and thyroid disease were the most prevalent autoimmune comorbidities. The findings also supported an increased risk of IBD, uveitis, and pemphigoid [39]. However, the authors stated that they could not draw conclusions because the study was mainly heterogeneous with respect to the populations studied, methods of ascertaining comorbidities, and reporting of findings [39].
A systematic review and meta-analysis on the overall risk of other autoimmune diseases in PwMS and their first-degree relatives showed that the OR of thyroid disease was increased in both PwMS (OR 1.66) and their relatives (OR 2.38). A comparable association was observed between MS and IBD (OR 1.56) and psoriasis (OR 1.31; *p* < 0.0001), though not in relatives [40].

Table 1 lists relevant studies on MS and concomitant autoimmune conditions.

### 3.1. *Type 1 Diabetes Mellitus*

The co-occurrence of type 1 diabetes mellitus (DM) and MS is supported by several studies. A population-based cohort study found that patients with type 1 DM were at 3-fold greater risk for developing MS. Furthermore, the risk for type 1 DM in first-degree relatives of patients with MS was increased by about 40% [41]. The authors suggested that similarities in immunological features between type 1 DM and MS and/or unknown environmental factors might contribute significantly to the co-occurrence of these two diseases [41]. Similarly, a Sardinian study observed a 5-fold and 2-fold higher prevalence of type 1 DM in patients with MS and their first-degree relatives compared with the general population. It concluded that common genes might contribute to susceptibility to both diseases [42].

Furthermore, Bechtold et al. conducted a cohort study on a pediatric and adolescent population affected by type 1 DM in Germany and Austria. They demonstrated a considerably higher risk of MS co-occurrence in the diabetic population [43].

### 3.2. *Autoimmune Thyroid Disease*

Autoimmune thyroid disease seems to affect PwMS and their first-degree relatives more than the general population, regardless of treatment with IFN-β and alemtuzumab, but the results are variable. A controlled prospective study found that thyroid disorders were at least three-times more common in women with MS than in female controls [44]. Another study on 353 patients not treated with IFN-β found a statistically significant higher prevalence of autoimmune thyroiditis in male MS patients compared with male controls but not in female patients [45]. In a study on a Spanish cohort of 93 untreated PwMS, MS patients had a higher prevalence of antithyroid antibodies compared with the general population [46].

### 3.3. *Inflammatory Bowel Disease*

Previous studies have established an association between MS and IBD, including Crohn's disease and ulcerative colitis (UC) [47,48]. A systematic review and meta-analysis showed that IBD and PwMS seem to be associated with a 50% increased risk of MS or IBD comorbidity, respectively, with no apparent differences between patients with Crohn's disease or ulcerative colitis [49].

### 3.4. *Psoriasis*

An association between MS and psoriasis has not been clarified, and several studies have tried to determine whether an association exists. Marrie et al. found that the risk of incident psoriasis was 54% higher in PwMS (HR 1.54; 95%CI: 1.07–2.24) [50]. One case-control study investigating whether patients with a diagnosis of MS had higher rates of concomitant psoriasis found a higher-than-expected frequency of psoriasis among PwMS [51]. In contrast, other studies did not corroborate the association between psoriasis and MS [52]. In a study on 658 consecutive patients, the prevalence of psoriasis in MS patients compared to the general population did not differ significantly [48]. Similarly, a large multicenter study on autoimmune disease risk in MS patients found that the frequency of psoriasis in MS patients did not differ from spousal controls (5.8% of the MS population and 5.4% of controls) [38]. The association between the two conditions may reflect shared genetic, environmental factors and immune pathways, and the effectiveness of fumarates in both conditions may yield etiologic insights into MS [53].
<table><caption>**Table 1.** Relevant studies on the co-occurrence of MS and autoimmune diseases.</caption><thead><tr><th>Author (Date) [Reference]</th><th>Concomitant AID</th><th>Study Population</th><th>Main Findings</th></tr></thead><tbody><tr><td>Nielsen (2006) [41]</td><td>Type 1 DM</td><td>11,862 PwMS, 6078 type 1 DM cases</td><td>RR for MS in type 1 DM patients: 3.26 (95% CI: 41.30–7.97)</td></tr><tr><td>Marrosu (2002) [42]</td><td>Type 1 DM</td><td>1090 PwMS, 2180 parents, 3300 siblings</td><td>Type 1 DM prevalence in MS is 3-fold greater than in healthy siblings and 5-fold the general population</td></tr><tr><td>Bechtold (2014) [43]</td><td>Type 1 DM</td><td>19 PwMS, 56,653 type 1 DM cases</td><td>RR of MS in type 1 DM patients: 3.35 (95% CI: 1.56–7.21) to 4.79 (2.01–11.39)</td></tr><tr><td>Edwards (2005) [48]</td><td>Type 1 DM</td><td>658 PwMS</td><td>Type 1 DM prevalence of 0.9%; OR 18.14 (95% CI: 6.40–2.17)</td></tr><tr><td>Ramagopalan (2007) [38]</td><td>UC</td><td>5032 PwMS, 2707 controls</td><td>No difference between PwMS and controls</td></tr><tr><td>Roshanisefat (2012) [47]</td><td>UC</td><td>20,276 PwMS, 203,951 controls</td><td>Increased risk in PwMS: HR 1.49 (95% CI: 1.22–1.82)</td></tr><tr><td>Roshanisefat (2012) [47]</td><td>CD</td><td>20,276 PwMS, 203,951 controls</td><td>Increased risk in PwMS: HR 1.45 (95% CI: 1.17–1.81)</td></tr><tr><td>Edwards (2005) [48]</td><td>IBD</td><td>658 PwMS</td><td>IBD prevalence of 1.2%; OR 3.17 (95% CI: 6.40–2.17)</td></tr><tr><td>Farez (2014) [52]</td><td>CD</td><td>211 PwMS, 211 controls</td><td>No difference between PwMS and controls</td></tr><tr><td>Ramagopalan (2007) [38]</td><td>Psoriasis</td><td>5032 PwMS, 2707 controls</td><td>No difference between PwMS and controls</td></tr><tr><td>Roshanisefat (2012) [47]</td><td>Psoriasis</td><td>20,276 PwMS, 203,951 controls</td><td>Increased risk in PwMS: HR 1.73 (95% CI: 1.42–2.10)</td></tr><tr><td>Edwards (2005) [48]</td><td>Psoriasis</td><td>658 PwMS</td><td>No higher prevalence compared to controls</td></tr><tr><td>Marrie (2017) [50]</td><td>Psoriasis</td><td>4911 PwMS, 23,274 controls</td><td>Risk of psoriasis was 54% higher in PwMS (HR 1.54; 95%CI: 1.07–2.24).</td></tr><tr><td>Fellner (2014) [51]</td><td>Psoriasis</td><td>214 PwMS, 192 controls</td><td>Psoriasis prevalence of 4.21%; OR: 8.39 (95% CI: 1.05–66.81)</td></tr><tr><td>Farez (2014) [52]</td><td>Psoriasis</td><td>211 PwMS, 211 controls</td><td>No difference between PwMS and controls</td></tr><tr><td>Niederwieser (2003) [45]</td><td>AITD</td><td>353 PwMS, 308 controls</td><td>Higher prevalence of AITD in male MS patients (9.4%) than in male controls (1.9%; p = 0.03)</td></tr><tr><td>Edwards (2005) [48]</td><td>AITD</td><td>658 PwMS</td><td>AITD prevalence of 3.2%; OR 1.80 (95% CI: 3.02–1.07)</td></tr></tbody></table>

AID, autoimmune disease; AITD, autoimmune thyroid disease; CD, Crohn's disease; CI, confidence interval; DM, diabetes mellitus; HR, hazard ratio; IBD, inflammatory bowel disease; OR, odds ratio; PwMS, people with multiple sclerosis; RR, relative risk; UC, ulcerative colitis.

### 3.5. Drug-Related Autoimmune Disorders

The possibility of comorbid autoimmune disorders developing secondary to DMTs has also been a concern. Autoimmunity following alemtuzumab therapy is a well-recognized adverse effect of alemtuzumab, with thyroid disease being the most common in more than a third of patients. Other antibody-mediated autoimmune disorders are associated with alemtuzumab, including idiopathic thrombocytopenic purpura and anti-glomerular basement membrane disease [54]. IFN-β might be associated with an increased risk of thyroid autoimmunity and dysfunction, particularly within the first year of treatment [55].

## 4. Effects of Autoimmune Comorbidities on the Clinical and Neuroradiological Course of MS

Several studies investigated the effect of different autoimmune conditions on the clinical course of MS. Patients with MS, and a concurrent autoimmune disorder seem to
have lesser disabilities compared to those with isolated MS after an average of 5.91 years. It has been suggested that the concurrent autoimmune disorder may increase body tolerance against autoantigens [56]. A study performed by Fanouriakis et al. on 9 patients with both systemic lupus erythematosus and MS showed that the coexistence of the two diseases does not seem to be associated with a severe phenotype for either entity. In particular, systemic lupus erythematosus remained quiescent in all patients while on standard immunomodulatory MS therapy [57]. A study on 66 patients with concomitant MS and IBD showed that these patients have a milder course of the disease than patients with MS alone, after a median of 12 years of disease duration [58].

Regarding the effects of comorbid autoimmune diseases on the radiological outcome, Zivadinov et al. analyzed magnetic resonance (MR) imaging findings in MS patients with autoimmune comorbidities. They found that comorbidities in patients with MS were associated with more severe MR imaging outcomes of demyelination and neurodegeneration, evidenced by several nonconventional MR imaging measures, including brain atrophy, magnetization transfer imaging, and diffusivity. The findings were significant for psoriasis, type 2 DM, and thyroid disease [59]. However, the study included 40 patients with type 2 DM, which is considered more a metabolic-acquired disease rather than an autoimmune condition, and only 3 patients with type 1 DM.

Lorefice et al. performed a case-control MRI study on 286 PwMS, of which 30 subjects had DM type 1, 53 patients had autoimmune thyroiditis, and 4 had celiac disease. Multiple regression analysis found an association between type 1 DM and lower grey matter and cortical grey matter volumes, independent from MS clinical features and related to type 1 DM duration [60].

The correlation between brain atrophy and autoimmune comorbidities may have significance in the progression of disability, as several reports have shown that brain and spinal atrophy may represent reliable biomarkers of neurodegeneration that correlate with physical and cognitive impairment in PwMS [61,62].

## 5. Effect of Autoimmune Comorbidities on Treatment Choices

The treatment choice in PwMS and concomitant autoimmune comorbidities that share common immunological interfaces is still challenging. Numerous therapeutic strategies are either approved for different autoimmune disorders or may be repurposed for several diseases, with the possibility of using a drug that can be effective in both conditions. Contrarily, other medications may exacerbate pre-existing autoimmune disorders or trigger their onset. For example, tumor necrosis factor-alpha (TNFα) blockers, established as effective agents in the treatment of several autoimmune conditions such as rheumatoid arthritis, psoriasis and IBD, can induce or worsen demyelinating diseases and are contraindicated in the treatment of MS [63].

Similarly, interferons can unmask silent autoimmune processes or induce de novo autoimmune diseases, and their use in MS with concomitant autoimmune diseases is not recommended [64–66].

Alemtuzumab is not recommended in the case of MS and autoimmune comorbidities for its association with autoimmunity. The cause of autoimmunity is not entirely understood and is likely related to the pattern of T- and B-cell repopulation after their depletion [67].

Natalizumab, a monoclonal anti-α4 antibody, inhibits the trafficking of lymphocytes from the blood into CNS. There have been several cases of patients with MS treated with natalizumab who developed rheumatoid arthritis or experienced an onset or exacerbation of psoriasis [68,69]. Natalizumab modifies the composition of lymphocyte subpopulations and alters the migration of leukocytes across the blood-brain-barrier, shifting the inflammatory response from the CNS towards other tissues [70]. Furthermore, natalizumab has been demonstrated to be an effective drug for the induction and maintenance of remission in patients with Crohn's disease [71,72]. Therefore, natalizumab may be an alternative
treatment option for patients with MS and Crohn's disease but should be used cautiously in patients with comorbid psoriasis or rheumatoid arthritis.

Anti-CD20 antibodies used for MS include rituximab, ocrelizumab and ofatumumab. Ocrelizumab has been demonstrated to be an effective and safe treatment option for rheumatoid arthritis [73]. In contrast, ocrelizumab and rituximab were associated with an increased risk of developing psoriasis and IBD. Therefore, it should be avoided in patients with MS plus psoriasis or IBD [74–76].

The sphingosine-1-phosphate receptor modulators (fingolimod, siponimod, ozanimod) are potentially useful in IBD, rheumatoid arthritis and psoriasis, as demonstrated in animal models and few reports [77–79]; however, further applications in clinical trials are still needed to ascertain the effectiveness in these pathologies. Ozanimod has been proven safe and effective in patients with moderate to severe ulcerative colitis and may represent an option for patients with concomitant highly active MS and ulcerative colitis [80].

Among first-line therapies, dimethyl fumarate enhances the nuclear factor erythroid 2 related factor 2 (Nrf2) transcriptional pathway. It is approved for both relapsing-remitting mild/moderate MS and moderate/severe psoriasis and represents the treatment of choice in case of co-occurrence of these pathologies [81,82].

The DMTs approved for multiple sclerosis and other common autoimmune conditions are synthesized in Table 2. A pragmatic treatment approach to MS and autoimmune disorders should foresee first a check for contraindications, second, an evaluation of the disease/severity of the concomitant conditions, to tailor therapies for the individual patient [83].

<table><caption>**Table 2.** DMTs approved for MS and their use in other autoimmune disorders.</caption><thead><tr><th>DMTs</th><th>MS</th><th>IBD</th><th>PsO</th><th>RA</th></tr></thead><tbody><tr><td>INF</td><td>+</td><td>—</td><td>—</td><td>—</td></tr><tr><td>DMF</td><td>+</td><td>—</td><td>*</td><td>—</td></tr><tr><td>TER</td><td>+</td><td>—</td><td>—</td><td>*</td></tr><tr><td>S1PR<br>Ozanimod</td><td>+</td><td>*</td><td>—</td><td>—</td></tr><tr><td>CLAD</td><td>+</td><td>—</td><td>—</td><td>—</td></tr><tr><td>NAT</td><td>+</td><td>+</td><td>—</td><td>—</td></tr><tr><td>ALE</td><td>+</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Anti-CD20</td><td>+</td><td>—</td><td>—</td><td>+</td></tr></tbody></table>

+, FDA approved; * used off-label; —, not used; ALE, alemtuzumab; Anti-CD20: CD20 antibodies; AZA, azathioprine; CLAD: cladribine; DMF, dimethyl fumarate; FDA, US Food and Drug Administration; IBD, inflammatory bowel disease; IFN, interferon; MS, multiple sclerosis; MTX, methotrexate; NAT, natalizumab; PsO, psoriasis; RA, rheumatoid arthritis; S1PR, sphingosine-1-phosphate receptor modulator; SLE, systemic lupus erythematosus; TER, teriflunomide; UC: ulcerative colitis.

## 6. MS and Autoimmune Comorbidities: Unmet Needs

The association between MS and different comorbidities is of rising interest as a factor that could explain the heterogeneity of outcomes.

Over the past decades, insufficient attention has been paid to comorbid conditions in MS, as it was considered mainly a disease of young adults with a limited comorbidity burden. Recent studies demonstrated the importance of investigating comorbidities in PwMS, as several comorbid conditions influence the course of the disease, disability progression, worsened QoL, treatment choices and mortality [84–86]. Another important point is the diagnostic delay in patients with comorbidities [13]. An explanation could be that the clinician could erroneously attribute MS symptoms to a preexisting condition, increasing the time from symptom onset to diagnosis and subsequently disability at diagnosis [13].
However, studies investigating comorbidities in PwMS have been performed mainly in small cohorts, and a global view of comorbidity in MS is lacking. A clear understanding of the risk of developing these pathologies and their prevalence in PwMS is necessary [6].

Furthermore, patients with comorbidities are usually excluded in clinical trials of disease-modifying therapies in MS. Thus, trial results may not be representative of a real-world scenario and cannot be applied to a standard clinic population with general comorbidities [87]. However, comorbidities may influence disease activity, disability progression and treatment choices [12].

Marrie et al. reviewed the published results of nine placebo-controlled trials of DMTs for MS. Of the nine trials evaluated, five excluded individuals with different comorbidities, and the explanation of the exclusions for comorbidities was unclear in four trials. None of the trials reported the comorbidity status of patients at enrollment [87].

To address this knowledge gap, the International Workshop on Comorbidity in Multiple Sclerosis produced several recommendations for future clinical trials, indicating relaxing restrictions on the inclusion of patients with comorbidity. The comorbidities prioritized were depression, anxiety, autoimmune disease, diabetes, cancer, hypertension, and migraine [87].

In this scenario, autoimmune comorbidities play a cardinal role for several reasons. First, the coexistence of autoimmune disorders may reflect common underlying pathobiology. Second, as the treatment landscape continues to expand with the development of new DMTs, concomitant pathologies may present a unique therapeutic target.

For example, MS and type 1 DM share T-cell-mediated autoimmunity [88]. Type 1 DM is caused by T lymphocytes' destruction of the insulin-producing β-cells in pancreatic islets once activated by particular insulin epitopes on antigen-presenting cells. In vitro, T-cells from type 1 DM patients reacted to pancreatic islet and CNS antigens [89]. Children with concomitant CNS demyelination and type 1 DM exhibited heightened T-cell reactivities to self-antigens, and these responses were not strictly limited to the disease target organs [90].

The presence of shared pathways and the involvement of similar cell types in the pathogenesis of autoimmune conditions may underlie the risk of both MS and other autoimmune diseases [91]. Furthermore, genetic loci shared between multiple autoimmune diseases are involved in a wide range of immune pathways (i.e., T-cell activation, B-cell activation, cytokine signaling), helping to explain common pathogenic features [92]. Apart from loci within the major histocompatibility complex (MHC) associated with the greater risk, multiple non-MHC genes mainly involved in the regulation of immune response may also explain the susceptibility of multiple autoimmune conditions [92].

However, the impact of an autoimmune comorbid condition on MS remains yet to be fully elucidated. The coexistence of another autoimmune disease may reduce the possibility of disability progression due to unknown changes in immunological pathways, increasing the tolerance against autoantigens. Alternatively, regulatory T-cells can prevent the inflammatory activity of Th1 and Th17 cells following the secretion of anti-inflammatory cytokines. The activation of more regulatory T-cells and the production of more anti-inflammatory cytokines could be another hypothesis for a milder course in patients with two concomitant autoimmune diseases. Further studies with larger sample sizes are required to confirm the finding of brain atrophy associated with autoimmune comorbidities.

## 7. Conclusions

In this comprehensive review, we summarized currently available data on the incidence and prevalence of autoimmune diseases comorbidity in PwMS, the possible effect of this association on clinical and neuroradiological MS course and its impact on treatment choice. We also highlighted the unmet needs in this field. The currently available data make it difficult to draw firm conclusions concerning the extent of coexistence of other autoimmune diseases in PwMS and all other topics discussed herein. Further studies in this area are warranted considering the implication on MS pathogenesis, the possible