The Center for the Imaging of Neurodegenerative Diseases (CIND) at the San Francisco VA was inaugurated on May 12, 2006. Located in historic Building 13 on the SFVAMC campus, CIND is a collaborative effort between the VA, the Department of Defense, the University of California, San Francisco, the National Institutes of Health, and NCIRE, which administers much of the funding for CIND researchers.

The Director of CIND is Michael Weiner, MD, who is also a professor of radiology, medicine, psychiatry, and neurology at the University of California, San Francisco.

The mission of CIND is research in the prevention, early detection, monitoring, and treatment of chronic and neurodegenerative brain diseases and conditions such as Alzheimer's disease, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), Gulf War illness, Parkinson's disease, epilepsy, HIV dementia, and other dementias.

Brain images are obtained with magnetic resonance imaging (MRI), a non-invasive, non-radioactive technology. At the heart of the CIND equipment array is a state-of-the-art 4.0 Tesla MRI instrument, the only one of its kind in the VA system, which is several times more powerful than conventional MRI devices. The Center features a 1.5 Tesla MRI instrument as well.

CIND has a staff of more than 60 physicians, researchers, physicists, computer scientists, radiologists, technicians, and support personnel. With more than 35 research grants, over a dozen research projects, and a number of clinical trials under way, they are one of the oldest and largest research groups in the world focusing on magnetic resonance imaging of neurodegenerative diseases.

For more information, contact CIND at www.cind.research.va.gov

Kenneth Covinsky, MD

Every day, Joe Johnstone, 85, deals with the effects of depression, Parkinson’s disease, chronic obstructive pulmonary disease, and macular degeneration. Yet he leads an active, productive life — reading, writing, and going out nearly every day. Mr. Johnstone has no doubts about why. "I’m surviving now because I’m at home. If I’d stayed in the hospital, I’d be dead."

SFVAMC Geriatrician and NCIRE researcher Dr. Kenneth Covinsky says that Mr. Johnstone is on to something. "Often, when an older person goes into the hospital, they seem to come out worse, even though whatever brought them into the hospital is seemingly fixed," observes Dr. Covinsky. "Our research shows this is extremely common — it happens to a third of people over the age of 70, and over half of people over the age of 85. We’ve also looked at why."

It turns out that for the elderly, the ability or inability to do day-to-day tasks is a better indicator of health, hospitalization, and death "than the list of diseases that you have," Dr. Covinsky explains. "Mr. Johnstone is a great example of how you can deal with disability and stay active." Because disability predicts health outcomes so accurately, says Dr. Covinsky, "We really need to pay attention to disability as a fundamental health measure in veterans. How can we help both patients and caregivers who are disabled? And how can we help older veterans with disabilities lead high-quality lives?"

Dr. Covinsky "is a guy who’ll fight for you," says Mr. Johnstone. "He’ll be there. He listens. He follows up. He understands that people don’t all fit into the same box. I think that’s the key."

Lynn Pulliam, MS, PhD

About 15 percent of people with HIV develop dementia, which impairs memory, thinking, and eventually the ability to function at all. Dr. Lynn Pulliam’s laboratory was the first in the world to show that HIV dementia can be caused when white blood cells called monocytes carry HIV into the brain, releasing toxins that kill brain cells.

"This infection of the brain occurs very early in HIV infection," says Dr. Pulliam. "Why do some people live with it and some develop dementia? That’s what we’re studying now."

She notes that there is more than one route to HIV dementia. "In the developed world, thanks to antiretroviral drug therapy, people with HIV live longer, healthier lives. But if you live with HIV infection for a long time, there are proteins that HIV can secrete into the brain."

One such protein, called Tat, interferes with the activity of the brain enzyme neprilysin. Without neprilysin to break it down, the protein amyloid beta starts to build up in the brain. Amyloid beta, in turn, is associated with dementias such as Alzheimer’s disease.

"We looked at brains of people who had died from HIV infection," reports Dr. Pulliam, "and found that there was indeed an increase in amyloid beta in their brains — in particular, those with long-term HIV infection as opposed to those in old age."

Currently, Dr. Pulliam and her team are working to develop ways of predicting who might develop this form of HIV dementia. One clue is a molecule called sialoadhesin (Sn), which is elevated in the blood of individuals with active HIV infection. "A high viral load with Sn-expressing monocytes could facilitate HIV infection," she explains. "We are presently looking at whether or not those monocytes could be more easily transported to the brain."

Karen Seal, MD

"Starting in 2005, I began seeing veterans newly returned from Iraq and Afghanistan in my primary care clinic here at the San Francisco VA Medical Center," recalls Karen Seal, MD. She began noticing how many were suffering from PTSD, substance use disorders, and stress. "The problem was, if I referred someone to a mental health provider, they wouldn’t necessarily follow up. Aside from the inconvenience of having to come back another day, they were worried about the stigma of a mental health diagnosis."

In response, Dr. Seal and her colleagues have developed an integrated OIF/OEF Transition Clinic. Newly returned veterans can see a medical provider, a mental health provider, and a social worker, and be screened and referred appropriately –– all in the same visit, in the same primary care setting. "It’s a one-stop shop, without the stigma," she says.

Dr. Seal calls the clinic "a model for intervention and readjustment that we hope to export to other VA medical centers." Currently, she and her research team are investigating ways to make sure more young Northern California veterans are referred to readjustment services more quickly. They are also working with VA investigators to look at other medical outcomes that may be associated with PTSD, such as sleep disorders or cardiovascular risk factors.

"What keeps it fresh and compelling for me is going to clinic every week and seeing young people who are clearly suffering," says Dr. Seal. "It is just not normal to see a 21 year old who can’t go back to school because he gets confused when he listens to lectures, or who can’t hold down a job because he’s worried he’ll become too angry."

Dr. Seal believes that "if these problems are not addressed early on, they can become entrenched and lead to the kind of long term functional disability that we’ve seen in the generation who served in Vietnam."

About 20 percent of military personnel returning from Iraq and Afghanistan suffer from the effects of traumatic brain injury (TBI). Symptoms of TBI are subtle and persistent. They can range from mild disorientation to severe memory problems, personality changes, and difficulty with activities of daily living. NCIRE researchers at the San Francisco VA Medical Center are tackling the problem of TBI from a number of different angles.

Scott S. Panter, PhD, is testing a nasal spray that could be administered on the battlefield to prevent brain cell death after TBI.

Raymond Swanson, MD, is researching compounds to prevent brain cell inflammation after TBI. Inflammation is a major cause of brain cell death. "These same compounds could also be used in treating the effects of stroke," reports Dr. Swanson.

Grant Gauger, MD, is developing ways to diagnose TBI by using magnetic resonance (MR) to track physical changes in the brain. Currently, there is no reliable way to diagnose TBI based on physical symptoms.

Mary Whooley, MD

Wiley Cowan was a high school athlete and a two-time participant in the Pan American Games. For most of his life, when he felt depression coming on, "I could get out and ride my bicycle for 20 or 30 miles, or swim, and that would bring me out of it." But in 1999, following heart surgery, he had a major stroke, followed by another stroke several years later.

Since then, he says, "I get out of breath if I walk more than 40 yards. It’s difficult to do a lot of little things like go to the market and lift the groceries. It’s difficult to do household chores." And when depression hits, "You have to grin and bear it or muck it through."

"One in five heart patients has depression," notes Mary Whooley, MD, principal investigator of the Heart and Soul Study. "In our study, we’re following 1,000 heart patients over the course of eight years with the goal of discovering what, if any, cause-and-effect relationship exists between depression and heart health."

"There is a very close correlation, in my view, between heart attacks and depression," says Mr. Cowan. "Because when you are depressed, you cannot even get out of bed to brush your teeth and shave. Heart patients need exercise, you see, and being prostrate in bed won’t do it."

That’s one possible explanation, thinks Dr. Whooley. She notes that there are a number of other potential connections as well, which she hopes the Heart and Soul Study will help identify. "If we understand the mechanisms behind depression and heart disease, we might be able to treat those mechanisms," she concludes. "Since heart disease is the leading cause of death in the United States, treating depression might reduce that rate substantially."