Parkinson Disease Medications

The Parkinson's-Reversing Breakthrough

The Parkinson's Breakthrough Program entails the most effective and natural strategies people can use to heal the root cause of Parkinson's Disease. It is a digital manual aimed at showing the users the most effective method for overcoming Parkinson's without high-priced prescription drugs riddled with harmful side effects.The program was not created to be a quick fix. In fact, like different programs, it is tasking. Yet, you will not have to spend a lot of time dealing with it. The system requires your full attention, perseverance, and discipline. For the period of its usage, you will have the opportunity to use to eat some food ingredients that will detoxify you.The methods employed in this book are natural ones that have been proven by many specialists. The users will be privy to what to do and what not to do to treat the underlying root cause of their Parkinson's and the way they can reverse the symptoms naturally and effectively. The system comes with bonus E-books- Lessons from The Miracle Doctors, Mind Control in the USA', and 10 Deadly Health Myths of The 21st Century. The book is in a digital format (PDF) and has been created at a very affordable price. More here...

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Energy Metabolism In Pd

Although the etiology of PD is unknown, the possibility of an underlying defect in mitochondrial metabolism has been addressed in several biochemical studies (76). There is evidence of reduced complex I activity in the substantia nigra in PD, and Gu et al. have suggested that a mitochondrial DNA abnormality may underlie this complex I defect in at least a subgroup of PD patients (77). Studies in other tissues, however, have produced conflicting results, perhaps in part because biochemical studies involve removal of mitochondria from their natural milieu, with consequent mechanical disruption and a loss of normal control mechanisms. In contrast, MRS provides the potential to study mitochondrial metabolism in vivo. for mitochondrial disease (78). Penn et al. have used 31P-MRS to investigate energy metabolism in muscle in patients with PD. The Pi PCr ratio was significantly increased in PD, suggesting a small, generalized mitochondrial defect (79). Further studies are needed to determine...

Activation And Regional Cbf Patterns In Normal Individuals And In Pd

It is hypothesized that the BG function by activating parts of the cortex into similar frequencies, thereby facilitating the performance of a motor or cognitive action. This pattern of activation, referred to as focused attention, would be the physiological substrate for the harmonic performance of movement. In PD, the imbalance between direct and indirect pathways as a consequence of dopamine deficiency leads to overactivation of BG output nuclei and subsequent failure to achieve the state of focused attention (10). Several reports have addressed the changes in CBF and 18F-FDG uptake during different tasks in PD patients. In an inhaled C15O2 CBF PET study, Playford et al. (14) evaluated six PD patients and six controls at rest during the execution of freely chosen movements and with programmed repetitive forward movement of a joystick. For the free-selection task, both groups had similar increases in blood flow in left sensorimotor and bilateral premotor cortices. However, PD...

Pet Studies In Familial Pd

A family history of parkinsonism is present in 5-10 of individuals with PD. Currently, at least 10 loci and 5 genes with both autosomal-recessive and autosomal-dominant patterns of inheritance recognized. A genetic component for PD is plausible even for sporadic cases because asymptomatic twins of PD individuals show decreased putaminal FDOPA uptake (85). Of utmost importance in the understanding of sporadic PD is the concept that a number of the recently described mutations result in impaired function of ubiquitin proteasomal function, a mechanism that is related to the clearance of cellular proteins (86).

Pet And Complications Of Longterm Levodopa Therapy

De la Fuente-Fernandez et al. (99), using FDOPA PET, studied 15 patients who had a stable response to L-dopa and 52 with MFs . Patients with MF had further decreases in stri-atal FDOPA uptake compared with those who had a stable response to L-dopa. As expected, patients with MF had a more prolonged disease course than the stable subjects, and the fluctuators had an earlier age of disease onset. This decrement in FDOPA Ki persisted even after adjustment for disease course and matching the two groups. However, there was significant FDOPA Ki overlap between the groups. This finding was interpreted as a suggestion of increased DA turnover in the fluctuators (99). This was confirmed by a longitudinal study with RAC PET, in which eight patients with early PD and a good response to L-dopa after an average of 1.5 yr of treatment were evaluated (Fig. 4). The subjects had the first scan washed-out of medications and two additional scans 1 h and 4 h after a single oral dose of L-dopa. After...

Diseases with Akinetic Rigidity Idiopathic Parkinsons Disease

Idiopathic Parkinson's disease (iPD), the most common movement disorder and a major cause of neurologic Akinetic-rigid form Parkinson's disease Progressive supranuclear palsy Dementia with parkinsonism linked to chromosome 17 Striatonigral degeneration Corticobasal degeneration Postencephalitic parkinsonism Parkinsonism-dementia complex of Guam disability in the elderly, may affect individuals of 40 to 60 years of age, but it is seen primarily in those in their sixth decade. The annual incidence is 7 to 10 per 100,000 population, and this figure increases with age. A slight male preponderance is noted. About 1 to 3 of the population over the age of 65 years is afflicted. A rare juvenile form has an onset between 20 and 40 years of age. The disease occurs sporadically, but a considerable number of familial incidences have been identified. Both environmental and genetic etiologies are considered. The role of environmental factors is suggested by the clinical resemblance of iPD to the...

Striatonigral Degeneration

Striatonigral degeneration is a slowly progressive degenerative disease of middle age that greatly resembles Parkinson's disease. Rigidity, akinesia, and postural Progressive supranuclear palsy (PSP). A 65-year-old man presented with a 6-year history of difficulty walking and frequent falls, inability to look up or down, difficulty speaking and swallowing, and declining memory. Family history was not contributory. On examination, he was not able to articulate words, but was able to follow simple commands. The vertical and horizontal eye movements were severely restricted. The muscle tone was increased in the neck, trunk, and extremities, but strength was good. No tremor was noted. He needed assistance to rise from a chair and ambulate. The gait was slow and shuffling. Tendon reflexes were brisk, plantar reflexes were flexor, and the vestibulo-ocular reflex was present. He died at age 66 following a 7-year clinical course. Midbrain shows degeneration of the substantia nigra (HE)....

Postencephalitic Parkinsonism

This disease has been reported among survivors of the epidemic of von Economo encephalitis lethargica that occurred in Europe in 1915 and in the United States in 1918. The parkinsonism developed many years following the encephalitis and afflicted young adults and children. It presented with parkinsonian features, extra-ocular muscle palsy, and oculogyric spasm, which is a tonic conjugate deviation of the eyes lasting minutes or hours. Grossly, the substantia nigra and locus ceruleus are depigmented. The histology is characterized by (a) lympho-plasmacytic perivascular infiltrations, particularly severe in the brainstem (b) neuronal losses and gliosis in the substantia nigra, locus ceruleus, and brain-stem (c) the presence of argyrophilic, tau-positive neurofibrillary tangles in neurons of the brainstem, hippocampus, frontal, temporal, and insular cortex and (d) the presence of tau-positive cytoplasmic inclusions in astrocytes.

Parkinsonism Dementia Complex of Guam

This disease occurs among the Chamorro tribe of Guam. It presents with parkinsonian features and progressive dementia, and it may be associated with ALS (see the section, Motor Neuron Diseases). Grossly, the brain is atrophic, and the substantia nigra and locus ceruleus are discolored. The histology is characterized by neuronal losses that are particularly severe in the hippocampus, temporal and frontal cortex, hypothalamus, substantia nigra, and locus ceruleus. Variable neuronal losses are present in the thalamus and basal ganglia. Tauimmunopositive neurofibrillary tangles are evident in the remaining neurons of affected areas. Neuritic plaques and neuropil threads are inconspicuous.

Micronutrients Parkinsons

In Parkinson's disease high doses of vitamin B6, iron, and manganese should be avoided. High doses of vitamin B6 may decrease the effectiveness of of L-dopa therapy, and high doses of iron and manganese can aggravate the disease. Parkinson disease, and low body stores of these B vit

Dementia Due to Parkinsons Disease

Although dementia rarely occurs as an initial symptom of Parkinson's disease, it is found in nearly 40 of such individuals older than 70 years of age. The prevalence in persons over 60 is 1 . The disease results from loss of dopamine production in the basal ganglia, and can be idiopathic or postencephalitic. Usually, the individual is 50 years of age or older, and unlike Alzheimer's and Pick's dementias, this disease occurs slightly more often in men. Dementia most commonly occurs in cases of Parkinson's disease in which the decline has been rapid and response to anticholinergics has been poor. The clinical features of Parkinson's disease are well described, with the cardinal triad being tremor, rigidity, and bradykinesia. Associated features include postural instability, a festinating gait, micrographia, sebor-rhea, urinary changes, constipation, hypophonia, and an expressionless facial countenance. The tremor in Parkinson's disease has a regular rate and is most prominent when the...

Mrs In Parkinsonism

Several studies that used H-MRS in PD have been reported, reviewed by Davie (62) and systematically by Clarke and Lowry (63). A large multicenter study of 151 patients with PD showed no significant difference in either NAA Cr or NAA Cho ratios between controls and patients who were not taking levodopa (64). Other groups (65-67) have reported similar results. Similarly, in a small study using absolute metabolite quantitation, NAA, Cr, and Cho concentrations in PD did not differ significantly from those in controls (68). Although no significant difference was observed in the NAA Cr ratio in levodopa-treated patients with PD, Ellis et al. reported reduced NAA Cr in drug-naive PD patients compared with both the treated PD group and with the control group (69). These authors suggested that the reduced ratio in PD might reflect a functional abnormality of neurons in the putamen that can be reversed with levodopa treatment. Clarke and Lowry have reported a significant decrease in the NAA Cho...

Functional Mri In Pd

Motor activation studies provide a means to investigate the regional cerebral mechanisms involved in motor control in normal subjects and in patients with disorders affecting these control systems. Typical fMRI experiments involve measurement of regional blood oxygen level-dependent signal increases associated with specific activation paradigms. These signal changes occur as a result of the increased local cerebral blood flow and altered oxyhemoglobin concentration associated with neuronal activation. Functional MRI experiments have extended our knowledge of disordered motor control systems, based on the extensive previous experience obtained with PET motor activation studies in control subjects and in patients with PD. PET studies have suggested that cortical motor areas, such as the supplementary motor area (SMA), seem to be underactive in akinetic parkinsonian patients (84,85), whereas other motor areas, such as the parietal and lateral premotor cortex and the cerebellum, appear to...

Parkinsons Disease

A similar prevalence of depression (i.e., about 40 ) has been observed in patients with Parkinson's disease, in a similar 50 50 ratio of major depression to dysthymia (Nuti et al. 2004). As in stroke, depression in Parkinson's disease patients increases the risk for and severity of dementia and exacerbates disability, and so is an important focus of diagnostic and therapeutic attention for geriatric psychiatrists (Troster et al. 2000). Treatment generally follows guidelines for primary mood disorder as detailed in Chapter 4 (Mood Disorders Treatment).

Diet Parkinsons

A low-protein diet can be beneficial in Parkinson's disease.1 L-dopa is one of several amino acids that compete for uptake into the brain from the bloodstream. During L-dopa therapy, restricting dietary protein reduces competition from other amino acids and allows more L-dopa to enter the brain. One limitation of L-dopa therapy is that its beneficial effects unpredictably wax and wane through the day. Protein restriction can reduce these daily fluctuations and make L-dopa therapy more effective, particularly if most of the daily protein is eaten with the evening meal.1 Free-radical damage (see pp. 115) appears to play a role in Parkinson's disease. Diets high in natural anti-oxidants (such as vitamins E and C and carote-noids) may reduce risk of Parkinson's disease or slow down its progression.2,3

Quantitative Estimation Of Regional Brain Iron With

The adult brain has a very high iron content, particularly in the basal ganglia. Direct postmortem measurements have shown nonheme brain iron to be very low throughout the brain at birth but to increase gradually in most parts of the brain during the first two decades of life (35). Brain iron concentration is maximal in the globus pallidus, substantia nigra, red nucleus, caudate, and putamen. Abnormally elevated iron levels are evident in various neurodegenerative disorders, including PD, in which increased iron in the substantia nigra has been reported (36,37). Laser microprobe studies indicate that iron normally accumulates within neuromelanin granules of nigral neurons and that iron levels within these granules are significantly increased in PD (38). Extended X-ray absorption fine-structure experiments have shown that ferritin is the only storage protein detectable in both control and parkinsonian brain, with increased loading of ferritin with iron in PD (39). Although ferritin in...

Summary And Conclusions

At present, conventional MRI shows no convincing structural changes in PD itself, but it may be useful in helping to distinguish PD from other neurodegenerative parkinsonian syndromes and from the occasional case of parkinsonism secondary to a focal brain lesion. MRS also may provide useful information in distinguishing PD from disorders such as MSA. opments to provide relevant information. Novel pulse sequences may provide more information regarding substantia nigra pathology in PD. The use of MR as a tool to measure regional iron concentrations should provide more information regarding the relationship between iron accumulation and parkinsonian symptoms. MRS provides a sensitive tool for the researcher to investigate in vivo the possible contribution of abnormalities in brain energy metabolism to the pathogenesis of PD. MRS also allows the assessment of other metabolite changes in PD, for example, providing for the evaluation of the potential importance of changes in regional brain...

Imaging Blood Flow And Metabolism

Striatal glucose metabolism and perfusion are generally found to be normal in PD (6-10), although some studies have demonstrated an asymmetry of striatal metabolism (11). Interestingly, atypical parkinsonian disorder has been differentiated from idiopathic PD by the appearance of striatal metabolic abnormalities in the atypical group (12), which may provide a useful adjunct to routine clinical examination. Many studies have shown more global cortical hypometabolism or hypoperfusion or a loss of posterior parietal metabolism with a pattern similar to that observed in Alzheimer's, and other neurodegenerative diseases (8,9,1318). Others have used the differences in regional metabolism or rCBF to discriminate between PD and MSA (10,19) or PSP (20). Studies of blood flow and glucose metabolism in patients with pure Lewy body disease with no features of Alzheimer's disease have consistently shown biparietal, bitemporal hypometabolism, a pattern that was once...

Imaging The Dopaminergic System

Dihydroxyphenylalanine ( 18F fluorodopa) as a measure of the integrity of dopamine neurons (43,44). 18F fluorodopa measures changes in aromatic L-amino decarboxylase activity, which is dependent on the availability of striatal dopaminergic nerve terminals and is proportional to the number of dopamine neurons in the substantia nigra (45). Quantitative parameters associated with 18F fluorodopa uptake, such as the striatal-to-background uptake ratio, and the influx rate constant, have been shown to be useful indicators of dopaminergic degeneration in PD and other syndromes (4667). Indeed, 18F fluorodopa and PET are often regarded as the gold standard in the detection of dopamine neuronal loss (68), although the contributions from SPECT imaging, and other direct measures of the dopaminergic binding sites, both pre- and postsynaptic, are increasing (55,56,69-71). The analysis of 18F fluorodopa PET studies is known to have a number of serious potential problems. 18F fluorodopa is...

Multimodality And Multitracer Studies

Glucose metabolism has been studied in parkinsonian disorders with 18F FDG and PET, and the data combined with striatal 18F fluorodopa uptake measurements to give an improved diagnostic indicator, and a better understanding of the underlying disease processes (19,51,59,201). However, it should be noted that the improvement was relatively small over the good predictive capabilities of 18F fluorodopa by itself in these patient groups. Some studies have used the complementary information coming from structural MRI and functional 18F FDG PET in distinguishing between control subjects and patients with MSA (53,202-205), in whom both focal MRI hypointensities, changes in striatal and midbrain size, and reduced glucose metabolism occurred on the side contralateral to clinical symptoms. Magnetic resonance spectroscopy adds an important new probe to complement functional PET and SPECT imaging studies (204). Other studies have combined data from MRI and postsynaptic dopamine receptor...

Imaging Other Neurotransmitter Systems

Although most imaging studies have investigated the effects of parkinsonian disorders on the dopaminergic system, neuro-pathologic and biochemical studies suggest that serotonin neurons also are affected by the disease process (214). The integrity of serotonin neurons in the midbrain region can be studied using the SPECT tracer 123I P-CIT (215,216). Although this radioligand is more commonly associated with measurements of the dopamine transporter, it also binds with high affinity to the serotonin transporter. However, owing to the high concentration of dopamine transporters in the striatum, imaging of the serotonergic system with this tracer is limited to the midbrain (217). Despite these technical difficulties, studies suggest that dopamine and serotonin transporters are differentially affected in PD, and serotonin transporters in the midbrain region may not be affected in relatively early stages of PD (218,219). In later stages of the disease, serotonin transporters are reduced in...

Imaging Pathophysiology Of Pd

In vitro and in vivo studies in humans have demonstrated that idiopathic PD is preceded by early degeneration of DA neurons in the ventrolateral substantia nigra pars compacta projecting to the posterior and dorsal putamen (5-8). With disease progression, nigrostriatal projections to more anterior and ventral putamen areas begin to decrease, with late loss of projections to the caudate nucleus. This leads to widespread decline Motor symptoms in PD patients develop after a preclinical period and evolve from unilateral to bilateral involvement. A clinical diagnosis is made if the patient shows at least two of the four cardinal signs of PD with a good response to levodopa treatment. A variable degree of cognitive impairment in frontal function is also present during advanced stages of the disease. The severity of the overall symptoms is evaluated objectively by standardized ratings such as Unified Parkinson's Disease Rating Scale (UPDRS). PET imaging has provided important insight into...

Presynaptic Da Function

18F fluorodopa (FDOPA) is the radioligand used mostly for quantifying the nigrostriatal dopaminergic dysfunction in PD. This tracer measures the rate of FDOPA decarboxylation and subsequent storage in the dopaminergic nerve terminals. FDOPA uptake is estimated by using a striatal occipital ratio (SOR striatal occipital - 1) (9,10) or influx constant (K ) computed from dynamic data (11-13). It has been established that FDOPA uptake is reduced in the posterior putamen but relatively preserved in the caudate nucleus and anterior putamen in early stages of PD (13-16). FDOPA uptake is decreased in both putamen (60 ) and caudate (40 ) in patients with advanced PD (Fig. 1). This has been valuable in discriminating PD from normal controls and also in early differential diagnosis of PD from other atypical parkinsonisms. More importantly, FDOPA uptake indices in putamen and caudate have been consistently shown to correlate negatively with the severity of motor symptoms in PD. FDOPA binding is...

Postsynaptic Da Function

Altered postsynaptic DA function in PD has also been investigated with a number of PET radioligands. It is known that dopaminergic transmission is facilitated mainly by D1 and D2 receptors in the striatum. Striatal D1 receptor binding is usually measured with 11C SCH23390 and remains normal in early PD patients who are not on drug therapy (33). However, D1 binding seems to be reduced by 10 if a patient receives treatment with levodopa for several years (34). Striatal D2 receptor binding is most often estimated using 11C raclopride (RAC) and is mildly elevated in early phases of PD, untreated with antiparkinsonian medications (34-36). The elevation is particularly pronounced in the putamen. This upregulation is reversed with DA replacement therapy at more advanced stage (37) . Striatal D2 binding remains unchanged in the putamen but reduced by 16 in the caudate after continued medical treatment (34). Because RAC has a low affinity to D2 receptors, PET imaging with this tracer has been...

Medical And Surgical Treatments Of Pd

PET imaging markers described above provide important functional basis for introducing effective interventions and directly assessing their therapeutic efficacy. Imaging evaluation is absolutely necessary because clinical observation is most likely to be insensitive to incremental improvement in the brain function. This can be performed by measuring longitudinal changes in functional indices in PD patients before and after the treatment. The patients should be off dopaminertic medications for at least 12 h before PET scanning to minimize any confounding effects. In recent years, many imaging studies have demonstrated an association between relative regional changes in brain function induced by treatment and corresponding clinical performance. It has been reported that impaired rCBF activations in regions involved in simple motor tasks can be restored by levodopa infusion and DBS of the internal globus pallidus (GPi) (60,61). UPDRS motor ratings are improved by more than 34 and rCBF...

Imaging Of Da Transporter

PET imaging with DAT radioligands may be used as molecular markers to assess striatal presynaptic function in PD patients after DA cell transplantation. This has been demonstrated in a unilateral rat model of neurotransplantation with 11C CFT and microPET scanner (91). Parkinsonian lesions were created by injecting 6-hydroxydopamine. DAT binding in the lesioned striatum was reduced to 15 to 35 of the unoperated side. After grafting with non-DA cells from dorsal mesencephalon, the binding remained to levels observed before transplantation and rats had no behavioral recovery. In contrast, after DA neuronal transplantation, behavioral recovery occurred only after the specific DAT binding had increased to 75 to 85 of the intact side. DAT radioligand has also been used to investigate the role of implanting DA neurons in the clinical manifestation of levodopa-induced dyskinesia in a rat model of PD (92). Dys-kinesia was induced gradually during the course of 1 mo with a low dose of levodopa...

Imaging Of Postsynaptic Da Receptors

Of striatocortical functional systems in patients treated with fetal cell implantation. It is reported that recovery of movement-related cortical function has been delayed in PD after striatal dopaminergic grafting (96). The cortical activation was still impaired at 6.5 mo after transplantation, although motor symptoms and mean striatal DA storage capacity had significantly improved. At 18 mo after surgery, there was further significant clinical improvement without any more increase in striatal FDOPA uptake. The surgery significantly improved rostral supplementary motor and dorsal prefrontal cortical activation during performance of joystick movements, in agreement with the results of subthalamic nucleus DBS (63,65). These data suggest that it is not enough for the graft to simply deliver DA and that functional integration of the grafted neurons within the host brain is necessary to produce substantial clinical recovery in PD.

Potential Complications After Transplantation

Complications related to the intrastriatal transplantation of human embryonic mesencephalic tissue are usually mild and transient as reported by most of clinical trials with PD. All patients have bilateral dyskinesias before grafting that are greatly decreased a few months after the surgery because of concurrent reduction in dopaminergic drugs. However, as the number of graft recipients increases, dyskinesias in the absence of or with only minimal amounts of dopaminergic medication have been reported after the surgery. One study examined five patients during the course of 1-3 yr after unilateral implantation in the caudate and putamen (100). There was a moderate increase in FDOPA uptake in the grafted putamen along with a different degree of bilateral improvement in motor skills. Delayed asymmetrical dyskinesias were observed in three patients on the side contralateral to the graft. It was speculated that this might reflect increased presynaptic storage and release of DA induced by...

Alternative Sources Of Da Tissue

Fully differentiated DA neurons (98). These DA neurons caused gradual and sustained behavioral recovery of DA-mediated motor asymmetry. Parallel increase in DAT binding was seen in the grafted striatum (equal to 75-90 of the intact side) and correlated with the number of neurons counted at postmortem in the graft. In contrast, there was much less DAT activity in sham controls. These findings demonstrate that transplanted embryonic stem cells can develop spontaneously into DA neurons to restore cerebral function and behavior in an animal model of PD. Other types of substitute DA cells and DA neurons cultivated from human embryonic cells are currently under investigation and may become available in the near future (74,107). A new therapy closely related to DA transplantation is the use of genetic manipulation to normalize DA production and delivery in the brain. This pioneering development has been actively tested in animal models of PD (108,109). However, clinical trials of these cell...

Evaluation With Multiple Imaging Markers

To establish whether the transplantation fully restores the cerebral brain function in PD patients, it is necessary to evaluate its efficacy by multitracer PET imaging. Previous studies have documented both striatal and frontal reductions in presyn-aptic DA function and their relationships with motor and cognitive impairment ( 15,29). The capacity to release endogenous DA in these areas has also been proven by measuring reduction in postsynaptic D2 receptor binding induced by pharmacological challenges (39). The successful DA transplantation should maximally increase and sustain the levels of these parameters of dopaminergic function postoperatively. PET FDG or H2 15O activation studies are ideal to investigate the graft-mediated recovery of metabolic or blood flow function and its role in improving motor and cognitive impairment in patients with PD. The best way is likely to involve acquiring presynaptic DA imaging, FDG, and rCBF activation data in the same patients before and after...


At present, conventional magnetic resonance imaging (MRI) shows no convincing structural changes in Parkinson's disease (PD) itself, but it may be useful in helping to distinguish PD from other neurodegenerative parkinsonian syndromes. Magnetic resonance spectroscopy (MRS) also may provide useful information in distinguishing PD from disorders such as multiple system atrophy. The general field of MRI and MRS is evolving rapidly, and a number of new developments may provide relevant information. Novel pulse sequences, for instance, may provide more information regarding substantia nigra pathology in PD. The use of MR technologies to measure regional concentrations of brain iron should provide more information regarding the relationship between iron accumulation and parkinsonian symptoms. MRS provides a sensitive tool to investigate the possible contribution of abnormal brain energy metabolism to the pathogenesis of PD. MRS also allows the assessment of other metabolite changes in PD,...


There are a large number of imaging techniques that can be used to attempt to differentiate between the various neurodegenerative disorders. Taken in isolation, many of them can diagnose parkinsonian disorders with some success. However, the diagnosis at an early stage in the progression of each disease, possibly even before clinical symptoms have become apparent, is much more difficult and may require multiple imaging modalities or combinations of tracers. The widespread availability of SPECT imaging, perhaps combined with newer and less expensive tracers, may lead to the routine implementation of SPECT scanning in the diagnosis of parkinsonian disorders.

The Dopamine System

In the CNS, dopamine (DA) is synthesized by neurons of the pars compacta of the substantia nigra (SNc) and the ventral tegmental area (VTA) in the midbrain. The aromatic amino acid tyrosine is converted to DA by means of two reactions the first one, involving tyrosine-hydroxylase, the rate-limiting enzyme in this pathway, converts tyrosine into l-3,4-dihydroxyphenylalanine (L-dopa). The second reaction is mediated by aromatic L-amino acid decarboxylase (AADC) and transforms L-dopa into DA, which constitutes approx 80 of all catecholamines (CAs) in the brain (3). Whereas AADC is not thought to be rate limiting for DA synthesis in the normal brain, the situation may be different in PD. DA is packaged via the vesicular monoamine transporter (VMAT2) in synaptic vesicles in concentrations up to 1000 times higher than in cytosol, until release from dopaminergic terminals after an action potential. The membrane dopamine transporter (DAT) is responsible for DA reuptake into presynaptic...

Clinical Studies

FDOPA was first used to visualize the nigrostriatal system in humans in the early 1980s (49). Studies in parkinsonism have been conducted since that time, when it was first used in MPTP-exposed individuals (50) and PD patients (51). After image acquisition, FDOPA uptake is usually calculated using multiple-timepoint graphical analysis (52-53). The typical finding in idiopathic PD (IPD) is an asymmetric FDOPA uptake with relative sparing of the caudate compared to putamen (39), corresponding to the preferential cell loss in the ventrolateral tier of the SNc (54). FDOPA may also identify subclinical deficits of DA production in individuals at genetic (55) or environmental (50) risk for PD. Of the cardinal signs of PD, the one that has the best correlation with striatal FDOPA is bradykinesia, as rated by the Purdue pegboard and modified Columbia scores (56).


Fluorodopa uptake measured by PET correlates well with tyrosine hydroxylase cell counts in the substantia nigra (courtesy of E. G. McGeer and UBC-TRIUMF PET group). Several studies addressed the issue of FDOPA PET in the diagnosis and, above all, its potential in the differential diagnosis of parkinsonian syndromes in clinical practice. Brooks and colleagues (63) used FDOPA and S- 11C -nomifensine, a DA reuptake blocker, to detect distinctive alterations in IPD compared with parkinsonism-dominant MSA (MSA-P) and pure autonomic failure patients and controls. Direct comparison between IPD and MSA-P disclosed a homogeneous reduction of striatal FDOPA Ki in MSA patients, in contrast with the rostrocaudal gradient in IPD (63). More recently, IPD was compared with MSA-P by means of FDOPA, RAC, and 18F-FDG PET as well as 3D-MRI volumetry. FDOPA had similar Ki values in both conditions and some MSA patients displayed the rostrocaudal gradient typical of IPD. However, unlike IPD, MSA...


With PET, it has become possible to understand the spectrum of changes that take place in cortical and subcortical structures in the course of PD, as well as in related diseases presenting with parkinsonism. The investigation of CBF and metabolism has disclosed patterns of activation in distant sites that previously could be only inferred by means of neuroana-tomical and neuropathological studies. Biochemical alterations at the receptor level are now visualized in vivo, and the use of radioligands aimed at different parts of the nigrostriatal synapse makes possible a better understanding of DA metabolism, such as progression of dopaminergic cell loss and adaptive mechanisms in these and other neurotransmitter systems.

Spect Radioligands

In diagnosis and evaluation of PD, multiple studies have demonstrated 123I-FP-P-CIT's ability to reveal reduced DAT density, perhaps more effectively than 123I-P-CIT (33-35). Like its progenitor, 123I-FP-P-CIT is also able to detect bilateral decreases in striatal DAT density in PD patients with minimal or unilateral symptoms (36). However, there is still some disagreement about whether striatal DAT density as measured by 123I-FP-P-CIT correlates with the stage of PD or the severity of PD symptoms (32,37,38). 99mTechnetium-TRODAT-1 has shown some promise in evaluating PD. Uptake of 99mTc-TRODAT-1 in the posterior putamen was significantly reduced in a controlled study of 42 patients with PD (43). In another study of 34 patients with PD, putaminal uptake of 99mTc-TRODAT-1 was significantly correlated with Hoehn and Yahr stage in addition, bilaterally decreased putaminal uptake could be identified in patients with Stage I disease (44). 99mTechnetium-TRODAT-1 has also been reported to be...

Pet Radioligands

One of the earliest discoveries using 11C-P-CFT was that more than more than 70 destruction of dopaminergic cells was required to produce parkinsonian symptoms in monkeys (47). 11C-P-CFT can reliably discriminate between changes in DAT distribution caused by PD and PSP (48). It may also be used to detect dopaminergic cell loss in early PD (49). (P-CBT) was developed to study the role of the halogenated site in DAT selectivity of cocaine analogs (58). Its radioactively brominated form (76Br-P-CBT) reaches peak concentration in the striatum in about 60 min and remains there for about 4 h, with a striatal-to-cerebellar activity ratio between 17 and 22 (58). In a study of 18 patients with PD, 76Br-P-CBT demonstrated reduction of DAT density better than 18fluorodopa but was not able to stratify disease severity (59).

Imaging With Fdopa

Animal models of parkinsonism induced with a neurotoxin (MPTP) have played an important role in the development of cell transplantation surgery (73,74). This has been performed mainly in primates and mice to provide controlled striatal lesions to test various aspects of transplantation strategy. The functional restoration of the DA innervation of striatum has been investigated in MPTP-lesioned Gottingen minipigs after grafting of fetal pig mesencephalic neurons (75). Pigs received bilateral Since early 1990s, many studies in PD patients have been performed to evaluate the safety and efficacy of fetal nigral transplantation into the striatum. This has evolved from unilateral transplantation (77-80) to bilateral transplantation ( 81-83) for a more complete functional recovery. Patients received transplants in caudate and putamen and exhibited significant clinical benefits along with increased FDOPA uptake in the grafted areas. Doses of medications often were reduced, resulting in the...

Organic Aciduria

Marked widening of the operculae is found on MRI in patients with glutaric acidemia type 1. White matter changes have been reported in approx half of patients with organic acidurias (128). Abnormal high signal intensity on T2-weighted images is seen in the basal ganglia and periventricular white matter in approx two thirds of children. Abnormal high signal on T2-weighted images may be seen in the dentate nucleus, substantia nigra, and the pontine medial lemniscus (129). Features seen on MRI in adult-onset cases have been described as a diffuse leu-koencephalopathy.

Social Cost and Market

Various projections indicate that sales of drugs to treat neurological diseases alone will approach 20 billion by 2007 reflecting an absence of effective treatments for AD and the use of generic L-dopa as first-line treatment for Parkinson's disease. Drugs for the treatment of psychiatric disorders represent a much larger market with sales of the selective 5HT reuptake inhibitor (SSRI) class of antidepressants currently in the 10 billion range. Together the current market for CNS drugs is in excess of 70 billion. Should effective drugs be identified for the treatment of AD, this will account for an additional 6-8 billion in sales given the incidence of these diseases and their long-term nature. At the decade beginning in 2001, the global CNS drug market (including pain) was approximately 50 billion1 with estimates of 105 billion in 2005, 200 billion in 2010, and one estimate2 approaching 1.2 trillion.

Central Nervous System Disorders Psychiatric and Neurodegenerative

Neurodegenerative disease involves a defined degenerative process in which neurons are lost either by necrosis or apopotosis. This category is typified by slow chronic disorders that include Parkinson's disease and AD, but also includes more acute cell loss due to traumatic insults including stroke (brain attack) and spinal or brain damage. There are major issues with diagnosis in the absence of robust biomarkers.6 For example, there are cases where the AD disease phenotype is predominant and where the diagnosis of AD has not been supported by autopsy.

Psychiatric Disorders 601411 Schizophrenia

Vascular dementia Dementia due to human immnodeficiency virus (HIV) disease, head trauma, Parkinson's disease, Huntington's disease, etc. Amnestic disorders Catatonic disorder Research into sleep disorders (see 6.06 Sleep) has intensified over the last decade given new generations of hypnotics and the success of the novel wake-promoting agent modafinil. The sleep spectrum involves insomnia, narcolepsy, and excessive daytime sleepiness (EDS). Dyssomnias are primary sleep disorders characterized by an abnormal amount, quality, or timing of sleep, and include primary insomnia, narcolepsy, and breathing-related sleep disorder. Primary insomnia is defined as a difficulty in initiating or maintaining sleep, or an inability to obtain restorative sleep. Insomnia is a highly prevalent sleep disorder estimated to affect 35 of the population during the course of a year, with 60 of those afflicted reporting chronic insomnia lasting longer than 1 month. Chronic insomnia is often accompanied by...

Neurodegenerative Diseases

Neurodegenerative diseases (see 6.08 Neurodegeneration) include AD Parkinson's disease amyotrophic lateral sclerosis (ALS) demyelinating diseases, e.g., multiple sclerosis neuropathies, e.g., diabetic, HIV, and chemotoxin-induced Down's syndrome (DS) prion diseases, e.g., Creutzfeldt-Jakob disease tauopathies, e.g., Pick's disease, frontal temporal dementia with Parkinsonism (FTDP) trinucleotide repeat or polyglutamine (polyQ) diseases, e.g., Huntington's disease (HD) spinocerebellar ataxias (SCA) dentatorubral-pallidolysian atrophy (DRPLA) Friedreich's ataxia multiple systems atrophy (MSA) stroke and traumatic brain injury.

Acquired immune deficiency syndrome dementia Parkinson's disease Parkinson's disease16 afflicts 1.5 million Americans with an additional 60 000 cases diagnosed each year (see 6.08 Neurodegeneration). The cardinal symptoms of Parkinson's desease include tremor, bradykinesia, rigidity, and postural instability, the result of the loss of DA-containing cells in the substania nigra. Parkinson's disease patients also suffer from a variety of nonmotor symptoms including sleep disturbance, depression, and dementia. As with AD, Parkinson's disease is a disease that predominately affects those over the age of 65 however, an estimated 15 of patients develop symptoms before the age of 50. Diagnosis is made based on neurological examination with imaging methods used primarily to rule out other conditions. Response to the gold standard of Parkinson's disease treatment, L-dopa, is a diagnostic criterion for this disease. Parkinson's disease is effectively treated early in the course of the disease with DA replacement therapies that...

How Does MS Affect the Nervous System

The central nervous system (CNS) is the part of the nervous system involved in MS. The CNS includes the brain and spinal cord. The nerves in the CNS communicate with each other through long, wire-like processes that have a central fiber (axon) surrounded by an insulating material (myelin). In MS, the immune system cells produce inflammation that injures the myelin. In addition, damage occurs to the axon. This damage is known as degeneration, which is the process that occurs in aging-related neurologic diseases such as Alzheimer's and Parkinson's disease. The injury to the myelin and axons results in a slowing or blocking of nerve impulses that prevents the affected parts of the nervous system from functioning normally.

Introduction To Bioregenerative Engineering

Regenerative engineering at the cellular level, which may be referred to as cellular regenerative engineering, addresses the preparation, modulation, and transplantation of autogenous and or allogenic stem progenitor cells in a controlled manner, resulting in enhanced regeneration of functional cells and structures. Examples of cellular regenerative engineering include the transplantation of hematopoietic stem and progenitor cells to repopulate impaired leukocytes due to leukemia, the transplantation of embryonic and bone marrow-derived stem cells to the heart to differentiate into cardiomyocytes in cardiac infarction, and the transplantation of neuronal stem cells to the brain to alleviate the symptoms of Alzheimer's and Parkinson's diseases.

Therapeutic Potential Of Embryonic Stem Cells

Most of the enthusiasm relating to embryonic stem (ES) cells results directly from the perceived need for cell replacement therapy for a host of degenerative diseases. Indeed, disorders of organ failure are not reversible, and organ transplantation cannot meet the needs of an ever-aging population. Primary pump failure in the heart, alcoholic or viral liver failure, P-cell-deficient type 1 diabetes, and Parkinson's disease (PD) are frequently cited as examples of monocellular deficiency states that might be amenable

First Generation Typical Antipsychotic Drugs

The serendipitous finding in 1951 that the major tranquilizer, chlorpromazine 1, was effective in treating delusions and hallucinations associated with schizophrenia and other psychotic disorders marks the beginning of modern therapy for schizophrenia.3 Unfortunately, treatment with chlorpromazine was accompanied by the development of EPS, some appearing even after the first dose (e.g., dystonias, akathisia). Other adverse effects were delayed for days or weeks such as parkinsonism, and the sometimes fatal neuroleptic malignant syndrome. Tardive dyskinesia, characterized by abnormal involuntary movements of the tongue, facial muscles, or limb muscles, develops in about 20 of patients and may be irreversible. Chlorpromazine also increased prolactin secretion leading to gynecomastia, galactorrhea, menstrual irregularities, sexual dysfunction, and possibly bone loss over the long term. Sedation, hypotension, and weight gain were also common with chlorpromazine. Despite these concerns,...

Mitochondria Aging and Human Disease

The identification of nuclear-encoded mitochondrial genes is yielding new insights into the interaction of both genomes in mitochondrial function. Some of the nuclear genes shown to influence mitochondrial function include frataxin (47), adenine nucleotide transporter 1 (ANT1) (48), TWINKLE (49), and SURF1 (50). An area of active investigation and debate is the relationship of mitochondrial dysfunction to common, sporadic, age-related neurodegenerative diseases such as Alzheimer's disease (AD) and Parkinson's disease (PD). AD affects memory, judgment, and other higher cognitive functions. The neuropathological hallmarks of AD include neurofibrillary tangles and amyloid containing plaques. Oxidative damage in AD has been reported (51), and reduced cytochrome oxidase (COX) activity has been described in AD brains (52,53). PD presents with bradykinesia, rigidity, and tremor in the sixth to eighth decades. Pathologically, there is selective loss of dopaminergic neurons in the substania...

Antidepressants 603521 Monoamine oxidase inhibitors

The first generations of MAOI antidepressants were hydrazine derivatives, e.g., phenelzine and isocarboxazide, which are probably converted into hydrazine to produce long-lasting inhibition of MAO. Tranylcypromine is essentially a cyclized amphetamine without the covalent bond. Selegiline (15), a propargylamine MAOI, contains a reactive acetylenic bond that interacts irreversibly with the flavin cofactor of MAO resulting in prolonged MAOI activity. Selegiline is still used in clinical practice today, mainly in Parkinson's disease. However, a new patch delivery formulation of selegiline that is proposed to overcome the adverse events associated with MAOIs is in Phase III studies for major depression. Rasagiline (16) is currently marketed for Parkinson's disease in Europe.

Alternative Nonneural Stem Cell Sources

Somatic stem cells have been claimed to possess a broad differentiation potential, and several studies over the past 5 yr have suggested that stem cells from tissues outside of the brain are also capable of generating neurons (92). Such stem cells may be considered alternatives in PD, and this chapter describes two potential sources bone marrow-derived cells (93-95) and umbilical cord stem cells (96). Other potential sources include adult multipotent progenitor cells derived from bone marrow (97) and skin-derived stem cells (98), but only a few studies on these cell sources have been published to date. A recent study suggested that engineered human bone marrow cells could be suitable for autologous transplantation in PD (94). In this study, human bone marrow cells transfected with the Notch intracellular domain protein and treated with neurotrophic factors differentiated into TH-expressing neurons. Transplantation of these TH-expressing neurons into the striatum of 6-OHDA-lesioned...

Fields Of Expertise Within Toxicology

The central nervous system is one of the most complex organs in living systems 17 . Neurotoxicity can be manifested rather globally, or very specifically, depending on the poison. One example of a very specific toxicity occurs with MPTP, a notorious meperidine analogue that can destroy the substantia nigra and leads to a very severe Parkinson-like syndrome. Another example of rather global neurotoxicity occurs with lead encephalopathy. Other metals can also be highly neurotoxic.

Catechol Omethyltransferase inhibitors

Expected to have higher levels of transynaptic catecholamines due to a reduced COMT degradation of NE and DA. COMT inhibitors (entacapone (40) and tolcapone (41)) could therefore be beneficial as adjuncts to L-dopa not only in Parkinson's disease but also in the coincident depressive illness associated with rapid cycling.

Pros And Cons With Sources Currently Available

Although DAergic neurons can be generated in large numbers from neural precursors under special conditions (25), they are still not a realistic option as donor cells for transplantation in PD. Limitations in long-term propagation of the cells and difficulties in achieving stable DAergic differentiation continue to be major problems. As mentioned in the DAergic Differentiation by Epigenetic Factors section, the efficiency of DAergic differentiation decreases with time in midbrain neural precursors after proliferation for extended periods in vitro (30). Furthermore, although expanded precursors The risk that undifferentiated cells are included among transplanted human ES-derived DAergic neurons is a major issue. Obviously, this can lead to the formation of lethal teratomas in the host brain. Chromosomal aberrations identified in mid-term cultured human ES cells are a cause for concern (122). This suggests that long-term propagation of human ES cells can lead to abnormalities in the...

Neuroimaging as Biomarker in ad

Although there is some overlap between the brain regions with the most pronounced atrophy in AD and atrophied brain in other types of dementia, degree of atrophy and pattern of involved brain areas seem to be useful for supporting a differentiation between various forms of dementia, describing patterns specific for the various nosologic entities, e.g., Lewy Body Dementia (LBD), Parkinson's disease with dementia (PDD), Fronto-Temporal Lobar Degeneration (FTLD) (Ballmaier et al., 2004 Borroni et al., 2007 Borroni et al., 2008 Burton et al., 2004 Chetelat et al., 2005 Rabinovici et al., 2007 Tam et al., 2005). An example of the results provided by such an approach is shown in Figure 1, showing the pattern of grey matter atrophy in the two major variants of Frontotemporal Dementia (FTD), frontal and temporal variants, respectively. VBM comparison with healthy controls is able to reveal a selective atrophy, involving dorsolateral frontal cortex, anterior cingulate cortex, insula, superior...

Clusterin Expression in the Adult Brain of Mammals

Cell type specificity of clusterin mRNA was determined by in situ hybridization in combination with immunohistochemistry.38 Colocalization of clusterin mRNA with neuron-specific enolase or tyrosine hydroxylase immunoreactivities confirmed neuronal expression of clusterin transcripts in the hippocampal pyramidal layer and hilar region, in subsets of neurons of the substantia nigra, as well as in the red nucleus, the trigeminal motor, facial, somatosensory mesencephalic, and other nuclei.38 Fig. 2.1. (opposite) Photomicrographs showing the distribution and levels of clusterin mRNA in selected coronal sections of the adult rat brain. Sections were hybridized with a 35S -labeled (antisense) riboprobe (for details see Danik et al26). Positive hybridization signals with different intensities are observed in various brain structures. 4V, fourth ventricle 3, oculomotor nucleus 7, facial nucleus CG, central gray CH, choroid plexus D3V, dorsal third ventricle DM, dorsomedial hypothalamic...

Studies in MS and Other Conditions

Limited studies indicate that aspartame may provoke migraine headaches and worsen depression. Interestingly, one migraine medication that dissolves in the mouth, known as rizatriptan or Maxalt-MLT, actually contains aspartame and may worsen headache in those with aspartame-provoked migraines. In terms of other neurologic disorders, clinical studies do not indicate that aspartame worsens Parkinson's disease or epilepsy.

Pathology General Aspects

Selective regional vulnerability determines the anatomic distribution of the lesions. Most vulnerable are the hippocampus, the neocortex, the cerebellar cortex, the thalamus, and the basal ganglia. The hypothalamus, the brainstem, and the spinal cord are the least vulnerable. In the hippocampus, the pyramidal neurons in the CA1 zone (Sommer's sector) are primarily affected (Fig. 3.1) in the neocortex, laminae 3, 5, and 6 in the cerebellum, the Purkinje cells . in the thalamus, the anterior and dorsomedial nuclei and, in the basal ganglia, the spiny neurons. Carbon monoxide poisoning has an affinity for the iron-rich globus palli-dus and the reticular zone of the substantia nigra.

Multiplicity and ligand specificity

Two forms of the enzyme exist, MAO-A and MAO-B, that are encoded by separate genes.53 These enzymes are 80 similar, and possess overlapping, albeit sometimes distinctive, substrate specificities. Serotonin, norepinephrine, and epinephrine are the major endogenous substrates for MAO-A. The indoleamine nucleus of serotonin appears in a few drug classes, notably the triptan class of antimigraine drugs. These drugs are metabolized by MAO-A via pathways that ultimately generate carboxylic acid metabolites.40 The acetylenic compound, clorgyline, is a selective mechanism-based inhibitor of MAO-A, and reversible inhibitors of the enzyme are under development as antidepressant drugs. Amongst the neurotransmitters, dopamine is selectively metabolized by MAO-B. Another acetylenic compound, deprenyl, is a selective mechanism-based inhibitor of MAO-B and the levo enantiomer, selegiline, is marketed as Eldepryl and used as an adjunct to l-DOPA in Parkinsonism. The rationale here is to minimize...

Adrenal Medulla Tissue Transplants

Early transplant protocols used a two-step method for transplanting adrenal tissue. First, a cavity was created in the brain at the transplant site using a small amount of sterile gelatin foam. This cavity was thought to set the stage for the transplant, as it was found that the brain releases neurotrophic factors during the first few days following damage (36,37). The adrenal tissue would then be transplanted into a site that was enriched with neurotrophins and blood vessels to increase graft survival. One study found that adrenal grafts placed into the striatum alleviated some motor impairments seen in hemiparkinsonian monkeys approx 3 mo after transplantation (38). Monkeys showed improvement in reaching with their contralateral limb and had decreased apomorphine-induced rotations. As the post-transplant time increased, the improvements began to reverse (38,39). At 6 mo, the transplanted monkeys were sacrificed, and no tyrosine hydroxylase-positive donor cells were found. In a...

Fetal Vm Tissue Transplants

By 3-6 mo after transplantation, many parkinsonian monkeys were less behaviorally impaired than nontransplanted monkeys (17,50-52,55, 63,65,68,71-73). In unilaterally dopamine-depleted monkeys, the fetal neural tissue transplants had improved voluntary reaching tasks and exhibited less drug-induced rotations (65,68,72). In a bilaterally dopamine-depleted monkey with motor impairments severe enough to require constant monitoring, the fetal VM grafts stimulated such improvement that the animal was considered nearly normal in behavior and regained the ability to feed without assistance (63). However, in that same study, another severely parkinsonian monkey showed no improvement, even at 7-mo post-transplant (63). Upon examination of the VM graft of this animal, few surviving dopamine neurons of graft origin were found, whereas numerous cells survived in the animal that had improved (63). Despite the large numbers of animals that benefited from the VM transplants, some did not improve...

Catechol Omethyltransferase

Catechol O-methyltransferase (COMT) typically metabolizes catecholamines and estrogens, forming mixtures of ortho and para methoxy metabolites118 Drug substrates include L-dopa, 2-hydroxy ethinylestradiol and isoproteranol and COMT inhibitors have therapeutic value in the treatment of Parkinsonism. The enzyme is the product of a single gene located on chromosome 22q11.2, but two forms of the protein exist soluble COMT (S-COMT, 25 kDa) and membrane-bound COMT (M-COMT, 30kDa), whose additional 50 amino acids provide the hydrophobic anchor for membrane localization. S-COMT predominates in peripheral tissues and M-COMT is the main form of the enzyme in brain tissue.119 COMT activity is inherited in an autosomal recessive manner. Individuals with low activity inherit a form of the enzyme that is thermolabile. A single G to A transition at codon 108 158 of the cytosolic membrane gene results in a Val to Met substitution which forms the molecular basis for the well-recognized interindividual...

Encapsulated Cell Lines And Neural Stem Cells

Lated chromaffin cells, a significant decrease in drug-induced rotations was seen which was maintained for the 9-mo study period (77). PC12 cells are a cell line derived from a tumor of the rat adrenal medulla that, when differentiated, will produce dopamine. Using encapsulation techniques, PC12 cells were transplanted into the striatum of parkinsonian monkeys. PC12-trans-planted animals performed better at contralateral reaching tasks than did animals transplanted with empty capsules or animals transplanted with encapsulated bovine chromaffin cells (76). Two other research groups found that encapsulated PC12 cells produced measurable levels of dopamine, and 18F-DOPA uptake could be seen within the areas of the transplanted capsules. However, there was no clear evidence of striatal reinnervation or sprouting of dopamine nerve terminals, suggesting that the PC12 cells within the capsules merely dispense dopamine and do not make functional connections with the host environment (78)....

Monoamine oxidases MAOs EC 1434

(MPTP) is an interesting example of metabolism-related selective toxicity. It is toxified via the intermediate 1-methyl-4-phenyl-2,3-dihydropyridinium salt (MPDP +) to the 1-methyl-4-phenyl pyridinium salt (MPP+). MPP+ is taken up by a high-affinity reuptake system specifically localized in the nigrostriatal dopaminergic neurons and blocks their mitochondrial energy metabolism. This leads to death of these neurons, which causes Parkinson's disease. Within the neurons only MAO can metabolize MPTP, while in other tissues CYP- and FMO-catalyzed detoxification reactions compete with MAO for the substrate. This combination of selective uptake into cells possessing a selective pattern of drug-metabolizing enzymes causes the selective neurotoxicity. MPTP is an experimental chemical. Related compounds such as beta-carboline or tetrahydroisoquinoline are present at low concentrations in food. Whether they behave in a similar way to MPTP and therefore are neurotoxicologically important by...

Total Tau Levels in CSF

Contrast, subjects with other neurological disorders, including Parkinson's disease and PSP, or psychiatric disorders (e.g. depression) showed normal CSF-T-tau levels (Blennow et al., 1995 Morikawa et al., 1999 Urakami et al., 1999). T-tau therefore has a diagnostic value to discriminate neurodegenerative disorders from pseudodementia due mainly to psychiatric disorders.

The Problem of Nary Associations

With neuronal data, however, associations between objects are typically not binary but N-ary (where N is greater than 1). For example, consider the following information on the neurons of the nigrostriatal pathway (whose function is impaired in Parkinsonism) Pars Compacta of Substantia Nigra Pars Reticulata of Substantia Nigra, Striato-Nigral 7. Within a single axis, entities may be inter-related through recursive relationships of the parent-child type. This complicates the query process because of the need to explodea query object instance, retrieving all its children prior to scanning the association data. E.g., in the example above, the pars compacta is part of the substantia nigra, which is part of the mid-brain. To process a query that asked for anatomical locations of various receptors in the mid-brain, one would first have to retrieve all child anatomical sites within the mid-brain and then search the association data against this set of child sites.

Hyperphosphorylated TTau Levels in CSF

Normal P-tau levels were found in psychiatric disorders such as depression (Buerger et al., 2003) and in chronic neurological disorders such as amyotrophic lateral sclerosis (ALS), Parkinson's disease (Blennow et al., 1995 Sj gren et al., 2002) and other dementias, including VaD, FTD and LBD (Parnetti et al., 2001 Vanmechelen et al., 2000 Hampel et al.,

Neural Transplantation Of Primary Fetal Striatal Tissue

The relatively focal loss of medium spiny GABAergic projection neurons in the striatum presents an opportunity to explore neural transplantation as a strategy for cell replacement and circuit reconstruction. The medium spiny neurons of the caudate nucleus and putamen form part of a complex circuitry of parallel feedback loops involving discrete areas of cortex and subcortical structures. The medium spiny neurons receive major inputs from the cerebral cortex, thalamus, and substantia nigra pars compacta, and their primary outputs occur via GABAergic projections to the globus pallidus and the substantia nigra pars reticulata. Experimental studies conducted in animals over the past two decades have established that striatal neurons that are lost through a lesion can be functionally replaced by transplantation of the homologous population of fetal neurons. To achieve this, the developing fetal striatum is dissected, dissociated using enzymatic digestion of the tissue or diced into small...

Additional Readings Books

Eighty-one patients with multiple sclerosis and Parkinson's disease undergoing upper cervical chiropractic care to correct vertebral subluxation a retrospective analysis. J Vertebral Sublux Res 2004 August 1-9. Ernst E. Chiropractic care attempting a risk-benefit analysis. Am J Public Health 2002 92 1603-1604.

Dementia with Lewy Bodies

Dementia with Lewy bodies (DLB), also called diffuse Lewy body dementia (DLBD), is the second most common degenerative dementia in the elderly, after AD. It is somewhat more common in men. It may coexist with AD and Parkinson's disease. Cognitive decline, visual hallucinations, parkinsonian features, syncope, sensitivity to neuroleptics, sleep abnormalities, and a slowly progressive and fluctuating course are characteristic. Generalized cortical atrophy with frontal-temporal predominance and discoloration of the substantia nigra are distinctive gross features (Fig. 5.11). Histologically, the presence of Lewy bodies in cortical neurons is the hallmark of the disease (see Fig. 5.11). These bodies are eosinophilic cytoplasmic inclusions, similar structurally to the Lewy bodies found in the substantia nigra of patients with idiopathic Parkinson's disease. They typically immunoreact with a-synuclein and ubiquitin (Table 5.5). Lewy bodies and Lewy Diffuse Lewy body dementia. A man diagnosed...

Substance Induced Mania

Substances known to induce mania include sympathomimetic agents (iproni-azid, procarbazine), psychostimulants (e.g., amphetamines, methylphenidate, cocaine, phencyclidine), tricyclic antidepressants, monoamine oxidase inhibitors, levodopa, yohimbine, bromide, alprazolam, corticosteroids, and many other substances (Table 3 11). In this regard, hypomania or mania that begins during or within 1 month of treatment with one or more of the medications listed here should be considered substance induced.

Discussion and Conclusion

Hamilton, G. Carroll, K. DeHaan, R. Parkinson, A. J. Biochem. Mol. Toxicol. 2000, 14, 177-188. 28. Madan, A. Usuki, E. Burton, L. A. Ogilvie, B. W Parkinson, A. Drugs and Pharmaceutical Sciences. In Drug-Drug Interactions Rodriguez, A. D., Ed. Marcel Dekker New York, 2002 Vol. 116, pp 217-294. 92. LeCluyse, E. L. Madan, A. Hamilton, G. Caroll, K. Dehaan, R. Parkinson, A. J. Biochem. Mol. Toxicol. 2000, 14, 177-188.

Whole Bone Marrow Transplants In An Hd Model

The disease is caused by an expansion of trinucleotide (cytosine-adenine-guanine CAG ) repeats on the IT15 locus of chromosome 4 (47) that codes for the huntingtin protein. Although the gene encoding huntingtin is expressed ubiquitously, selective degeneration occurs, causing GABAergic neuronal loss in the corpus striatum (caudate nucleus, putamen, and globus pallidus). To date, neither curative nor neuroprotective therapies are available to stop disease progression. However, positive results from fetal neural transplants in patients with Parkinson's disease have demonstrated the potential clinical value for this type of therapy (48,49). Recently, intracerebral transplantation of fetal neuroblasts from the striata primordia has been conducted in some HD patients, and beneficial results of this procedure have also been reported (50,51). Nevertheless, the use of primary immature neurons or precursors in transplantation has some limitations owing to the heterogeneity...

Clinical Features

Diseases with Parkinsonism Progressive supranuclear palsy Striatonigral degeneration Corticobasal dementia Chromosome 17-linked dementia Parkinsonism-dementia complex of Guam Postencephalitic parkinsonism Multiple system atrophy Progressive supranuclear palsy Striatonigral degeneration Corticobasal dementia Chromosome 17-linked dementia Parkinsonism-dementia complex of Guam Postencephalitic parkinsonism Multiple system atrophy Neurodegenerative Diseases with *Parkinsonism *Parkinsonism refers principally to motor disturbances of idiopathic Parkinson's disease (iPD). **PSP, progressive supranuclear palsy CBD, corticobasal degeneration FTDP-17, frontotemporal dementia parkinsonism linked to chromosome 17 MSA, multiple system atrophy.

Disease State Diagnosis

PD is primarily a movement disorder resulting from the loss of dopaminergic neurons of the substantia nigra pars compacta (SNpc). It is diagnosed by the presence of resting tremor, bradykinesia (slowness of voluntary movement), rigidity (stiff muscles, expressionless face), and postural instability (poor recovery of balance). The gait of individuals with PD is also distinctive, with a tendency to lean unnaturally forwards or backwards, a diminished arm swing, and a shuffling step. Although loss of DA-containing neurons is a hallmark pathological feature of the disease, other neuronal populations are also affected.62 Structures that are initially affected in stages 1-2 of PD include the vagal nerve, the dorsal motor nucleus and the olfactory bulb, and the anterior olfactory nucleus. At stage 3, involvement of basal portions of the midbrain and forebrain and a number of cholinergic nuclei and the tuberomamillary nucleus is apparent. At stage 4, portions of the cerebral cortex are...

Experimental Disease Models 608331 Neurotoxin models

Several neurotoxins have been used to produce selective dopaminergic neuron loss to model sporadic disease, and, in some species, e.g., the nonhuman primate, parkinsonism-like symptoms are evident following exposures.67 The three major toxins used to lesion the brain are (MPTP 52), 6-hydroxydop-amine (6-OHDA 53), and rotenone 54. Unilateral lesion of the substantia nigra, medial forebrain bundle, or striatum with 6-OHDA produces dopaminergic neuron loss, albeit at different rates, leading to a 'hemiparkinson' model where the injected side of the brain exhibits degeneration. Administration of DA agonists like apomorphine or the stimulant amphetamine elicits rotation or circling toward the contralateral side in animals, unmasking the DA loss. Although 6-OHDA causes dopaminergic neuron loss, other neurons affected in PD (e.g., lower brainstem nuclei and locus coeruleus) are unaffected and Lewy bodies do not occur. The MPTP model of PD is based on the idiopathic parkinsonism seen in...

Unmet Medical Needs

As with AD, a large unmet medical need in PD is the development of drugs that slow disease progression. A paucity of established biomarkers for early disease diagnosis confounds indicators of treatment efficacy. This is particularly evident for drugs in which there is no symptomatic benefit demonstrated, since clinical trials of long duration ( 18-24 months) need to be carried out with large patient numbers in order to power the study appropriately to see perhaps small but significant effects. For drugs that do have symptomatic effects, neuroprotective events of the compounds can be established using a drug wash-out study design. This strategy has been used for selegine and pramipexole, but as of yet no drug is approved and has US FDA labeling indicative of a disease-modifying effect.

First Line Agents NonSelective Serotonin Reuptake Inhibitors

The dopaminergic properties of bupropion may be beneficial for patients with Parkinson's disease. It does not cause sexual side effects or orthostatic hypotension, and it is very safe in overdose. It does not cause weight gain a review (Settle et al. 1999) of three clinical trials found that the sustained-release form of bupropion produced dose-related weight loss in all three studies.

Fetal Neural Transplantation

Promising laboratory findings in animal models of Parkinson's disease (PD) and Huntington's disease (HD), which were treated with neural transplantation strategies, have formed the scientific basis for clinical trials (2,5). More than 350 PD, HD, and stroke patients have already received intracerebral neural transplantation. However, these patients have demonstrated variable degrees of clinical improvement, owing partly to the low viability of the grafts (2,6-11). Because graft survival is greatly altered by the host immune response, cells that can avoid immunosurveillance, particularly autologous cells (e.g., the transplant recipient's adrenal or stem cells), may limit graft rejection (12-18). Fetal cells persist as the most widely studied graft source for transplantation. Unfortunately, many logistical and ethical issues hinder the use of primary fetal cells in the clinic. Thus, a primary research endeavor in cell transplantation has concentrated on searching for a nonprimary fetal...

Third Line Agents Monoamine Oxidase Inhibitors

As cyclic antidepressants in elderly patients, but they appear to be as effective (Georgotas et al. 1986). In the United States, phenelzine and tranylcypromine are available for treatment of depression, and selegiline, which selectively inhibits MAO B, is marketed primarily for adjunctive treatment of Parkinson's disease but also has been studied in depression. Moclobemide, one of the first reversible inhibitors of MAO A, is available in Canada but not in the United States at the time of this writing. Phenelzine is administered at an initial dosage of 15 mg twice a day, gradually increasing to a maximum of 60 75 mg day tranylcypromine is administered at an initial dosage of 10 mg twice a day, increasing to a maximum of 50 mg day. Selegiline is administered at dosages of 5 15 mg day (with levodopa) for Parkinson's disease at this dosage, it is selective for MAO B and enhances dopaminergic transmission. But at antidepressant dosages (i.e., 40 mg day), it loses this selectivity. Each of...

No In Neurological Disorders

Nitric oxide may mediate other forms of neurotoxicity. NOS inhibitors protect against CNS oxygen toxicity (106). Selective nNOS inhibitors protect against the dopaminergic neurotoxin (MPTP), which is a model of Parkinson's disease (107,108). Further evidence of a role for neuronally derived NO in Parkinson's disease is the recent observation that mice lacking the nNOS gene (109) and 7-nitroindazole-treated baboon (110) are markedly resistant to MPTP neurotoxicity.

Mechanisms of Meditation

The mechanism of meditation response for mediating antiepileptic response largely remains a matter of speculation. Areas in the brain that generate and modulate seizure activity have been identified. Gale (31) has done extensive studies in this direction and suggests that two brain areas, the substantia nigra and area tempastas, are connected to control of seizures. Circuits involving the thalamus and substantia nigra and or limbic system and pyriform cortex may influence the activity of target areas (the seizure focus), thus modifying their activities.

Transplantation Of Nt2n Cells In Stroke Patients

Additional challenges in the field of neural transplantation include demonstration of graft viability and functional effects. A subsequent clinical report evaluated the function of NT2N-transplanted cells using positron emission tomography (PET) (64). Uptake of fluorodeoxyglucose (FDG) was measured at baseline and at 6 and 12 months after transplantation of NT2N neurons. At 6-mo posttransplantation, 7 of 11 patients showed more than 10 increase in FDG uptake in the area of cell implantation this increase correlated with clinical improvement, as measured by stroke scale values. In a recent study that reported the first postmortem brain in an NT2N-transplanted patient at 2 yr posttransplantation (65), histological examination revealed neurofilament immunoreactive neurons resembling those seen in NT2N neurons in vitro. The observed NT2N cell graft survival in this patient suggests that these transplanted cells mediated functional outcome. The PET and histological data from transplanted...

Potential Roles for apoE and apoJ in CNS Disease

Further studies to understand the structure and function of apoE and apoJ-containing lipoproteins produced by cells within the brain is likely to provide important insights into the role of these proteins in neurodegenerative and other diseases of the CNS. This issue will be considered in regard to Alzheimer's disease (AD) and brain repair following CNS injury. Genetic epidemiological studies have shown that the e4 allele of apoE is a major risk factor for AD.43 In addition, recent data suggests that apoE4 is also a risk factor for poor outcome after head trauma,44,45 cerebral hemorrhage,46 cardiac bypass,47 and possibly stroke.48 ApoE4 also appears to influence the age of onset of Parkinson's disease.49 In regard to AD, one hypothesis is that the association between apoE4 and AD is due to the ability of apoE to interact with the Ap protein. Ap deposition in the AD brain appears to be an early and important pathogenetic event in AD.50 A recent in vivo study highlights the potential...

Potential Clinical Applications Of Bmscs In Neurologic Injury And Disease

Cell replacement mechanisms are self-evident. Although the prevention of pathologic processes is the ultimate goal, replacing lost CNS tissues with autologous grafts is an ideal alternative for conditions in which these measures are not available. Parkinson's disease (PD) is the classic example of a disease in which a specific cell population becomes dysfunctional and dies by a process that is poorly understood and not yet preventable. Moreover, there is longstanding experimental and clinical evidence that supports the idea that replacement of dopaminergic neurons can ameliorate functional disabilities. Thus, BMSC-derived dopaminergic neurons could have significant therapeutic potential. Whether the BMSCs are induced to undergo neural differentiation prior to transplantation, rather than naturally in situ, will need to be carefully evaluated, but cell replacement strategies using BMSCs hold major promise. Indeed, Huntington's disease, spinocerebellar ataxia, stroke, traumatic brain...

Use in Prevention and Therapy

Abnormalities in the acetylcholine system in the brain may produce motor disturbances. Therefore, choline and lecithin supplements may benefit people with Parkinson disease, Huntington disease, and other nervous disorders characterized by abnormal movements.7 Choline and lecithin may also be beneficial in reducing tardive dyskinesia associated with antipsychotic drug use.1

Neurobiochemistry of Alzheimers Disease

The first and most thoroughly confirmed neurobiochemical abnormality found in brain tissue affected by Alzheimer's disease neuropathology was reduced temporoparietal and hippocampal cortical activity of choline acetyl-transferase, an enzyme found only in cholinergic cells, which catalyzes the synthesis of acetylcholine. Biopsy studies have detected significant losses of this enzyme as early as the first symptomatic year, and autopsy studies have reported a strong correlation (r 0.8) between the degree of choline acetyl-transferase loss and premortem measurements of cognitive and functional decline. Concentrations of acetylcholinesterase and acetylcholine, both of which are less specific indicators of cholinergic cell activity than is choline acetyltransferase, also have been found to be reduced in affected brain tissue. Altogether, these findings support a working analogy between Alzheimer's disease and Parkinson's disease, in which a single neurotransmitter (dopa-mine) is also...

In Search of a Mechanisms of Action

At least in narcoleptic dogs, via a mechanism independent of the hypocretin receptor.36 Additionally, in DAT knockout mice, modafinil-like methamphetamine and the selective DAT blocker, GBR 12909, lacked wake-promoting effects.36 Increases in dopamine release in the rat nucleus accumbens were observed following modafinil administration but this was secondary to a reduction in GABAergic transmission that led to a reduction of GABAA receptor signaling in dopamine terminals.37 Modafinil dose-dependently reduced g-amino-butyric acid (GABA) outflow from the cortex of awake guinea-pig,38 and from the striatum, pallidum, and substantia nigra,39 and, more importantly, from the medial preoptic area and posterior hypothalamus of the awake rat.40 The latter are hypothalamic fields where functional inhibition of GABA release by modafinil may be relevant for its vigilance-promoting effects. Modafinil also increased glutamate release in the ventrolateral and ventromedial thalamic areas,...

In Search and Discovery of Potential New Therapeutic Indications

The search for additional indications for modafinil naturally focused on diseases associated with wake deficits and somnolence. The effects of the drug in an animal model of sleep-disordered breathing suggested that modafinil might be effective in reducing sleepiness associated with sleep apnea,50 and this was subsequently demonstrated in the clinic.51-53 Other disorders where somnolence or sedation was concomitant with the disease, e.g., Parkinson's disease,54-56 myotonic dystrophy,57-60 fibromyalgia,61 amyotrophic lateral sclerosis,62 multiple sclerosis,63 cerebral lymphoma,64 or resulting from the side-effects of other medications such as antidepressants,65 antipsychotics,66 dopaminergic D2 agonists,67,68 opioids,69 or valproic acid,70 have also proven to be amenable to treatment with modafinil.

Differential Diagnosis

The other degenerative dementias (Alzheimer's disease and dementia with Lewy bodies) vascular dementia the dementias associated with Huntington's disease, Parkinson's disease, Creutzfeldt-Jakob disease, human immunodeficiency virus (HIV) infection, and head trauma and those associated with other general medical conditions all must be ruled out before a diagnosis of frontotemporal dementia is made. Because of the lack of differentiating physical signs, and the tendency for Alzheimer's disease to include signs and symptoms of frontal lobe involvement, the most challenging distinction is between frontotemporal dementia and Alzheimer's disease. Table 6-2 summarizes the main differentiating features of these two conditions. Knopman et al. (2005) reviewed 433 cases that went to autopsy and found that frontotemporal dementia was correctly identified on the basis of clinical and laboratory findings in 29 of 34 autopsy-verified cases. This finding represents 85 sensitivity the authors also...

Of Antidepressant Treatments

This hypothesis could also explain the individual variability and susceptibility to stress-induced affective illness. Prior exposure of an individual to stress or some other type of neuronal insult, such as hypoxia-ischemia, hypo-glycemia, or infection, could induce a relatively small degree of neuronal damage that is not sufficient to result in behavioral abnormalities. However, with subsequent exposures to stress or environmental insults over time, the damage to neurons may be cumulative and eventually lead to illness. This type of scenario is observed in Parkinson's disease, where up to 80 of the substantia nigra dopamine neurons are lost before the illness is expressed. It is also possible that there are genetic factors involved that increase the vulnerability hippocampal neurons to stress.

Diagnostic Criteria

Consensus criteria published originally by McKeith et al. (1996) and recently revised (McKeith et al. 2005) require dementia and two of the following three core features to make a diagnosis of probable dementia with Lewy bodies fluctuating cognition with pronounced variations in attention and alertness recurrent visual hallucinations that are typically well formed and detailed and spontaneous motor features of parkinsonism (McKeith et al. 2005, p. 1864). The diagnosis of dementia with Lewy bodies is less likely if cerebrovascular disease evident as focal neurological signs or on brain imaging is present in the presence of any other physical illness or brain disorder sufficient to account in part or in total for the clinical picture and if parkinsonism only appears for the first time at a stage of severe dementia (McKeith et al. 2005, p. 1864). Although the consensus criteria have enjoyed widespread acceptance, Serby and Samuels (2001) reexamined their usefulness via a critical...

Encouraging Human Experience With Pig Transplants

An Food and Drug Administration-approved US clinical phase I study is being conducted using neural xenotransplantation in 12 PD patients (18,19). This safety trial is focused on the unilateral transplantation of fetal pig mesencephalic neural cells into the putamen and caudate. Six patients received continuous systemic cyclosporine. An interim report at 12 mo listed no evidence of serious adverse events. Cultures were negative for bacterial and viral contamination, and no porcine endogenous retrovirus DNA sequences were found. As assessed by magnetic resonance imaging, the cannula tracts were localized within the putamen and caudate without noticeable tissue trauma. In the medication-off state, total Unified Parkinson's Disease Rating Scale scores improved by 19 (p 0.01), with three patients improving over 30 and two patients exhibiting improved gait. 18F-Levodopa positron emission tomography failed to show changes on the transplanted side. Histological analysis of the graft in a...

Sertoli Cells Is There A Role In Transplantation

PD is a progressive neurodegenerative disease characterized by a selective and severe loss of dopaminergic neurons in the substantia nigra. The most common therapy for PD is the administration of levodopa (L-dopa). Although quite effective in the early disease stages, L-dopa does not stop disease progression, and debilitating side effects manifest over several years. Transplantation of fetal dopaminergic neurons into the striatum of PD patients has been under clinical investigation for nearly two decades and has been met with generally encouraging results (26). As already mentioned, however, the limited availability and ethical issues concerning the use of human fetal tissue precludes this approach from widespread practice. Therefore, there is a great deal of interest in developing the use of fetal dopaminergic tissue transplants from other species. Based largely on the successful demonstration that Sertoli cells promote the survival of discordant islet cell grafts to reverse diabetes...

Physical and Neurological Examination

Dysarthria, impaired gag reflex, extensor plantar reflex, and signs of frontal release such as grasp or snout reflex. Evidence of systemic atherosclerosis (e.g., bruits) and signs of poor peripheral circulation (e.g., diminished pulses, atro-phic skin changes) also may increase the probability that dementia is at least partly of vascular origin. Physical and neurological examination may show abnormal findings associated with Parkinson's disease (tremor, cogwheel rigidity, and akinesia), Huntington's disease (choreoathetoid movements), head trauma (motor or sensory deficits), HIV infection (tremor, ataxia, atonia and hyperre-flexia, frontal release signs), or Creutzfeldt-Jakob disease (ataxia, myoclonus).

Dementia Due to General Medical Conditions

Although many other conditions can cause impairment in cognition severe enough to meet criteria for dementia (see Chapter 5, Dementia and Alzheimer's Disease, Table 5-6), DSM-IV-TR specifically recognizes HIV disease, head trauma, Parkinson's disease, Huntington's disease, Creutzfeldt-Jakob disease, and Pick's disease (a form of frontotemporal dementia, described earlier in the Pathology subsection of Frontotemporal Dementia) as capable of causing dementia via direct damage to brain structures (by infection, trauma, or degeneration). Differentiation of each of these conditions from Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, vascular dementia, and other dementing conditions depends on identification of the characteristic physical and laboratory abnormalities associated with each disease entity, supported by appropriate historical information. These characteristics are summarized in Table 6-5. Parkinson's disease The dementias of Parkinson's disease and...

Relationship Approaches to Absorption Distribution Metabolism and Excretion Predictions

A second class of conjugating enzymes that attracted great interest are the catechol O-methyltransferases (COMTs). These enzymes catalyze the methylation of various catechol derivatives such as catecholamines, catechol estrogens, and their metabolites, and several drug metabolites. There are two forms of COMTcoded by a single gene the soluble, cytosolic form (s-COMT) and the membrane-bound form (mb-COMT), found in the rough endoplasmic reticulum. COMT inhibitors are used as drugs in the treatment of Parkinson's disease. CoMFA analyses133,134 have revealed the key role played by the electrostatic field in predicting the enzyme kinetic parameters of s-COMT. These studies underline how CoMFA results are sensitive to the method used to calculate atomic charge calculation. Semi-empirical charge calculations performed clearly better than fully empirical ones. The CoMFA results are in agreement with docking analyses of the s-COMT crystal structure, which have revealed the interaction between...

Tolerance Induced By Foreign Protein Antigens

Some systemic infections (e.g., with viruses) may initiate an immune response, but the response is impaired before the virus is cleared, resulting in a state of persistent infection. In this situation, virus-specific T cell clones are present but do not respond normally and are unable to eradicate the infection. This phenomenon has been called clonal exhaustion, implying that the antigen-specific lymphocyte clones make an initial response but then become anergic, or exhausted. There is some evidence that clonal exhaustion is due to upregulation of inhibitory receptors such as PD-1 on virus-specific CD8+ T cells. This phenomenon has been seen in patients infected with the human immunodeficiency virus (HIV) and in animal models of chronic viral infection. How some microbes upregulate expression of inhibitory molecules in T cells is not known. Clonal exhaustion may favor viral persistence and is thus a mechanism of immune evasion used by some pathogens. Understanding of this process may...

Allotransplantation In

The EBMT has recently updated data on the outcome of 209 allogeneic transplants from their registry (13) (Table 1). There were 163 men (78 ) and 46 women (22 ), with a median age of 42 yr (range, 22-64 yr). The median interval between diagnosis and transplantation was 45 mo (range, 5-198 mo) and at diagnosis, 76 of patients studied were in stages B or C 22 of patients had received one conventional line of therapy, 28 two lines, and 50 three lines. These lines included fludarabine for 44 of 209 patients (21 ), chlorambucil in 30 of 209 patients (14 ), and 32 of 209 (15 ) received ChOP. At transplantation, 172 patients were evaluated for response to therapy 19 of 172 patients (11 ) were in CR, 78 of 172 (45 ) in PR, and 75 of 172 (44 ) in PD. Ninety patients (43 ) received BM, 115 PBSCs (55 ), and 4 BM and PBPCs (2 ). One hundred and sixty-six patients (83 ) received an allotransplant from HLA-identical sibling donors, 6 from syngeneic donors (3 ), 16 (8 ) from matched and mismatched...

Myoclonus Epilepsy with Ragged Red Fibers

The pathology consists of (a)neuronal degenerations and gliosis in the dentate nuclei and cortex of the cerebellum, inferior olivary nuclei, red nucleus, substantia nigra, globus pallidus, and Clarke nucleus of the spinal cord (b) demyelination of the superior cerebellar peduncles and posterior columns and spinocerebellar tracts of the spinal cord and (c) ragged-red fiber myopathy.

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