Niacin improved rigidity and bradykinesia in a Parkinson's disease patient but also caused unacceptable nightmares and skin rash—A case report

A patient with Parkinson's disease taking levodopa/carbidopa, selegiline, buproprion, aspirin and niacin had decreased rigidity and bradykinesia when his niacin dose was steadily escalated for treatment of high triglycerides, but ultimately the patient could not tolerate niacin because of severe nightmares and skin rash. If further research can reproduce this patient's initial beneficial experience while avoiding the adverse effects, niacin could be a useful adjunctive agent for Parkinson's disease, either population-wide or in a pharmacogenomically defined set of responders.

Cerebroventricular clozapine would be a viable treatment modality for clozapine-dependent schizophrenia patients with neutropenia

The atypical antipsychotic clozapine is very effective for treatment of schizophrenia, but it causes agranulocytosis requiring drug cessation in up to 2% of cases. There has been some success rechallenging with clozapine at a later date or giving granulocyte colony stimulating factor or lithium while continuing clozapine. However, there are still some patients for whom these strategies do not work yet who cannot be controlled on other medications. This paper proposes that for such individuals, cerebroventricular administration of clozapine via Ommaya catheters could allow continued use of clozapine therapy. Direct infusion into cerebrospinal fluid means far smaller amounts of drug would be needed for efficacy, and clozapine concentrates in the central nervous system where it would not be exposed to bone marrow stem cells to cause agranulocytosis. This treatment paradigm would also provide a means for court-ordered clozapine therapy and a possible delivery system for future therapeutics based on trophic factors such as brain-derived neurotrophic factor.

Intrathecal corticosteroids might slow Alzheimer's disease progression

Anti-inflammatory drugs for treatment and prevention of Alzheimer's disease have to date proved disappointing, including a large study of low-dose prednisone, but higher dose steroids significantly reduced amyloid secretion in a small series of nondemented patients. In addition, there is a case report of a patient with amyloid angiopathy who had complete remission from two doses of dexamethasone, and very high dose steroids are already used for systemic amyloidosis. This paper presents the hypothesis that pulse-dosed intrathecal methylprednisolone or dexamethasone will produce detectable slowing of Alzheimer's progression, additive to that obtained with cholinesterase inhibitors and memantine. A protocol based on treatment regimens for multiple sclerosis and central nervous system lupus is outlined, to serve as a basis for formulating clinical trials. Ultimately intrathecal corticosteroids might become part of a multi-agent regimen for Alzheimer's disease and also have application for other neurodegenerative disorders.

Nightly high dose lactulose infusion could be a cost-effective treatment for hepatic encephalopathy, renal insufficiency and heart failure

Lactulose is an established remedy for hepatic encephalopathy and shows efficacy for chronic renal insufficiency, reducing volume overload, uremia and hyperkalemia. Potentially lactulose could also be used for non-diuretic treatment of congestive heart failure. However, use of lactulose is limited by diarrhea and flatulence. Chronic lactulose administration might be tolerable if it was accomplished by nocturnal infusion through a percutaneous duodenostomy tube, also placing a rectal foley each night following a clearing enema so that large volumes of liquid stool could be passed while patients sleep. Each morning the duodenostomy would be clamped and the foley removed. For acute patients without duodenostomies, a temporary dobhoff feeding tube with accompanying rectal foley could be employed. Patients who did not want a rectal foley could elect to have a permanent colostomy. Clinical trials could establish the relationship between lactulose infusion and clearance of water, salt, potassium, hydrogen, urea and other wastes, and compare efficacy, cost and tolerability with that of peritoneal dialysis and ultrafiltration. Lactulose could potentially allow inexpensive home-based therapy for hepatic encephalopathy, chronic renal failure and congestive heart failure, and might be life-saving in countries where renal replacement in any form is currently unavailable.

The coming problem of HIV-associated Alzheimer's disease

BACKGROUND

Dementia associated with human immunodeficiency virus (HIV) is a subcortical neuropathology that does not resemble Alzheimer's disease. However, several lines of evidence suggest that in the future there may be significant numbers of long-term HIV survivors with true Alzheimer's disease. Age is itself a risk factor Alzheimer's disease, and an aging population and widespread use of highly active antiretroviral therapy (HAART) means more elderly HIV patients. Immune reconstitution inflammatory syndrome, lypodystrophic effects of HAART medications, HIV-induced amyloid deposition and excitotoxic effects of gp120 and TAT protein all could be risk factors for subsequent Alzheimer's disease. Finally, HIV patients will have greater vulnerability to common non-HIV pathogens that may contribute to development of Alzheimer's disease.

PRESENTATION OF THE HYPOTHESIS

It is predicted that in the future there will be seen measurable numbers of long-term HIV survivors on HAART who have Alzheimer's disease, with a cortical deficit profile on neuropsychological tests, pronounced cerebral atrophy seen on brain MRI, and neurofibrillary tangles, senile plaques and neuronal loss in post-mortem brain tissue. VALIDATING THE HYPOTHESIS: The hypothesis could be validated through case reports, longitudinal clinical studies, brain bank programs and animal models.

IMPLICATIONS OF THE HYPOTHESIS

Management of HIV may become more difficult, requiring greater provisions for long-term care of HIV patients with chronic dementia. However, it may be possible to reduce or prevent HIV-associated Alzheimer's disease through early use of cholinesterase inhibitors, glutamate-blocking drugs, insulin sensitizing agents, statins and anti-oxidants.

A TAT-modified fusion protein efficiently penetrates mouse hypoglossal nuclei from transduced ependyma

Future gene therapy for brainstem variant amyotrophic lateral sclerosis may be technically difficult if gene therapy vectors are injected near vital cardiorespiratory centers or if large portions of the tongue and pharyngeal muscles must be peripherally injected for retrograde transport of vectors to motor neurons. In this study we show that it is possible to deliver recombinant proteins to the hypoglossal nuclei without brainstem or muscle injections, by taking advantage of enhanced uptake of fusion proteins containing the protein transduction domain from the human immunodeficiency virus TAT protein. Adenoviral vectors expressing either TAT-modified or native beta-glucuronidase (beta-gluc) were injected into the lateral cerebral ventricles of mice, transducing ventricular epithelium down to the level of the obex in the brainstem. There was significant uptake into the hypoglossal nuclei of TAT-modified but not native beta-glucuronidase. The TAT-modified beta-gluc appeared to encompass half or more of the hypoglossal nuclei as visualized by retrograde labeling with cholera toxin subunit b in adjacent sections. TAT-modification of gene products may allow a relatively non-invasive approach to brainstem gene therapy via cerebroventricular injection.

Dexamethasone could improve myocardial infarction outcomes and provide new therapeutic options for non-interventional patients

BACKGROUND

Statins reduce death and morbidity of acute myocardial infarction in part through immunosuppressive mechanisms, suggesting glucocorticoids could produce similar benefits. Glucocorticoids inhibit proliferation of smooth muscle cells and activation of macrophages within atherosclerotic plaques and protect ischemic myocardium through inhibition of a heat shock protein. Dexamethasone-eluting coronary stents have a decreased rate of restenosis, and oral prednisone reduces restenosis of conventional stents. Some studies from the 1970's and 1980's showed that steroids improve survival in myocardial infarction, but no conclusive large-scale randomized well-powered trials have been conducted.

PRESENTATION OF THE HYPOTHESIS

Dexamethasone administered alongside statins in the setting of acute myocardial infarction could attenuate myocardial damage in patients with diffuse disease.

TESTING THE HYPOTHESIS

Patients with acute myocardial infarction who cannot undergo angioplasty or coronary artery bypass grafting could be given a statin and intravenous and oral dexamethasone. Dexamethasone minimizes fluid retention and avoids mineralocorticoid-induced cell proliferation in plaques. Blood glucose monitoring should be ordered for all patients, but diabetic patients need not be excluded. There should be measures to prevent steroid-induced homocystinuria or more common complications such as ulcers, osteoporosis, infections and psychosis.

IMPLICATIONS OF THE HYPOTHESIS

Showing that acute coronary syndrome is a steroid-responsive disorder would have immediate relevance for patients limited to medical management because of anatomy and comorbidities, and results would similarly have application for acute ischemic stroke.

Neurotransmitter depletion may be a cause of dementia pathology rather than an effect

BACKGROUND

There is widespread loss of acetylcholine and other neurotransmitters in Alzheimer's disease and vascular dementia. It has generally been assumed that death of neurons causes neurotransmitter loss, but alternatively neurotransmitter depletion itself may at least contribute to neurodegeneration.

PRESENTATION OF THE HYPOTHESIS

Transgenic mice and pigs with inducible 50% depletion of acetylcholine, dopamine, norepinephrine, serotonin, gamma-aminobutyric acid (GABA) and corticotrophin releasing factor will reproduce Alzheimer's disease or vascular dementia neuropathology, and pharmacologically restoring neurotransmitters will attenuate neuronal injury.

TESTING THE HYPOTHESIS

Through nuclear transfer cloning, transgenic mice and pigs would be created with transgenes on one X chromosome, so that transgenes would only be expressed in half of all cells in female animals. Transgenes would encode tetracycline-inducible short hairpin RNA (shRNA) designed to form small interfering RNA (siRNA) to knock down neurotransmitter biosynthesis in late adulthood. Transgene expressing neurons could be readily identified in tissue sections with fluorescent reporter genes. Cholinesterase inhibitors, antidepressants, benzodiazepines and CRF would then be administered in an attempt to rescue degenerating neurons.

IMPLICATIONS OF THE HYPOTHESIS

The mice and pigs could serve as an important new model for the pathogenesis of dementia, especially if pharmacologically restoring neurotransmitters rescues degenerating neurons. The animals may also be useful for as models for other disorders such as multi-system atrophy, Parkinson's disease, and depression.

Integrated electronic monitoring systems could revolutionize care for patients with cognitive impairment

Dementia and other causes of functional disability can create considerable burdens for families and society as a whole, but it may be possible to partially alleviate this strain through technical innovations that replace some functions of human caregivers. This article proposes the hypothesis that cell phones, internet communication and global positioning satellite receivers could be integrated into computer based care-giving systems to provide orientation and safety cues, daily reminders of activities, protection against wandering and direct links to medical assistance in case of incapacitation. Hypothetical case histories describe assistance systems for a patient with moderate Alzheimer's disease living at home, a patient in a nursing home with more advanced dementia and incontinence, an epileptic with intermittent transient postictal amnesia, and a head injury survivor with explosive disorder.

Is the immobility of advanced dementia a form of lorazepam-responsive catatonia?

Patients with end-stage dementia typically are very immobilized. Could this state actually be a form of lorazepam-responsive catatonia? Catatonia has been documented following cerebrovascular accidents, head injury, HIV encephalitis, brain tumors, and multiple sclerosis. Identified anatomical substrates include frontal lobes, parietal lobes, limbic system, diencephalon, and basal ganglia. Given that Alzheimer's disease, vascular dementia, Lewy body dementia, corticobasal degeneration, frontotemporal dementia, and Parkinsonian dementia often have degeneration in some of the same areas, dramatic awakenings might be possible by giving lorazepam challenges to locked-in dementia patients. If even a small percentage were lorazepam responders, the impact worldwide would be tremendous. Serious consideration should be given to undertaking large-scale clinical trials.

Xenografts are an achievable breakthrough

The objective of this communication is to show that pig-to-human organ transplantation could be feasible through genetic engineering. By introducing into donor pigs several different tolerance promoting genetic modifications there can be a synergistic effect to produce extended tolerance for xenografted organs in human recipients. Nuclear-transfer cloning allows production of pigs with knockout mutations in the galactose-alpha-1,3-galactosyl transferase gene, in principle eliminating hyperacute rejection. Once hyperacute rejection is circumvented, long-term tolerance of xenografted organs should be possible through a combination of transgenic immunomodulating molecule, bone marrow chimerism and short to intermediate term use of immunosuppressive drugs. If immunomodulating transgenes are deleterious during pig development, inducible cre-recombinase excision of stop codons provides a means to delay expression of such transgenes until after transplantation. Zoonotic diseases can be circumvented via pathogen-free colonies and additional knockout mutations to disable porcine endogenous retrovirus and prion disease. Thus, there is now a technical and theoretical framework for serious efforts at cross-species transplantation.

Viral-mediated delivery of the late-infantile neuronal ceroid lipofuscinosis gene, TPP-I to the mouse central nervous system

Classical late-infantile neuronal ceroid lipofuscinosis (LINCL) is caused by mutations in tripeptidyl peptidase I (TPP-I), a pepstatin-insensitive lysosomal protease, resulting in neurodegeneration, acute seizures, visual and motor dysfunction. In vitro studies suggest that TPP-I is secreted from cells and subsequently taken up by neighboring cells, similar to other lysosomal enzymes. As such, TPP-I is an attractive candidate for enzyme replacement or gene therapy. In the present studies, we examined the feasibility of gene transfer into mouse brain using recombinant adenovirus (Ad), feline immunodeficiency virus (FIV) and adeno-associated virus (AAV) vectors expressing TPP-I, after single injections into the striatum or cerebellum. A dual TPP-I- and beta-galactosidase-expressing adenovirus vector (AdTTP-I/nlsbetagal) was used to distinguish transduced (beta-galactosidase positive) cells from cells that endocytosed secreted TTP-I. Ten days after striatal injection of AdTTP-I/nlsbetagal, beta-galactosidase-positive cells were concentrated around the injection site, corpus callosum, ependyma and choroid plexus. In cerebellar injections, beta-galactosidase expression was confined to the region of injection and in isolated neurons of the brainstem. Immunohistochemistry for TPP-I expression showed that TPP-I extended beyond areas of beta-galactosidase activity. Immunohistochemistry for TTP-I after FIVTTP-I and AAV5TTP-I injections demonstrated TPP-I in neurons of the striatum, hippocampus and Purkinje cells. For all three vectors, TPP-I activity in brain homogenates was 3-7-fold higher than endogenous levels in the injected hemispheres. Our results indicate the feasibility of vector-mediated gene transfer of TPP-I to the CNS as a potential therapy for LINCL.

Gene therapy for amyotrophic lateral sclerosis and other motor neuron diseases

There are several incurable diseases of motor neuron degeneration, including amyotrophic lateral sclerosis (ALS), primary lateral sclerosis, hereditary spastic hemiplegia, spinal muscular atrophy, and bulbospinal atrophy. Advances in gene transfer techniques coupled with new insights into molecular pathology have opened promising avenues for gene therapy aimed at halting disease progression. Nonviral preparations and recombinant adenoviruses, adeno-associated viruses, herpesviruses, and lentiviruses may ultimately transduce sufficient numbers of cerebral, brainstem, and spinal cord neurons for therapeutic applications. This could be accomplished by direct injection, transduction of lower motor neurons via retrograde transport after intramuscular injection, or cell-based therapies. Studies using transgenic mice expressing mutant superoxide dismutase 1 (SOD1), a model for one form of ALS, established that several proteins were neuroprotective, including calbindin, bcl-2, and growth factors. These same molecules promoted neuronal survival in other injury models, suggesting general applicability to all forms of ALS. Potentially correctable genetic lesions have also been identified for hereditary spastic hemiplegia, bulbospinal atrophy, and spinal muscular atrophy. Finally, it may be possible to repopulate lost corticospinal and lower motor neurons by transplanting stem cells or stimulating native progenitor populations. The challenge ahead is to translate these basic science breakthroughs into workable clinical practice.

Transduction of murine cerebellar neurons with recombinant FIV and AAV5 vectors

Our data demonstrate that vectors derived from recombinant feline immunodeficiency virus (rFIV) and adeno-associated virus type 5 (rAAV5) transduce cerebellar cells following direct injection into the cerebellar lobules of mice. Both recombinant viruses mediated gene transfer predominantly to neurons, with up to 2500 and 1500 Purkinje cells transduced for rAAV5 or rFIV-based vectors, respectively. The vectors also transduced stellate, basket and Golgi neurons, with occasional transduction of granule cells and deep cerebellar nuclei. rAAV5 also spread outside the cerebellum to the inferior colliculus and ventricular epithelium, while rFIV demonstrated the ability to undergo retrograde transport to the physically close lateral vestibular nuclei. Thus, AAV5 and FIV-based vectors show promise for targeting neurons affected in the hereditary spinocerebellar ataxias. These vectors could be important tools for unraveling the pathophysiology of these disorders, or in testing factors which may promote neuronal survival.

Quantitative analysis of converging spinal and cuneate mossy fibre afferent projections to the rat cerebellar anterior lobe

The convergence/divergence of mossy fibre afferent projections to the cerebellar anterior lobe from a single lumbar segment, from adjacent or widely separated lower thoracic and lumbar segments, and finally from the lower thoracic-upper lumbar spinal cord and the brainstem cuneate nuclei was quantitatively analysed in adult rats. Spinal and cuneate mossy fibre terminals were differentially labelled with biotinylated dextran amine and cholera toxin subunit B, immunohistochemically identified in the same histological sections, and their spatial distributions quantitatively plotted in computer reconstructions of the unfolded anterior lobe cortex. Afferent convergence was quantified by calculating the number of biotinylated dextran amine-labelled terminals that radially overlapped with cholera toxin-labelled terminals at points on the unfolded cortical map that represented theoretical Purkinje cells. Spino- and cuneocerebellar mossy fibre terminals are organized in patches that are oriented in parasagittally-oriented stripes or transversely oriented bands. Afferent convergence was greatest following biotinylated dextran amine and cholera toxin injections in the same or adjacent spinal lumbar segments (60 and 52%, respectively). When biotinylated dextran amine and cholera toxin were injected in a single segment differentially labelled terminals appeared randomly intermingled in common patches. There was a trend for terminals labelled from adjacent lumbar segments to be more segregated in the patches. Segmentally separated biotinylated dextran amine and cholera toxin spinal cord injections (four lumbar segments) resulted in clearly segregated (80%) biotinylated dextran amine from cholera toxin-labelled terminal patches or patches with distinct divergence of the differentially labelled terminals in the patch. Cuneocerebellar terminals labelled with biotinylated dextran amine were located in patches, stripes, and bands spatially segregated from terminal patches, stripes, and bands of cholera toxin-labelled spinal afferents except at their immediate borders where some radial overlap occurred (9-22%). These anatomical findings for a fractured somatotopy of spinal and cuneate inputs to the cerebellar anterior lobe complement neurophysiological findings for a very similar pattern of organization of cutaneous inputs to the posterior lobe, and are discussed in light of potential mechanisms for anterior lobe processing of somatosensory information.

Chronic NMDA receptor blockade or muscimol inhibition of cerebellar cortical neuronal activity alters the development of spinocerebellar afferent topography

The requirement for cerebellar cortical neuronal activity in the development of spinocerebellar afferent topography was investigated in neonatal rats. In adult rats lower thoracic-upper lumbar spinocerebellar projections are localized to sharply circumscribed patches in the granule cell layer of the cerebellar anterior lobe. In transverse sections these patches appear as sagittally oriented stripes. This pattern develops postnatally as many spinal axons which initially project between the incipient stripes are eliminated thereby sharpening the stripe boundaries. We attempted to alter cerebellar cortical neuronal activity in neonatal animals to study the effects of these changes on the development of spinocerebellar stripes. In some experiments glutaminergic excitatory synaptic transmission was chronically blocked with the N-methyl-D-aspartate (NMDA) receptor antagonist 2-aminophosphovaleric acid (APV). In other experiments postsynaptic activity was directly inhibited by the gamma-aminobutyric acid agonist muscimol. Chronic exposure to APV or to muscimol did not affect the initial development of spinocerebellar projections; many spinal axons were present in the anterior lobe and arranged in incipient stripes. Both the APV and the muscimol appeared to prevent the elimination of interstripe projections; consequently the boundaries of the stripes remained poorly defined. These findings suggest that cerebellar cortical neuronal activity is a necessary requirement for the refinement of spinal afferent topography in the anterior lobe.

Differential labeling of converging afferent pathways using biotinylated dextran amine and cholera toxin subunit B

We report a new technique for 2-tracer anterograde labeling that permits unequivocal identification of the differentially labeled projections in the same section. One pathway is labeled with biotinylated dextran amine and is visualized as a black to dark gray diaminobenzidine (DAB)-cobalt precipitate by an avidin-biotinylated peroxidase reaction. The other pathway is labeled with cholera toxin subunit B and is visualized as a reddish-brown reaction product using DAB without cobalt as the substrate for peroxidase immunohistochemistry. To maintain serial order, sections can be processed mounted on slides without any loss of sensitivity for either tracer.

Lower thoracic upper lumbar spinocerebellar projections in rats: a complex topography revealed in computer reconstructions of the unfolded anterior lobe

The topography of wheatgerm agglutinin-horseradish peroxidase/horseradish peroxidase-labeled mossy fiber terminals of lower thoracic-upper lumbar (T12-L3) spinal projections to the cerebellar anterior lobe was quantitatively analysed in adult rats. Computer-based image analysis mapped the orthogonal (parallel to the surface) distribution of labeled terminals in two-dimensional reconstructions of the unfoled anterior lobe cortex. The radial (perpendicular to the surface) distribution of terminals within the granule cell layer was mapped by computing whether the terminals were in either the outer- or inner-halves of this layer. The number of labeled terminals in each lobule was calculated. In the anterior lobe, lower thoracic-upper lumbar spinocerebellar projections terminate primarily in lobules II (mean 27.14%), III (mean 38.68%), and IV (mean 19.31%). Different-sized bilateral injections restricted to L1 were used to study the organization of intrasegmental spinocerebellar projections. Small injections into L1 labeled a limited number of terminals which were located either in clusters or were spatially isolated. Intermediate-sized intrasegmental injections resulted in additional clusters of labeled terminals. Many of the terminal clusters were spatially related and formed larger irregularly shaped patches. Large intrasegmental injections labeled terminal clusters and patches that were discontinuous but aligned parallel to the longitudinal (transverse) axis of lobules II-IV. Injections including segments rostral and caudal to L1 were used to study the topography of intersegmental lower thoracic-upper lumbar spinocerebellar projections. Multisegmental injections increased the number of labeled terminal clusters and patches which obscured the pattern of segmental input, but there was still a transversely oriented pattern of termination. Distinct transversely aligned terminal free areas remained apparent. Lower thoracic-upper lumbar spinocerebellar projections terminated in both the outer- and inner-halves of the granule cell layer, but overall were more numerous in the outer-half of this layer. In serially spaced sagittal sections, however, the majority of terminals alternated between the outer- and inner-halves of the granule cell layer. Outer- and inner-terminals were not spatially segregated in their orthogonal distribution. These results indicate lower thoracic-upper lumbar spinocerebellar projections have a complex three-dimensional topography in the anterior lobe. These findings are discussed in relation to previous findings for a sagittally oriented topography for lower thoracic-upper lumbar spinocerebellar projections and in the context of how cerebellar somatosensory afferent input may be organized.

The postnatal spatial and temporal development of corticospinal projections in cats

Orthograde labeling and immunocytochemical techniques were used to study the postnatal spatial and temporal development of corticospinal projections in cats. Findings from the orthograde labeling studies indicate that there are three major phases in the spatial development of corticospinal projections: an early period (1-10 postnatal days) when cortical axons grow into the spinal gray from the white matter; an intermediate period (2-5 postnatal weeks) where corticospinal axons develop terminal arborizations in a rostral to caudal, medial to lateral and intermediate gray to dorsal and ventral horn sequence; and, a late period (6-7 postnatal weeks) during which some corticospinal projections are eliminated. The time period over which cortical axons grow into the spinal cord was determined immunocytochemically using a monoclonal antibody against a microtubule associated protein (MAP 1B) present in growing axons. The corticospinal tracts were strongly immunoreactive for MAP 1B during the first three postnatal weeks. MAP 1B immunostaining of these tracts started to decline in the fourth postnatal week and was completely absent by five weeks of age. These findings indicate that the postnatal development of corticospinal projections is spatially and temporally protracted in cats.