Is aceruloplasminemia treatable? Combining iron chelation and fresh-frozen plasma treatment

We report the case of a patient with hereditary ceruloplasmin deficiency due to a novel gene mutation in ceruloplasmin gene (CP), treated with fresh frozen plasma (FFP) and iron chelation therapy. A 59-year-old man with a past history of diabetes was admitted to our department due to progressive gait difficulties and cognitive impairment. Neurological examination revealed a moderate cognitive decline, with mild extrapyramidal symptoms, ataxia, and myoclonus. Brain T2-weighted MR imaging showed bilateral basal ganglia hypointensity with diffuse iron deposition. Increased serum ferritin, low serum copper concentration, undetectable ceruloplasmin, and normal urinary copper excretion were found. The genetic analysis of the CP (OMIM #604290) reported compound heterozygosity for two mutations, namely c.848G > A and c.2689_2690delCT. Treatment with FFP (500 mL i.v./once a week) and administration of iron chelator (Deferoxamine 1000 mg i.v/die for 5 days, followed by Deferiprone 500 mg/die per os) were undertaken. At the 6-month follow-up, clinical improvement of gait instability, trunk ataxia, and myoclonus was observed; brain MRI scan showed no further progression of basal ganglia T2 hypointensity. This case report suggests that the early initiation of combined treatment with FFP and iron chelation may be useful to reduce the accumulation of iron in the central nervous system and to improve the neurological symptoms.

Clinical pharmacology and vascular risk

Pharmacological treatment and several drugs of abuse have been associated with ischemic heart disease (IHD) and cerebrovascular diseases (CVD). However, there is a paucity of data on the independent risk of vascular disease (VD) associated with pharmacological treatment and no controlled trials demonstrating a reduction in risk with abstinence. Information about IHD and CVD-related drug abuse is mainly limited to epidemiological studies focused on urban populations. The potential link between some pharmacological treatments (estrogen, some oncologic drugs and some atypical antipsychotics) and cerebrovascular adverse events was analyzed, but disagreement about an association persists. Drugs of abuse, including cocaine, amphetamines and heroin, have been associated with an increased vascular risk. These drugs can cause abrupt changes in blood pressure, vasculitic-type changes, lead to embolization caused by infective endocarditis, and hemostatic and hematologic abnormalities that can result in increased blood viscosity and platelet aggregation. Long-term treatment strategies based on medication, psychological support, and outreach programs play an important role in treatment of drug dependency. In these last years public interest in risk factors for VD has been constantly increasing and the successful identification and management of pharmacological treatment and drug abuse can be challenging. One of the major public health issues for the future will be to focus more on new vascular risk factor recognition and management. The objective of this chapter is to review the relevance of IHD and CVD associated with various pharmacological treatments and drug abuse with focusing on ischemic disease. This chapter reports the clinical evidence of this association and analyzes the experimental role of new drugs as a growing risk factor of VD with the hypothetical new association. In conclusion, in this chapter great attention is paid to evaluating the scientific and real evidence of cerebrovascular effect and drug use and abuse so as to identify a new groups of "modifiable" risk factors.

Mild hyperhomocysteinemia is a risk-factor in all etiological subtypes of stroke

The role of hyperhomocysteinemia as independent risk factor for stroke needs to be confirmed. The aims of our study were to assess (i) the association between risk of stroke and increasing values of plasma homocysteine and (ii) the interaction between mild hyperhomocysteinemia and conventional vascular risk factors. We studied 161 consecutive patients with first-ever ischemic stroke classified using TOAST criteria and 152 neurologically healthy controls. Homocysteine was measured using high performance liquid chromatography (HPLC). Homocysteinemia was elevated in all stroke subtypes: 13.0+/-2.5 micromol/l in patients with cardioembolic disease, 13.9+/-5.4 micromol/l in those with small vessel diseases, 15.5+/-6.8 micromol/l in cases of undetermined stroke, and 17.8+/-13.5 micromol/l in patients with large vessel disease. Mean homocysteinemia was 8.10 micromol/l (SD=2.5) in controls. The logistic regression analysis showed that important independent risk factors for ischemic stroke were hypertension (p<0.0001; OR= 3.205; 95% CI, 1.788-5.742), hyperhomocysteinemia (p<0.0001; OR=1.425; 95% CI, 1.300-1562) and hyperlipidemia (p=0.018; OR=2.243; 95% CI, 1.147-4.385). Hyperhomocyst(e)inemia is an independent risk factor for all stroke subtypes and should be routinely measured and treated in stroke patients.

Cerebrospinal fluid biochemical markers in early detection and in differential diagnosis of dementia disorders in routine clinical practice

Measurement of total tau and amyloid beta1-42 (Ab42) in cerebrospinal fluid (CSF) improves diagnostic accuracy of Alzheimer's disease (AD). We examined a consecutive patient sample referred to our center for diagnostic assessment of cognitive decline. CSF tau and Abeta42 were assayed each week as routine neurochemical analyses. There were 119 patients investigated. These included 61 with probable AD (35 mild AD, 26 severe AD), 24 with mild cognitive impairment (MCI), 14 with vascular dementia, 11 with Lewy body dementia, and 9 with fronto-temporal dementia. Mild AD showed significantly lower CSF Abeta42 levels and significantly higher CSF tau levels than the other diagnostic groups; 79% of MCI patients had pathological values for both biomarkers. We confirm that these biomarkers have a role in the clinical work-up of patients with cognitive deficits.

Cerebrospinal fluid levels of biomarkers and activity of acetylcholinesterase (AChE) and butyrylcholinesterase in AD patients before and after treatment with different AChE inhibitors

In order to evaluate the biochemical effects of long-term treatment with inhibitors of acetylcholinesterase (AChE) in patients with Alzheimer's disease (AD), we measured the activities of AChE and butyrylcholinesterase (BuChe) and the concentrations of beta-amyloid (1-42), tau and phosphorylated tau proteins in the cerebrospinal fluid (CSF). A total of 91 patients suffering from probable AD of mild to moderate degree were treated for 6 months with donepezil (n=59), galantamine (n=15), rivastigmine (n=10), or placebo (n=7). AChE activity in CSF was significantly increased after treatment with donepezil and galantamine; the opposite was observed in the rivastigmine-treated group. Untreated patients did not show any AChE activity variation. BuChE did not show any change in any of the groups studied. Mean values of beta-amyloid(1-42), total tau and phosphorylated tau also did not vary significantly. We conclude that AChE inhibitors induce different effects on CSF AChE activity, while other CSF biomarkers are not significantly affected by treatment.

Pharmacological treatment of non-cognitive disturbances in dementia disorders

Behavioral and psychological symptoms of dementia (BPSD) occur in 50-90% of patients with Alzheimer's disease (AD). They cause premature institutionalization, increased costs of care and significant loss of quality-of-life for the patient and his/her family and caregivers. Non-pharmacological interventions are first-line in dealing with milder BPSD, while for moderate to severe BPSD, medication is clearly indicated in conjunction with non-pharmacological interventions. An imbalance of different neurotransmitters (acetylcholine, dopamine, noradrenaline, serotonin) has been proposed as the neurochemical correlate of BPSD. An involvement of some specific brain regions responsible for emotional activities (parahippocampal gyrus, dorsal raphe, locus coeruleus) and cortical hypometabolism have been suggested to contribute to BPSD. Atypical or novel antipsychotic drugs represent the reference drugs for treating BPSD. Among these, risperidone is considered as a drug of choice. Also, selective serotonin reuptake inhibitors (SSRIs) are useful in the treatment of BPSD.

Cerebrospinal fluid acetylcholinesterase activity after long-term treatment with donepezil and rivastigmina

At present acetylcholinesterase (AChE) inhibitors (AChEIs) represent the only reliable therapeutic resource for symptomatic treatment of Alzheimer Disease (AD). This study was designed to assess the effects of 6-12 month treatment with AChEIs donepezil and rivastigmine on cerebrospinal fluid (CSF) AChE and butyrylcholinesterase (BuChE) activity in AD patients. The pattern of AChE isoforms (G4, G1, G2) before and after treatment was investigated as well. In AD patients treated with donepezil a significant increase of CFS AChE activity was observed, whereas treatment with rivastigmine induced a significant decrease of AChE activity. Both drugs did not change BuChE activity and tended to restore the physiological pattern of AChE isoform. The possible significance of the influence of AChEIs on CSF AChE activity and isoforms is discussed.

Plasma total homocysteine levels and the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene: a study in an Italian population with dementia

Hyperhomocysteinemia is a known risk factor for vascular disease and commonly occurs in the elderly. Several studies have shown an association between elevated plasma homocysteine levels and cognitive impairment, indicating that it may play a role in the pathophysiology of dementia. We studied plasma homocysteine, folate, vitamin B12 levels and the MTHFR C677T genotype in an Italian population of patients with dementia. We confirmed that elevated plasma tHcy (>14 micromol/l) is common in elderly subjects with dementia. Although we found a high prevalence of the MTHFR TT genotype (21.2%) the allele frequency is not over-represented relative to the control population. We also observed a high incidence of folate deficiency (38%) in subjects with dementia. Elevated homocysteine was associated with low plasma folate (<5.7 nmol/l) and the MTHFR TT genotype. Moderate to severe hyperhomocysteinemia (>26.1 nmol/l) was associated with a significantly lower MMSE score. Hyperhomocysteinemia may be neurotoxic by several different mechanisms affecting cognitive function. Further studies are needed to fully explore the potential of B vitamin supplementation to lower plasma homocysteine and improve cognitive function.

[Gastric duplication of 3 observations]

Gástric duplicación si an infrequent congenital malformation present in both, neonatal period and childhood, and exceptionally during adulthood. We present here there cases of gastric duplication from patients of different ages, in which it was not possible to make diagnosis before surgery. In all of them cystic form was the predominating one, without communication with gastric lumen (cavity). Diagnosis was performed after laparotomy and histopathological examination.

CSF phosphorylated tau is a possible marker for discriminating Alzheimer's disease from dementia with Lewy bodies. Phospho-Tau International Study Group

Tau and beta-amyloid (1-42) (Abeta42) are two independent markers for the early diagnosis of Alzheimer's disease (AD). In the present study, biochemical markers were validated as tools for differential diagnosis between AD and dementia with Lewy bodies (DLB). Tau, Abeta42 and phospho-tau (181P) were measured in cerebrospinal fluid (CSF) from controls (n=40) and from patients with AD (n=80) or DLB (n=43) using the HT7-AT270 assay (prototype version). In comparison with AD, in DLB no differences were found for Abeta42 and lower phospho-tau. ROC analysis was used to compare the discriminatory power of total tau with that of phospho-tau. The area under the curve (AUC) amounted to 0.782 +/- 0.048 (mean +/- SE) for tau and to 0.839 +/- 0.042 for phospho-tau (p = 0.039) for differentiation of AD from DLB. The present results indicate that CSF phospho-tau may be a good marker for differentiation between AD and DLB.

[Propafenone and verapamil poisoning. Report of 2 clinical cases]

We described the self-poisoning of two young adolescents who took improper doses of two major cardiovascular drugs: propafenone and verapamil. The young girls developed markedly different clinical patterns: ECG abnormalities without clinical consequences were found in one case progressively ingravescent ECG abnormalities leading to cardiac arrest in the other. These differences are probably due to varying doses taken and metabolic states. Conventional detoxication and resuscitation techniques proved successful in both cases.

Local renin-angiotensin system in human adrenals and aldosteronomas

The local renin-angiotensin system may regulate adrenal cell growth and function. Angiotensinogen, renin, and angiotensin converting enzyme gene expression were studied in four normal adrenal glands (removed from patients with renal carcinomas) and five aldosterone-secreting adenomas. Northern blot analysis showed expression of angiotensinogen messenger RNA (mRNA) in normal adrenals at levels approximately 35-fold lower than liver and sixfold lower than kidney. Similar angiotensinogen mRNA levels were present in two aldosteronomas, whereas a third had levels approximately 50% of those found in kidney. Renin mRNA was detectable in most normal adrenals and in three adenomas, one of which had relatively high renin mRNA levels. Angiotensin converting enzyme gene was expressed in adrenal tissue and in three adenomas. Portions from these normal adrenals and two of these aldosteronomas, as well as samples from two other adrenals and three aldosteronomas, were also studied in an in vitro superfusion system coupled with active renin radioimmunometric assay, angiotensin II/III, and aldosterone radioimmunoassay. Total amounts of active renin and angiotensin II/III released from normal adrenals during 270 minutes of superfusion were higher than the amounts released from aldosteronomas (312 +/- 35 versus 187 +/- 43 and 823 +/- 100 versus 436 +/- 55 pg/100 mg tissue, respectively; mean +/- SEM, p less than 0.05), whereas aldosterone release from the adenomatous tissue was approximately threefold higher (320 +/- 21 versus 115 +/- 18 ng/100 mg tissue; mean +/- SEM, p less than 0.01). Total amounts of active renin and angiotensin II/III released by normal or adenomatous adrenal samples exceeded threefold to fourfold the amounts extracted from similar samples of the same surgical specimen.(ABSTRACT TRUNCATED AT 250 WORDS)

Growth inhibition of fibroblasts by progesterone and medroxyprogesterone in vitro

This study was carried out to evaluate in vitro the beneficial effects observed in various aggressive fibromatoses (mediastinal, retroperitoneal, paraneoplastic fibrosis and desmoid tumors) after treatment with progesterone. Primary cultures of fibroblasts were prepared from fetuses of Swiss strain mice. Continuous fibroblast lines LM and Vero were also used. Moreover, cultures of non-fetal human fibroblast from skin and lung were employed. Epithelial tumor cell line HeLa was used as a control. All cultures were incubated with various doses of progesterone at concentrations from 1.4 X 10(-4) to 1.4 X 10(-3) M. Human cells and monolayers of fetal murine fibroblast were submitted to the action of medroxyprogesterone solution at the same concentrations as used for progesterone. Other steroids (estrone, estriol, testosterone and prednisolone) were used at the identical concentrations in the same vehicles. Progesterone affected all lines of fibroblasts studied and destroyed them within either 2-4 or 24-48 h depending on the steroid concentrations used. Medroxyprogesterone had a comparable effect on human cell lines and monolayers of fetal murine fibroblasts provided that the same ratio between the hormone concentration and the time of exposure was maintained. With higher medium concentrations shorter times of incubation were required for the destruction of fibroblast. However, to observe a degree of lysis similar to that elicited by progesterone, it was necessary to use 4 times higher concentrations of medroxyprogesterone. No effect on HeLa epithelial cells was observed nor were the controls affected by the steroids or diluents used at the appropriate concentrations. Results from incubation studies using monolayers of murine fibroblast and 14C-progesterone suggested that the cells were destroyed by the progesterone and not by a bioproduct of its metabolism.

[A possible treatment of hepatic tumors: ligation of the hepatic artery and perfusion with desoxigenated saline]

Hepatic artery ligation has been performed as a treatment for primary and metastatic tumors of the liver since they receive their blood supply from the hepatic artery. The results showed a slight and transient improvement because large tumors underwent extensive necrosis or diminished their growth rate. However, small metastatic growths that obtain oxygen by diffusion remain histologically viable, It would therefore be convenient to have a method that could produce an elective and controlled anoxia of the hepatic tissue. In this work we started on the hypothesis that if one could impede the reflux of portal blood through the hepatic sinusoids, and the reflux coming from collaterals of the hepatic artery, a controlled anoxia could be produced. On this premise desoxigenated saline was infused through the distal end of the ligated hepatic artery of mongrel dogs weighing 15-20 kg anesthetized with Embutal. With a flux of 500 ml/h maintained during 2 h slight lesions were produced similar to those resulting from hepatic artery ligation. With a flux of 1000 ml/h - pressure at the level of hepatic artery around 50 mm Hg during 1 h - centrilobular necrosis (area 3 of Rappaport) of moderate magnitude and irregular distribution was obtained. With a flux of 1000 ml/h during 2 h, extensive lesions in the same areas were produced and some of the dogs died a few days later. The lesions produced were those of ischemic massive necrosis or confluent submassive necrosis. Serum transaminases and alkaline phosphatase markedly increased during the first 20 days. Lesions were reversible since dogs' livers studied 20 days after ligation and infusion did not show significant lesions. We believe that this method could be attempted, with the necessary precautions, in cases of primary and metastatic tumors of the liver because the anoxia, and thus the extension of liver necrosis, can be controlled at will.

[Progressive decrease of the causes that maintain ventricular fibrillation after experimental coronary occlusion]

Progressive diminution of the causes that maintain ventricular fibrillation after coronary occlusion. Extracorporeal circulation was performed on a group of normal dogs in which a ligature was placed on the left anterior descending coronary artery, immediately beneath the bifurcation of the left coronary artery. The incidence of ventricular fibrillation was of 15 dogs out of 20 (table 1). In a control group without extracorporeal circulation ventricular fibrillation appeared in 24 dogs out of 30 (table 2). These results demonstrate that extracorporeal circulation performed with the idea of improving coronary circulation does not prevent ventricular fibrillation in coronary occlusion. In those dogs with the cross circulation, attempts to defibrillate the ventricles with an electric a.c. defibrillator (three electrical shocks applied directly on the myocardium every 4 or 5 minutes) were uniformly unsuccessful until a period ranging from 12 to 80 minutes elapsed after the onset of ventricular fibrillation. After these periods all fibrillating dogs were defibrillated and recovered either normal or idioventricular rhythm. It is assumed that a "fibrillator substance" liberated by the injury in the initial state of infarction is washed out of the myocardium, or a zone of increased excitability and conduction disturbance is progressively eliminated so that the chances of originating circus movements are diminished.