Cerebral amyloid angiopathy

Cerebral amyloid angiopathy affects the cerebral vasculature selectively, and there is no systemic amyloidosis. Amyloid is deposited in small and medium-sized vessels of the cortex and leptomeninges. Cerebral amyloid angiopathy is a common cause of spontaneous lobar haemorrhage in elderly patients. However, cerebral amyloid angiopathy may have atypical clinical and radiological presentations. We report on five patients (three males and two females, aged 43-77 years) with histologically verified cerebral amyloid angiopathy. One patient experienced an acute headache attack and classical lobar haemorrhage. The other patients had various neurological symptoms and signs, such as seizure, disturbed vision, pareses, aphasia, and dementia that were initially diagnosed as cerebral infarction or tumour. Two patients with cerebral amyloid angiopathy and granulomatous angiitis responded to immunosuppressive treatment.     

Cerebral amyloid angiopathy. A review

Cerebral amyloid angiopathy (CAA) is a condition characterized by amyloid deposition in cerebral blood vessels. It occurs most frequently in association with clinical Alzheimer's disease but also occurs in some nondemented elderly people. CAA is a cause of spontaneous cerebral hemorrhage and may therefore present as a sudden unexpected death in an elderly person. The amyloid is deposited in cortical blood vessels, and on hematoxylin-eosin sections takes the form of pink hyaline thickening of arteries and arterioles, often with narrowing of the lumina. For diagnosis apple-green birefringence after Congo red staining is the most widely practiced and reliable tool. CAA-related hemorrhage may also occur in any lobe of the cerebrum close to the external surface and may occur at multiple sites and at the same or different times. CAA-related hemorrhage may occur in the setting of trauma necessitating distinction between the two and raising the question of whether it precipitated trauma or vice versa. Usually CAA-related hemorrhage is infrequent in sites where traumatic hemorrhages occur, and traumatic hemorrhages are often associated with other hemorrhages in sites typical for trauma. Five cases demonstrating many of the clinical and pathological features of CAA-related hemorrhage are presented. In two of the five cases, the hemorrhage followed trauma, suggesting that trauma as a precipitating factor for CAA-related hemorrhage may be more common than is generally recognized. CAA-associated hemorrhage should be considered in the differential diagnosis of cerebral hemorrhage in the elderly whether or not dementia is present.     

Cerebral amyloid angiopathy: amyloid beta accumulates in putative interstitial fluid drainage pathways in Alzheimer's disease

Cerebral amyloid angiopathy in Alzheimer's disease is characterized by deposition of amyloid beta (Abeta) in cortical and leptomeningeal vessel walls. Although it has been suggested that Abeta is derived from vascular smooth muscle, deposition of Abeta is not seen in larger cerebral vessel walls nor in extracranial vessels. In the present study, we examine evidence for the hypothesis that Abeta is deposited in periarterial interstitial fluid drainage pathways of the brain in Alzheimer's disease and that this contributes significantly to cerebral amyloid angiopathy. There is firm evidence in animals for drainage of interstitial fluid from the brain to cervical lymph nodes along periarterial spaces; similar periarterial channels exist in humans. Biochemical study of 6 brains without Alzheimer's disease revealed a pool of soluble Abeta in the cortex. Histology and immunocytochemistry of 17 brains with Alzheimer's disease showed that Abeta accumulates five times more frequently around arteries than around veins, with selective involvement of smaller arteries. Initial deposits of Abeta occur at the periphery of arteries at the site of the putative interstitial fluid drainage pathways. These observations support the hypothesis that Abeta is deposited in periarterial interstitial fluid drainage pathways of the brain and contributes significantly to cerebral amyloid angiopathy in Alzheimer's disease.     

Cerebral amyloid angiopathy and plaques, and visceral amyloidosis in aged macaques

BACKGROUND: We wanted to verify whether the calculations of segmental tubular reabsorption obtained during water diuresis were supported by direct micropuncture measurements. METHODS: Experiments were performed on 18 rats during baseline water diuresis (B) and after the administration of frusemide (F), 10 mg/kg, by whole-kidney clearance measurements and micropuncture collections from early distal (ED) and last proximal (LP) tubular segments. RESULTS: GFR was 957+/-79 in B, 1053+/-77 microl/min in F, P>0.013. SNGFR was 38+/-1 in 166 and 38+/-1 nl/min in 165 tubules respectively, P>0.77. In LP collections the percentage reabsorption was 71+/-2 in B and 76+/-2% during F (P>0.07) in 99 and 95 samples respectively. The absolute proximal reabsorption was not changed by F (27.6+/-1.5 versus 27.7+/-1.3 nl/min, P>0.96) The data were superimposable when the analysis was restricted to paired data. The difference between ED and LP resorption was 17+/-3 during B and fell significantly (P<0.008) to 5+/-3% during F, measured by clearance techniques, and the percentage of GFR excreted during F, measured by clearance techniques, and the percentage delivery of filtrate beyond the proximal tubule, measured independently by micropuncture, were not different (27+/-2 versus 24+/-2%, P>0.10), while they were significantly correlated (P<0.04). The calculations of segmental Na reabsorption along the different nephron segments by clearance techniques were not significantly different from and were significantly correlated with the reabsorptions measured directly by micropuncture. CONCLUSIONS: The present experiments validate the calculations of reabsorption by techniques applicable to human studies of clinical physiology.     

Butyrylcholinesterase K variant and cerebral amyloid angiopathy

BACKGROUND and PURPOSE: Cholinesterases are found histochemically in the vessels affected with cerebral amyloid angiopathy (CAA). A gene for the K variant of butyrylcholinesterase (BCHE-K) may be associated with late-onset Alzheimer's disease (AD). In search of genetic risk factors for CAA, we investigated the association of BCHE-K with CAA. METHODS: The association between the severity of CAA and BCHE-K was investigated in 155 autopsy cases of the elderly, including 48 patients with AD. RESULTS: There was no significant association of BCHE-K with the severity of CAA in the total, AD, or non-AD cases. Status of the epsilon4 allele of apolipoprotein E gene did not influence the results. CONCLUSIONS: Our results may suggest that BCHE-K is not a definitive risk factor for CAA in the elderly, although further study with larger samples is necessary to confirm this.     

Association of apolipoprotein E epsilon2 and vasculopathy in cerebral amyloid angiopathy

Endogenous opioid peptides appear to be involved in acute behavioral effects induced by single doses of ethanol. However, its role in repeated ethanol exposure has not been studied. In the present study ethanol was given to rats at the doses of 2 and 4 g/kg by a stomach gauge for 15 days, and its effects on spontaneous motility, open-field activity, and active avoidance behavior recorded on the 3rd, the 6th and the 15th days. Then the effect of naloxone (0.5 and 2 mg/kg by intraperitoneal route) was tested against a challenge ethanol dose, administrated by oral route, on the 16th day. Control animals received tap water and saline instead of ethanol or naloxone, respectively. Both doses of ethanol induced a decrease in spontaneous motility that was antagonized by naloxone. Open-field ambulations were increased by the high dose of ethanol, low-dose lacking effect; naloxone did not modify these ethanol effects. The low dose of ethanol shortened latency time in shuttlebox, the high dose causing escape and freezing responses; none of these effects were modified by naloxone. Therefore, endogenous opioid peptides appear to play a limited role in the chronic effects of ethanol in rats; particularly its effects in tests inducing an increase in the level of anxiety were resistant to naloxone.     

Oral candidiasis: clinical manifestations, diagnosis, and treatment

Oral candidiasis (candidosis) is an infection with multiple manifestations. To prevent prolongation of undiagnosed cases, it is essential that the dental clinicians have an understanding of the etiology, pathogenesis, and treatment of this disease. The learning objective of this article is the identification of the various clinical features of candidiasis. The underlying causes of oral candidiasis include antibiotic therapy, poor denture hygiene, xerostomia, immune deficiencies, diabetes, and some less common conditions. Candidal infection may be superimposed on other mucosal diseases and may disguise the underlying disease. The diagnosis is established using clinical appearance and patient history, and it may require diagnostic tests. A significant segment of the population carries intraoral Candida, without any symptoms of infection, complicating the use of diagnostic tests.     

The watermelon stomach: clinical presentation, diagnosis, and treatment

The watermelon stomach syndrome is an increasingly recognized cause of persistent acute or occult gastrointestinal bleeding, typically in elderly women. This disorder often presents with severe iron deficiency anemia, and a variety of associated conditions including autoimmune disease, cirrhosis, achlorhydria, and hypochlorhydria. Diagnosis is made by the characteristic endoscopic appearance of visible linear watermelon-like vascular stripes in the antrum. Histology confirms the vascular nature of this disorder, showing dilated and thrombosed capillaries in the lamina propria, associated with reactive fibromuscular hyperplasia. The optimum treatment of choice is not known. Several treatment options, including surgical antrectomy, and endoscopic photocoagulation with Nd:Yag laser, heater probe therapy, and bipolar electrocautery, have yielded excellent results. Pharmacological agents have also been used to treat selected numbers of patients, most of which comprise a small number of case reports.     

Female idiopathic urethra tumor: clinical features diagnosis and treatment]

Female idiopathic urethra tumors are reported rarely. We treated fourteen patients patients, and described the clinical manifestations and local features of the tumors, urethra liomyoma, and fibropolypus. We found that there are close relations among tumor stage, prognosis and pathological classification. The main diagnostic methods include vaginal touch, urethroscopy, B-ultrasound exam and biopsy. The diagnostic procedure recommended is tumor location-quality-stage or a three-step method. The main treatment is operation, however, the operative mode should depend on tumor stage and patient's life quality after operation.     

Small-cell lung cancer: treatment progress and prospects

Although small-cell lung cancer (SCLC) represents only 20% of all lung cancer cases in the United States, it is the most lethal subtype. Combination chemotherapy unequivocally offers the best chance for improved survival in SCLC. Either PE (platinum plus etoposide) or CAV (cyclophosphamide, Adriamycin, and vincristine) is a reasonable first-line therapy. Alternating PE with CAV does not appear to be significantly superior to PE or CAV alone. Increasing dose intensity, although sometimes associated with higher response rates, does not appear to significantly improve survival and should not be used outside of a clinical study. Several new agents with novel mechanisms of action show promise in treating SCLC. These include: gemcitabine (Gemzar), paclitaxel (Taxol), docetaxel (Taxotere), topotecan (Hycamtin), and irinotecan (Camptosar). Given the poor survival and response rates in relapsed patients and the chemoresponsiveness of SCLC, patients with newly diagnosed extensive disease should be encouraged to enroll in phase I or II trials. Thoracic radiotherapy confers a small survival advantage in limited-stage SCLC patients. Although prophylactic cranial irradiation does not significantly improve survival, it does reduce central nervous system (CNS) recurrences with minimal long-term sequelae. Surgery should be considered only for: (1) resection of a solitary pulmonary nodule, which must be followed by adjuvant chemotherapy; and (2) resection of an unresponsive chest tumor, which may harbor a non-small-cell lung cancer component.     

Clostridium difficile-associated diarrhea and colitis: clinical manifestations, diagnosis, and treatment

PURPOSE: This review examines the pathogenesis, clinical manifestations, diagnosis, and current medical and operative strategies in the treatment of Clostridium difficile diarrhea and colitis. Prevention and future avenues of research are also investigated. METHODS: A review of the literature was conducted with the use of MEDLINE. RESULTS: C. difficile is a gram-positive, spore-forming bacterium capable of causing toxigenic colitis in susceptible patients, usually those receiving antibiotics. Overgrowth of toxigenic strains may result in a spectrum of disease, including becoming an asymptomatic carrier, diarrhea, self-limited colitis, fulminant colitis, and toxic megacolon. Diagnosis requires a high index of suspicion and depends on clinical data, laboratory stool studies (enzyme-linked immunoabsorbent assay and cytotoxin test), and endoscopy in selected cases. Protocols for treatment of primary and relapsing infections are provided in algorithm format. Discontinuation of antibiotics may be enough to resolve symptoms. Medical management with oral metronidazole or vancomycin is the first-line therapy for those with symptomatic colitis. Teicoplanin, Saccharomyces spp. and Lactobacillus spp., and intravenous IgG antitoxin are reserved for more recalcitrant cases. Refractory or relapsing infections may require vancomycin given orally or other newer modalities. Fulminant colitis and toxic megacolon warrant subtotal colectomy. Cost, in terms of extended hospital stay, medical and surgical management, and, in some cases, ward closure, is thought to be formidable. Review of perioperative antibiotic policies and analysis of hospital formularies may contribute to prevention and decreased costs. CONCLUSION: C. difficile diarrhea and colitis is a nosocomial infection that may result in significant morbidity, mortality, and medical costs. Standard laboratory studies and endoscopic evaluation assist in the diagnosis of clinically suspicious cases. Appropriate perioperative antibiotic dosing, narrowing the antibiotic spectrum when treating infections, and discontinuing antibiotics at appropriate intervals prevent toxic sequelae.     

Xenotransplantation: risks, clinical potential, and future prospects

Psychodynamic clinical studies as well as empirical research have pointed out the importance and the specificity of object relations in eating disorders. Given this, the aim of this work was to identify the presence of significant differences in the object relations patterns, as described by the Parental Bonding Instrument (PBI), between anorectic and bulimic subjects. PBI was administered to 42 anorectic female and 26 bulimic female subjects, consecutively admitted to the Eating Disorders Outpatient Unit of H San Raffaele of Milan. Profile analysis revealed the presence of significant (T2 = 11.3453, d.f. 3,64, p = 0.017) qualitative differences in PBI profiles between anorectic and bulimic subjects. The most striking difference was represented by the bulimics' view of their parents as both caring and overwhelming, which contrasted with the anorectics' perception of their parents as absolutely caring.