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PATHOLOGIC FEATURES OF GLOM ERULOSCLEROSIS ASSOCIATED W ITH HUM AN IM M UNODEFICIENCY VIRUS INFECTION Collapsed glomerular capillaries Visceral glomerular epitheliosis Microcystic tubules with variegated casts Focal tubular simplification Interstitial lymphocytic infiltration Endothelial reticular inclusions FIGURE 7-26 Pathologic features of glom erulosclerosis purchase 100mg kamagra chewable mastercard. N one of the features list- FIGURE 7-25 ed is pathognom onic purchase kamagra chewable 100 mg mastercard. The concom itant presence of glom erular and Ultrasonography of a hyperechogenic 15-cm kidney in a patient tubular lesions with tubuloreticular inclusions in the glom erular with H IV-associated glom erulosclerosis, nephrotic syndrom e, and and peritubular capillary endothelial cells, however, is highly sug- renal failure. Renal Disease in Patients Infected with Hepatitis and Human Immunodeficiency Virus 7. M icrograph of a m ore FIGURE 7-27 advanced stage of glom erulosclerosis with large hyperplastic viscer- Glom erulosclerosis. M icrograph of segm ental glom erulosclerosis al epithelial cells loaded with hyaline protein droplets, interstitial with hyperplastic visceral epithelial cells (arrows). FIGURE 7-29 FIGURE 7-30 Collapsing glom erulosclerosis. M icrograph of global collapsing Dilated m icrocystic tubules. M icrograph of m assively dilated m icro- glom erulosclerosis. In the cystic tubules filled with variegated protein casts adjacent to nor- sam e patient, norm al glom eruli, glom eruli with segm ental sclerosis, m al-sized glom eruli. The and glom eruli with global sclerosis m ay be found [172]. The tubulointerstitial changes likely play an im portant role in the pathogenesis of the renal insufficiency and offer one explanation for the rapid decrease in renal function. M icrograph of diffuse m esangial hyperplasia in a child with perinatal AIDS and nephrotic syndrom e. Both diffuse and global m esangial hyperplasia are identified in 25% of children with perinatal AIDS and protein- uria. The characteristic m icrocystic tubular dilations and the kidney enlargem ent of glom erulosclerosis associated with hum an im m un- odeficiency virus infection are absent in patients with diffuse m esan- gial hyperplasia. M icrograph of tubuloreticular cytoplasmic inclusions in glomerular endothelial cell. The latter are virtually diagnostic of nephropathy associated with HIV infection, provided systemic lupus erythematosus has been excluded. On immunofluo- rescent examination, findings in the glomeruli are nonspecific and similar in HIV-associated glom erulosclerosis and idiopathic focal segm ental glom erulosclerosis. These findings consist largely of immunoglobulin M and complement C3 deposited in a segmental granular pattern in the m esangium and capillaries. The sam e deposits also occur in 30% of patients with AIDS without renal disease [134,163,167]. FIGURE 7-33 HIV infection Possible pathogenic m echanism s of glom erulosclerosis associated with HIV infection. HIV-associated glomerulosclerosis is not the result of opportunistic infections. Indeed, the nephropathy m ay be the first m anifestation of H IV infection and often occurs in patients HIV in glomerular, tubular HIV in lymphocytes, before opportunistic infections develop. H IV-associated glom eru- epithelial cells monocytes losclerosis also is not an im m une-com plex-m ediated glom erulopathy because im m une deposits are generally absent. Three m echanism s have been proposed: direct injury of renal epithelial cells by infective H IV, although direct renal cell infection has not been dem onstrated Cytopathic HIV gene Cytokines, conclusively and systematically; injury by HIV gene products; or injury effects products growth factors by cytokines and growth factors released by infected lymphocytes and m onocytes system ically or intrarenally or released by renal cells after uptake of viral gene products. The variable susceptibility to Glomerular epithelial cell proliferation Tubular epithelial cell apoptosis and proliferation glom erulosclerosis also suggests that unique viral-host interactions m ay be necessary for expression of the nephropathy [132,156,166,173–175]. Glomerulosclerosis Tubular microcysts Renal Disease in Patients Infected with Hepatitis and Human Immunodeficiency Virus 7. HIV-associated glomerulosclero- FIGURE 7-35 sis has been viewed as a complication that occurs either as a direct Treatm ent of glom erulosclerosis. There have been no prospective cellular effect of HIV infection or HIV gene products in the kidney, controlled randomized trials of any therapy in patients with nephropa- as an indirect effect of the dysregulated cytokine milieu existing in thy associated with H IV infection. Thus, the optim al treatm ent is patients with acquired immunodeficiency syndrome, or both.

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Proc Natl Acad Sci high molecular weight tau present in the peripheral nervous USA 1997;94:4113–4118 cheap 100 mg kamagra chewable with amex. Neuroscience 1984;11: and association of A beta 40 with cored plaques order 100mg kamagra chewable amex. Proc Natl Acad Sci USA 1981; mer neurofibrillary tangles in diseases other than senile and 78:3269–3273. Frequency of stages of Alzheimer-related tion of axonal microtubules. Paired helical filaments in electron microscopy of Alz- and nonuniformity in the dendrite. Microtubule densities and total numbers in selected Alzheimer paired helical filaments: abnormal phosphorylation axons of the crayfish abdominal nerve cord. Projection domains of MAP2 mer paired helical filament. Acta Neuropathol 1996;92:42– implications for the microtubule-associated protein tau: locali- 48. Lab Invest 1991;64: phorylated tau protein segregates to the somatoaxonal compart- 693–702. Tau pathol- factor-induced neurite outgrowth in PC12 cells involves the coordinate induction of microtubule assembly and assembly- ogy in two Dutch families with mutations in the microtubule- promoting factors. Ultrastructure tubule protein levels during cellular morphogenesis in nerve and biochemical composition of paired helical filaments in corti- growth factor-treated PC12 cells. Microtubule formation and sequencing of the cDNA encoding a core protein of the paired neurite growth in cerebellar macroneurons which develop in helical filament of Alzheimer disease: identification as the micro- vitro: evidence for the involvement of the microtubule-associ- tubule-associated protein tau. Proc Natl Acad Sci USA 1988;85: ated proteins, MAP-1a, HMW-MAP2 and Tau. A protein is tightly bound to paired helical filaments. Neuron 1988;1: factor essential for microtubule assembly. Modulation of gragment of tau derived from the core of the paired helical the dynamic instability of tubulin assembly by the microtubule- filament of Alzheimer disease. Proc Natl Acad Sci USA 1988; associated protein tau. Epitopes that span the sense oligonucleotides in primary cerebellar neurons. Nature tau molecule are shared with paired helical filaments. A68: a major subunit of oligonucleotides on neurite formation of cultured cerebellar ma- paired helical filaments and derivatized forms of normal tau. Straight and paired helical filaments in Alzheimer nization in small-calibre axons of mice lacking tau protein. The distribution of tau tivity, and impairment in fear conditioning in tau-deficient in the mammalian central nervous system. Dephosphoryla- associated protein tau containing four tandem repeats: differen- tion of tau protein and Alzheimer paired helical filaments by tial expression of tau protein mRNAs in human brain. Expression of separate isoforms of human filament tau. Tau protein binds to microtubules recapitulates phosphorylation during development. Proc Natl through a flexible array of distributed weak sites. Identification of a novel microtubule in human, primate, and rat brain: evidence that a pool of tau binding and assembly domain in the developmentally regulated is highly phosphorylated in vivo and is rapidly dephosphorylated inter-repeat region of tau. Biopsy-derived between the proline-rich and repeat regions of tau enhance mi- adult human brain tau is phosphorylated at many of the same crotubule binding and assembly. Proc Natl Acad Sci USA 1992;89:1983– phosphorylation at specific sites.

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Subse- quently order kamagra chewable 100mg line, the other 'new' antipsychotics have been tested and have generated results consistent with clinical data generic kamagra chewable 100 mg on line, demonstrating low TD potential for the second-generation antipsychotics (29,39). Neither olanzapine nor sertindole produce the CM syndrome at drug doses that produce human therapeutic plasma levels in the animals (21); risperi- done at low doses is not associated with CMs, whereas high doses produce haloperidol-like CMs (Gao, unpublished ob- servations). Data using quetiapine or ziprasidone in this animal model have not been reported. NEUROCHEMICAL CHANGES WITHIN THE BASAL GANGLIA THALAMOCORTICAL PATHWAYS IN A RODENT MODEL OF TARDIVE DYSKINESIA We designed and carried out a series of studies in a putative rodent model of TD based on the broadly accepted, func- FIGURE 126. Specific binding of 3H-spiperone to D2-familydo- tional architecture of the basal ganglia and thalamus already pamine receptors in the nucleus accumbens of control and chroni- described. These studies were based not only on the exis- callyhaloperidol-treated rats. D2 binding data were similar in the tence of these theoretic models, but also on early experimen- caudate and putamen. Significant dopamine-receptor up-regula- tal data in nonhuman primates with chronic antipsychotic tion was apparent in the haloperidol-treated rats with chewing movements (CMs) and in those without CMs; there was no appar- treatment implicating GABAergic transmission in TD (30, ent difference between CM and non-CM rats in the magnitude 31). The drug- and time-induced changes in GABAergic of increase. Haloperidol Haloperidol Olanzapine, Sertindole, + VCMs – VCMs no VCMs no VCMs Striatum ↑D2R, ↑GAD ↑D2R, ↑GAD S1 ↑D2 o ∆ D2R No ∆ GAD ↑GAD Globus pallidus ↓GAD, No ∆ GAD, No ∆ GAD No ∆ GAD, ↓GABAA o ∆ GABAA o ∆ GABAAR ↓GABAAR Substantia nigra ↑GABAAR Tr ↑GABAAR∆ Nl, GABAAR Nl, GABAAR1 pars reticulata ↓D1 o ∆ D1 o ∆ D1 o ∆ D1R MD thalamus ↑GABAA o ∆ GABAA o ∆ GABAA o ∆ GABAAR GABAAR/ No correlation No correlation No correlation VCM correlation Right thalamus ↑GAD mRNA ↑GAD mRNA ↑GAD mRNA ↑GAD mRNA arrow, significant change; D1R, D1 family dopamine receptor; D2R, D2 family dopamine receptor; GABAAR, GABAA receptor; GAD, glutamic acid decarboxylase mRNA; Tr, trend; VCMS, vacuous chewing movements. Here the CM rats show reduced efferent pathway to thalamus. A reduction in GABA-me- nigral D1-receptor numbers, whereas the non-CM treated diated transmission from SNR to the target nucleus in the rats show no change in D1-receptor density (Fig. In the haloperidol-treated animals, a significant eleva- treatment with the GABA agonist progabide (Fig. The reduction in D1-receptor CMs in the mediodorsal thalamus (Fig. This posi- number in SNR could be associated with an antipsychotic- tive correlation implicates a nigral D1 defect along with induced increase in the dendritic release of dopamine (Fig. The Hence, an increase in dopamine release within SNR could idea that a reduction in the activity of the basal ganglia mediate the release of GABA at striatonigral terminals and output nuclei disinhibits the thalamus and is associated with subsequently could inhibit activity in the GABA-mediated drug-induced rat hyperkinetic oral CMs is consistent with the already established functional models of these interac- tions (2). Two second-generation antipsychotics tested in the same animal chronic treatment paradigm differed from haloperi- dol in their actions. Both olanzapine and sertindole, each at two doses, were compared with haloperidol after 6 months of treatment (56). Neither olanzapine nor sertin- dole substantially up-regulated striatal D2 binding in the rat, even though we know from human studies that D2 blockade of some strength and duration occurs with each of these drugs (21). Because of the relatively high receptor affinities of these drugs at the D2 receptor, the data suggest that any regional reduction in blockade may occur only at some of the D2 receptors, and the resultant antidopami- nergic action is weaker or of a reduced duration than with haloperidol. Nonetheless, olanzapine shows mild, haloperi- dol-like actions in striatum, and sertindole shows mild, FIGURE126. Specific bindingof 3H-SCH23390to D1-familydo- pamine receptors in the substantia nigra pars reticulata (SNR). Still, in SNR, nei- binding was down-regulated bychronic haloperidol (HAL) treat- ther new compound is associated with D1-receptor down- ment onlyin the rats that displayed the vacuous chewing move- regulation or GABA up-regulation (Table 126. This reduction was blocked bythe GABA agonist progabide (P), as were the CMs themselves. Progabide alone had GABAA receptors altered in mediodorsal thalamus by either no effect on the D1 binding. It is possible Chapter 126: Tardive Dyskinesia 1837 FIGURE126. Hypotheticalmodelforthe mechanism of chronic haloperidol-induced chewing movements (CMs) in rat. The data collected can be parsimoniouslyexplained bypostulating an increase in dendritic do- pamine release associated with the devel- opment of dyskinetic movements in the CM rats.

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Evidence has been obtained of the effect sizes within a population to be made purchase kamagra chewable 100 mg line. Accounting location of some genes of moderate effect purchase 100mg kamagra chewable amex, but none of these for specific genetic effects will also facilitate the search for findings can be regarded as conclusive, and proof in each independent environmental factors and the investigation of case will probably have to await identification of the suscep- potential gene–environment interactions. The clearest molecular genetic risk factor is likely to be enhanced by ensuring as far as possible that for schizophrenia that has been identified to date is deletion control samples are drawn from the same base population of a gene or several genes on chromosome 22, which can as patients. In addition, the use of incident cases should markedly increase the risk for schizophrenia. However, guard against the risk of identifying loci related to con- founds, such as chronicity of illness, rather than susceptibil- fairly strong data suggest that allelic variation in genes en- ity. Phenotypic assessment is likely to benefit from a pro- coding the 5-HT2A and D3 dopamine receptors confer a spective element to studies, which counteracts the tendency small degree of susceptibility. However, successful application of these methods period and larger number of investigators that will be re- requires access to large, well-characterized patient samples, quired to ascertain detailed data from thousands of subjects. We need to focus research on the development and refinement of phenotypic measures and biological markers. Genetic Testing Success will also depend on the traditional medical disci- A further implication concerns genetic testing. This is a plines of clinical description and epidemiology, and on our complex area that raises a number of ethical issues, which ability to integrate these with genetic approaches. Chapter 49: Molecular and Population Genetics of Schizophrenia 683 ACKNOWLEDGMENTS phrenia: implications for understanding the heterogeneity of the illness. Sex differences Preparation of this chapter was supported in part by Na- in olfactory identification and Wisconsin Card Sorting perfor- tional Institute of Mental Health grants 1 R01MH41879- mance in schizophrenia: relationship to attention and verbal 01, 5 UO1 MH46318-02, and 1 R37MH43518-01 to Dr. In: search, Health Services Research, and Development and Tsuang MT, Tohen M, Zahner GEP, eds. Cooperative Studies Programs; and a NARSAD Distin- 18. Owen wishes Washington, DC: American Psychological Association, 1993: 231–244. Schizophrenia and Alastair Cardno in the preparation of this manuscript. Am J Med Genet (Neuropsychiatr Genet) 1997;74:353–360. Genetic epidemio- logical study of schizophrenia in Palau, Micronesia: prevalence REFERENCES and familiality. Am J Med Genet (Neuropsychiatr Genet) 1999; 88:4–10. Psychiatric diagnosis with special reference to schizophrenia. In: Tsuang MT, Tohen in New York and London: a comparative study of mental hospital M, Zahner GEP, eds. London: Oxford University Press, 1972 (Institute York: Wiley-Liss, 1995:283–300. Pregnancy/delivery complica- Kaplan HI, Sadock BJ, eds. Sex and brain abnormalities in schizophrenia: ophrenia. Epidemiology of schizophrenia: a European per- posterior brain regions. The case for heterogeneity in the factor research in schizophrenia: an overview and methodologic etiology of schizophrenia. Hypoxic ischemia-related phrenia 3: nosology , epidemiology and genetics. Amsterdam: Else- fetal/neonatal complications and risk of schizophrenia and other vier Science, 1988:151–168. Methods, diagnosis of probands, and risk 1991:33–52. Morbidity risks of schizo- fective psychosis as assessed in a U.

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