residues are causative factors in the disease. Furthermore, the ratio of A 42 to A 40 is increased in Down syndrome. Another suggestive connection has been the nding that there are genetic defects in the genes encoding APP and in a pair of endosomal proteins termed presenilin 1 and 2 in some familial forms of Alzheimer disease. The presenilins interact with or may be a component of secretase, the enzyme that produces the A 42 fragment. Mutations of presenilin 1 and 2 also increase the relative levels of A 42. It should be noted that mutations of the APP and presenilin genes explain fewer than 0.1 percent of Alzheimer cases (Terry). Transgenic mice that express human Alzheimer disease associated mutations in APP or presenilin genes develop plaques with A 42 but not neuro brillary tangles. There is also a provocative relationship between certain circulating proteins, particularly -amyloid and selected isoforms of the ApoE lipoproteins, as discussed further on. The current notions of amyloid metabolism and the role of A 42 are summarized in Fig. 39-2. Many of the relationships and mechanisms depicted in the gure are derived from the understanding of genetic forms of Alzheimer disease; the extent to which they will be implicated in the idiopathic disease is not known. However, some form of disruption in these mechanisms are likely be involved in the sporadic disease.
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Conjugate roots The discriminant in a quadratic can be negative even when b, the coefficient of x, is not equal to 0. The only requirement is that 4ac be larger than b 2. Here s an example:
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your investments get crushed in the last stock market crash No, not in 1929 in 2000 to 2002. Most investors got a rude awakening when they opened their year-end statements for each of the past three years because 2000 to 2002 was only the second time in history that the market was down three years in a row. Are you confused by the daily gyrations of the stock market Are you upset that you lost a bundle in the past three years Are you ready to give up on the stock market, and cash in at any price If so, then join the club, since almost everyone is in the same boat. The talking heads on the business shows continually profess a bullish stance, no matter what the market is doing. Ignore their opinions. No one knows where the market is going tomorrow, let alone in the months and years further down the road. Just because the stock market has averaged an annual return of nearly 10.2 percent since 1926 does not mean that you can expect that rate of return to continue in the coming year or the next 5 years. Just because you may not be retiring soon does not mean that you can afford to ignore what is going on in the stock market. If you have been investing since 1982, or perhaps since early 1995, you were probably ecstatic with your returns through the first quarter of 2000. Since then, the market has dramatically and swiftly reversed direction, and it has dropped faster than it rose. Did you sell at or near the top and put the proceeds into cash You probably did not. Did you sell after your stocks or mutual funds fell 10 percent, then 20 percent, then 30 percent, and perhaps 90 percent in some cases Probably not, since you thought the market would come back, as it always has. Perhaps you followed the widely touted buy-and-hold approach. And if you are like most investors, you have no game
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1. Buy: An equity Put/Call Ratio higher than 1.0 (more puts are being bought) is a buy signal. Higher than 1.20 is a screaming buy.
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the total clinical picture is often uncertain. Despite this ambiguity, certain features have emerged as typical of CMV encephalitis in the AIDS patient. According to Holland and colleagues, late in the course of AIDS and usually concurrent with CMV retinitis, the encephalopathy evolves over 3 to 4 weeks. Its clinical features include an acute confusional state or delirium combined, in a small proportion of cases, with cranial nerve signs including ophthalmoparesis, nystagmus, ptosis, facial nerve palsy, or deafness. In one of our patients, there were progressive oculomotor palsies that began with light- xed pupils. Pathologic specimens and MRI show the process to be concentrated in the ventricular borders, especially evident as T2 signal hyperintensity in these regions. It may be seen to extend more diffusely through the adjacent white matter and be accompanied by meningeal enhancement by gadolinium in a few cases. Extensive destructive lesions have also been reported; this has been true in two of our own cases. Such lesions may be associated with hemorrhagic changes in the CSF in addition to showing an in ammatory response. CMV may also produce a painful lumbosacral polyradiculitis in AIDS. The diagnosis of CMV infection during life is often dif cult. Cultures of the CSF are usually negative and IgG antibody titers are nonspeci cally elevated. Newer PCR methods may prove useful here. Where the diagnosis is strongly suspected, treatment with the antiviral agents ganciclovir and foscarnet has been recommended; but, as pointed out by Kalayjian and colleagues, the CMV disease may develop and progress while patients are taking these medications as a form of maintenance therapy. Cryptococcal Infection Meningitis with this organism and less often solitary cryptococcoma are the most frequent fungal complications of HIV infection. Flagrant symptoms of meningitis or meningoencephalitis may be lacking, however, and the CSF may show little abnormality with respect to cells, protein, and glucose. For these reasons, evidence of cryptococcal infection of the spinal uid should be actively sought with India ink preparations, antigen testing, and fungal cultures. Treatment is along the lines outlined (on page 621). Varicella Zoster Cerebral infections with this virus are less common complications of AIDS, but when they do occur, they tend to be severe. They take the form of multifocal lesions of the cerebral white matter, somewhat like those of progressive multifocal leukoencephalopathy, a cerebral vasculitis with hemiplegia (usually in association with ophthalmic zoster), or rarely a myelitis. Encephalitis due to HSV-1 and HSV-2 has also been identi ed in the brains of AIDS patients, but the clinical correlates are unclear. There is no evidence that acyclovir or other antiviral agents are effective in any of these viral infections. Shingles involving several contiguous dermatomes is known to occur in AIDS, as in other immunosuppressed conditions. Tuberculosis Two particular types of mycobacterial infection tend to complicate AIDS Mycobacterium tuberculosis and Mycobacterium avium-intracellulare. Tuberculosis predominates among drug abusers and AIDS patients in underdeveloped countries, and a higher than usual proportion of these immunosuppressed individuals develop tuberculous meningitis. Diagnosis and treatment are along the same lines as in non-AIDS patients (page 612). Atypical mycobacterial infections are usually associated with other destructive cerebral lesions and respond poorly to therapy.
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