By A. Uruk. Rhodes College. 2019.

In this regard purchase nizagara on line amex, cholera toxin is a heterol- ogous macromolecule consisting of two structurally and functionally separate A and B 48 Boyaka and McGhee subunits (133 generic nizagara 25 mg line,134) purchase 25 mg nizagara mastercard. Cytokines and Chemokines as Mucosal Adjuvants The use of cytokines and chemokines to enhance the immune responses to mucosal vaccines is an attractive strategy for several reasons. First, cytokines and chemokines act by often known mechanisms through specific interactions with corresponding receptors. Furthermore, whereas important adverse effects are often associated with large and repeated parenteral cytokine doses generally required for the effective tar- geting of tissues/organs, only low serum cytokine levels are achieved after mucosal delivery of these regulatory molecules (156). Finally, cytokines/chemokines that influ- ence the development of Th cell subsets can help promote targeted Th1-type responses for protection against intracellular pathogens or Th2-type responses required for pro- tection against soluble antigens and toxins. As mentioned above, a number of innate molecules are secreted in mucosal epithe- lia. To test whether these molecules could provide signals to bridge the innate and adaptive mucosal immune systems, protein antigens were given nasally with -defensins, (i. All of these vaccine regimens were found to promote systemic immune responses to the coadmin- istered antigen (161 163). It is now clear that CpG motifs can induce B-cell proliferation and Ig synthesis as well as cytokine secre- tion (i. Since CpG motifs create a cytokine microenvironment favoring Th1-type responses, they can be used as adjuvants to stimulate antigen-specific Th1-type responses or to redirect harmful allergic or Th2-dominated autoimmune responses. It has also been reported that CpG motifs can enhance systemic as well as mucosal immune responses when given intranasally to mice (169). This molecule promotes both humoral and cell-mediated immunity when added to systemic vaccine formulations (175 177) and is now being tested in several parenteral vaccine formulations (173). Although regulation of these innate defenses is only partially understood, a growing body of evi- dence shows that mucosal innate factors can provide the necessary signals for the development of adaptive immunity. It is also clear that effective protection of mucosal surfaces can only be achieved by vaccines promoting both systemic and mucosal immunity. A number of mucosal adjuvants and delivery systems capable of inducing mucosal S-IgA Abs as well as systemic immunity have been identified. Safe mucosal adjuvants and vaccination strategies are being developed to induce tar- geted Th1- or Th2-type immunity for optimal protection against different pathogens. Epithelial cell specialization within human Peyer s patches: an ultra- structural study of intestinal lymphoid follicles. Morphometric and cytochemical analysis of lysosomes in rat Peyer s patch follicle epithelium: their reduction in volume fraction and acid phos- phatase content in M cells compared to adjacent enterocytes. Uptake and transport of copoly- mer biodegradable microspheres by rabbit Peyer s patch M cells. Conversion by Peyer s patch lym- phocytes of human enterocytes into M cells that transport bacteria. Surface phenotype of Peyer s patch germinal center cells: implications for the role of germinal centers in B cell differentiation. Relationship between expression of IgA by Peyer s patch cells and functional IgA memory cells. The preference for switching to IgA expression by Peyer s patch germinal center B cells is likely due to the intrinsic influence of their microenvironment. Surface lymphotoxin alpha/beta complex is required for the development of peripheral lymphoid organs. Alternate mucosal immune system: organized Peyer s patches are not required for IgA responses in the gastrointestinal tract. Immunogenicity of recombinant adenovirus- human immunodeficiency virus vaccines in chimpanzees following intranasal administra- tion. Specific secretory immune responses in the female genital tract following intranasal immunization with a recombinant adenovirus expressing glyco- protein B of herpes simplex virus. Intranasal immunization induces long-term protec- tion in mice against a Chlamydia trachomatis genital challenge. Induction of antigen-specific antibodies in vagi- nal secretions by using a nontoxic mutant of heat-labile enterotoxin as a mucosal adju- vant. Salivary, nasal, genital, and systemic antibody responses in monkeys immunized intranasally with a bacterial protein antigen and the cholera toxin B subunit. Antibod- ies and antibody-secreting cells in the female genital tract after vaginal or intranasal immunization with cholera toxin B subunit or conjugates. Intranasal vaccination of humans with recombinant cholera toxin B subunit induces systemic and local antibody responses in the upper respiratory tract and the vagina. Induction of mucosal and systemic immunity to a recombinant simian immunodeficiency viral protein. T- and B-cell functions and epitope expression in nonhuman primates immunized with simian immunodeficiency virus antigen by the rectal route. Peyer s patches: an enriched source of precursors for IgA-producing immunocytes in the rabbit. Rabbit Peyer s patches, appendix, and popliteal lymph node B lym- phocytes: a comparative analysis of their membrane immunoglobulin components and plasma cell precursor potential. Characteristics of mesenteric lymph node cells homing to gut-associated lymphoid tissue in syngeneic mice. Mesenteric lymph node B lym- phoblasts which home to the small intestine are precommitted to IgA synthesis. IgA antibody-producing cells in peripheral blood after antigen ingestion: evidence for a common mucosal immune system in humans. Specific immunoglobulin-secreting human blood cells after peroral vaccination against Salmonella typhi. Oral cholera vaccination induces strong intestinal antibody responses and interferon-gamma production and evokes local immunological memory. Expression of a protective intestinal immune response can be inhib- ited at three distinct sites by treatment with anti-alpha 4 integrin. A fundamental subdivision of circulating lymphocytes defined by adhesion to mucosal addressin cell adhesion molecule- 1. Comparison with vascular cell adhesion molecule-1 and correlation with beta 7 inte- grins and memory differentiation. Mice lacking expression of secondary lymphoid organ chemokine have defects in lymphocyte homing and dendritic cell localization [see com- ments]. Nasal-associated lymphoid tissue: phenotypic and functional evidence for the primary role of peripheral node addressin in naive lymphocyte adhesion to high endothelial venules in a mucosal site. Role of very late activation antigen-4 in the antigen-induced accumulation of eosinophils and lymphocytes in the lungs and airway lumen of sensitized brown Norway rats. Differential expression of tissue- specific adhesion molecules on human circulating antibody-forming cells after systemic, enteric, and nasal immunizations. Gene expression, immunolocalization, and secre- tion of human defensin-5 in human female reproductive tract. Production of beta-defensin antimicrobial pep- tides by the oral mucosa and salivary glands. The potent anti-Staphylococ- cus aureus activity of a sterile rabbit inflammatory fluid is due to a 14-kD phospholipase A2.

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Sural nerve biopsies are easily accessible sources of nerve tissue when a mononeuritis is present generic 25 mg nizagara visa. The use of a second drug is guided by the severity of presentation and if there is failure to respond to steroids alone buy nizagara 50mg with amex. The presence of two or more of these factors portends a mortality of nearly 50% (7) order cheapest nizagara and nizagara. A review of long-term follow-up of these patients suggests that those with more severe illness as defined with one of the above factors have a higher survival rate when treated with cyclophosphamide (19). Clinical presentations may involve concomitant capillaritis with or without alveolar hemorrhage and rapidly progressive glomerulonephritis, the so-called pulmonary renal syndrome. Glomerulonephritis occurs in most cases, and pulmonary involvement ranging from cough and dyspnea to frank hemoptysis occurs in up to 30% of cases. Treatment involves corticosteroids at 1 mg/kg per day orally or intravenous methylprednisolone, and cyclophosphamide orally or intravenously with transition to azathioprine or other similar agent after induction of remission (27). Pulmonary disease includes fleeting or diffuse infiltrates, nodular lesions, and peripheral infiltrates occur in up to 75% of patients (30,31). As mentioned earlier, the presence of any of the five prognostic factors has been associated with a higher mortality and should guide the choice of treatment, suggesting corticosteroids for limited disease and the addition of cyclophosphamide in the setting of severe disease (19). Therapy in severe cases consists of corticosteroids and cyclophosphamide with careful attention to the potential risk of increased hepatitis C replication and treatment with antiviral therapy if hepatitis C is present. In severe cases involving progressive glomerulonephritis, plasmapheresis or cryofiltration may be of additional benefit (41,42). Although the disease may affect individuals of a wide range of ages, the disease most commonly affects persons in their fourth or fifth decades of life with a slight predominance for men over women (44,45). Possible infectious etiological associations with Staphylococcus aureus have been proposed but are as yet unproven (46). Fever, in addition to being caused by the underlying disease, may result from suppurative otitis or S. Granulomatous vasculitis of the upper respiratory tract may lead to damage of nasal cartilage resulting in the saddle- nose deformity, sore throat, and oral and nasal mucosal ulcers (51). Chondritis of the nose or ear may develop and laryngeal involvement may result in severe narrowing of the upper respiratory tract (52 54). This complication is distinctly more common in younger adult and pediatric populations. Approximately 10% of patients present with only nonspecific constitutional symptoms such as arthralgias, myalgias, fever, and weight loss. Renal manifestations are often asymptomatic although urinalysis reveals renal involvement in approximately 80% of patients at presentation. Functional renal impairment may progress rapidly if appropriate therapy is not instituted promptly (57). Cyclophosphamide therapy is associated with significant morbidity and patients or their proxy need to be counseled prior to consent for treatment. Opportunistic infection, particularly with pneumocystis carinii, was reported in 6% of patients in initial trials with combination cyclophosphamide and corticosteroids (61) and it is now standard of care for patients to be prophylactically treated with double strength trimethoprim/sulfamethoxazole, three times per week or one single-strength tablet daily. Previously, these have been described as hypersensi- tivity reactions causing small-vessel vasculitis (62). More recent work in drug-induced vasculitis has broadened the group to include a large variety of small- and medium- vessel syndromes. There are no specific pathological or clinical features that distin- guish this group from other forms of vasculitis. Cases ranging from self-limiting cutaneous involvement to severe multiorgan failure have been reported. Diagnosis is simply based on the development of vasculitis where a causal drug/agent can be identified, which in most cases leads to resolution of the vasculitis after drug discon- tinuation. There is a large variation in the length of drug exposure before symptoms develop, with many reports of years of exposure before the apparent sudden onset of vasculitis. Other cases have been reported following vaccination, particularly for hepatitis B (65) and influenza (66). Frequently, patients have hypertension that aggravates their underlying disease or raises questions about their primary diagnosis. Disease manifestations may develop precipi- tously but often can present with a long prodrome over months involving subtle mental status changes and cognitive dysfunction (71,72). The disease has a predilection for the small and medium vessels especially of the leptomeninges. Cyclophosphamide may be added in severe cases or with progressive disease, although firm recommendations are limited by a lack of prospective trials (77). Physical examination is notable for tenderness or nodularity over the temporal or facial arteries. Diagnosis should be confirmed by temporal artery biopsy, which typically shows an inflammatory infiltrate composed of lymphocytes and multinucleated giant cells, although giant cells are not required to confirm the diagnosis. In cases where biopsy is negative (and the contralateral temporal artery is also negative), it still may be appropriate to treat if the clinical suspicion for the disease is high. In the case of threatening visual loss, some clinicians will use high-dose methylprednisolone (1 g intravenously for 3 days) although data supporting this approach is limited (82). The use of methotrexate and s steroid-sparing agents has been met with variable results (83,84). Morbidity associated with the disease beyond visual loss mostly involves side effects of corticosteroids including weight gain, glucose intolerance, and also a higher risk of thoracic aortic aneurysm and rupture (86). Patients frequently present with constitutional symptoms such as weight loss, fatigue, and myalgias. Devel- opment of inflammation within blood vessels can result in vessel stenosis and aneurysm, leading to symptoms such as claudication caused by subclavian artery occlusion and stroke owing to occlusion of the carotids and vertebral arteries (87,88). Physical exami- nation is notable for decreased or absent pulses, bruits, carotid tenderness, and heart murmurs most frequently related to aortic regurgitation owing to proximal dilatation of the aortic root. Stenosis that remains symptomatic despite medical treatment may be amenable to vascular intervention with varying degrees of success (92 94). Other important manifestations include a variety of skin lesions which include erythema nodosum, pustular lesions and a charac- teristic pathergy phenomenon. There are, however, nutritional factors that should be considered in managing these patients. Weight loss is also a common feature of any systemic inflammatory state and is frequently seen in systemic vasculitis. Concomitant treatment with calcium and vitamin D supplementation is now standard in patients being treated with corticosteroids with prophylactic bisphosphonate therapy also being used in most patients to decrease bone loss. Methotrexate use is associated with folate deficiency through its inhibition of dihydrofolate reductase. Supplementation with folic acid 1 mg daily is standard in these patients with some requiring higher doses or the addition of folinic acid given 12 hours before and/or after their weekly dose of methotrexate. Recent research on the pathophysiology of systemic inflammatory disease has highlighted the role of superoxide production and its possible role in tissue damage. One study has examined the potential role of antioxidant supplementation in decreasing neutrophil superoxide production in vasculitis. In vivo studies are still lacking to determine if vitamin C and E supplementation could lead to any clinical response.

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Mucin has antibacterial activity generic 25 mg nizagara with visa, and cilia trans- power microscopy order 100mg nizagara free shipping, this region has an appearance similar port mucin out of the lung purchase nizagara with amex. Alveoli can deliver polymorphonuclear leuko- grayer color and forms the zone of gray hepatization. Gram-negative rods and anaerobic First, an outpouring of edema uid into the alveoli bacteria also cause permanent tissue destruction. As uid accumulates, it spills over to Predisposing Factors adjacent alveoli through the pores of Kohn and the ter- minal bronchioles, resulting in a centrifugal spread of Most bacterial pneumonias are preceded by a viral upper infection. Viral infections of the upper respiratory tract can damage the bronchial epithelium and cilia. The low viscosity of this fluid, combined with depressed ciliary motility, enables the viral exudate to 1. Pathogens are aspirated or inhaled as small carry nasopharyngeal bacteria past the epiglottis into the aerosolized droplets. As a conse- a) edema fluid that spreads to other alveoli quence, smokers have an increased risk of developing through the pores of Kohn, and pneumonia. Congenital defects in ciliary function (such as Kartagener s syndrome) and diseases resulting in b) infiltration by polymorphonuclear leuko- cytes and red blood cells, followed by highly viscous mucous (such as cystic brosis) predis- macrophages. Infection spreads centrifugally: ally prevent nasopharyngeal contents from gaining access a) Newer regions in the periphery appear red to the tracheobronchial tree. Streptococcal pneumonia does not cause per- larly after a cerebrovascular accident, often develop manent tissue destruction. Viral infections damage cilia and produce the patient noted some improvement in her cough, serous exudate that can transport nasopharyn- muscle aches, and joint pains; however, on the 4th geal bacteria into the alveoli. In mediated immunity, and may have impaired general, this was a very ill-appearing, anxious swallowing because of stroke. Cold weather dries the mucous membranes and increases person-to-person spread of infection. Patients with impairments in immunoglobulin pro- duction, T- and B-cell function, and neutrophil and macrophage function are also at greater risk for develop- ing pneumonia. Cold, dry weather can alter the viscosity of mucous and impair bacterial clearance. Cold weather also encourages people to remain indoors, a sit- uation that enhances person-to-person spread of respi- ratory infections. She also noted diffuse radiograph demonstrates classical lobar inltrate (Cour- severe muscle aches and joint pains and a generalized tesy of Dr. In her epidemiologic history, she noted that Gram stain shows Streptococcus pneumoniae. Note that she had recently seen her grandchildren, who all had the cocci come to a slight point,explaining the term high fevers and were complaining of muscle aches. The onset of the new illness can be classied a) Community-acquired patient not recently as acute. An illness is termed acute when symptoms (>14 days) in a hospital or chronic care facility. Symptoms that b) Nosocomial patient in a hospital at the develop over 3 days to 1 week are generally classied as time the infection developed. In generating a potential list of causative agents, the infectious disease specialist frequently uses the pace of the 1. Pneumonias are gener- sputum, and color of the sputum should be docu- ally classied into two groups: acute and chronic. A nonproductive cough or a cough bacterial and viral pneumonias develop quickly; fungal productive of scanty sputum suggests an atypical and mycobacterial pulmonary infections tend to develop pneumonia; a cough productive of rusty-colored at a slower pace. Pain is usually sharp nity-acquired pneumonia, certain key clinical characteris- and stabbing. Because the pulmonary parenchyma tics are helpful in guiding the determination of the most has no pain-sensing nerves, the presence of chest likely causes (Table 4. Generation of a logical differen- pain indicates inammation of the parietal pleura. Because istic of pleurodynia, a pain syndrome caused by the many respiratory illnesses spread from person to enteroviruses coxsackievirus and echovirus. Mild chills are encountered in most febrile ill- friends with illnesses should be ascertained. However, a teeth-chattering, bed-shaking chill pational and sexual history should also be elicited. A single rigor is the rule in pneumococcal infec- tion; multiple rigors are more typical of S. Frequency,production of sputum,color ness of breath suggests poor alveolar oxygen and thickness of sputum. Pain on deep inspiration, usually patients experience shortness of breath as a result of sharp, suggests pleural involvement. Seen in pleuritic chest pain that limits the ability to breath Streptococcus pneumoniae, Staphylococcus deeply. Travel history, animal exposure, struction sites should be identied (legionnaires exposure to people with respiratory illnesses, disease). About the Physical Exam in Pneumonia Laboratory Findings Physical examination is unreliable for making the diag- 1. Depressed mental status and stiff neck suggest guideline to possible causative agents; however, the use bacterial meningitis. Pulmonary auscultation often underestimates decreased cell-mediated immunity, and depressed the extent of pneumonia: macrophage function) can greatly alter the typical a) Bronchial breath sounds and egophony sug- radiologic appearance of specic pathogens. As it spreads, this form of infection respects the anatomic boundaries of the lung and does not cross the ssures. The bronchopneumonia form performed during the initial evaluation for possible of pulmonary infection originates in the small pneumonia. A respiratory rate of more than Inltrates tend to be patchy, to involve multiple areas 30 breaths per minute, a systolic blood pressure under of the lung, and to extend along bronchi. Inltrates 90 mm Hg, a pulse above 125 beats per minute, and a are not conned by the pulmonary ssures. Bron- temperature below 35 C (95 F) or above 40 C (104 F) chopneumonia is commonly observed with S. Depressed mental status is gram-negative bacilli, Mycoplasma, Chlamydia, and also associated with a poor prognosis. Miliary extent of infection, and when pneumonia is being con- tuberculosis commonly presents with micronodular sidered, the physical exam should be followed by a interstitial inltrates. Asymmetry of chest movements may be observed, movement being diminished on the side with the pneu- 4. When infection has progressed to consolidation, often cause extensive tissue necrosis, resulting in loss as in case 4. Histoplasmosis, coccidiomycosis, patient is asked to say E, an A is heard on ausculta- and cryptococcosis can present as nodular lung tion (egophony). Deoxygenated blood passes from the right side of the heart to the left side, creating a physiologic About Chest X-Ray in Pneumonia right-to-left shunt.

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As a group discount nizagara 25 mg mastercard, these familial diseases were referred to as Azorean neurodegeneration to reflect their common From:Contemporary Clinical Neuroscience: Molecular Mechanisms of Neurodegenerative Diseases Edited by: M buy discount nizagara 100 mg on-line. Because of their different clinical manifestations buy 100mg nizagara otc, they were thought to represent distinct genetic disorders. Only when fami- lies were described with a phenotype spanning the full clinical spectrum did it become evident that Azorean degeneration might represent a single genetic entity. As this became clear and as additional families were described in locales beyond the Azores (e. In the 1990s, molecular genetic advances resulted in further unexpected findings about the disease. This illustrates the important point that a genetic disorder may not manifest the same way in every genetic background and can be influenced by additional genetic and/or environmental factors. However, genetic studies using flanking microsatellite markers and intragenic polymor- phisms make the single-founder hypothesis untenable (Stevanin et al. Nonetheless, there is evidence for local-founder effects in some geographi- cally distinct populations in France, Brazil, and Japan. Nearly all disease alleles have 60 or more repeats (a single disease allele shorter than this, 55 repeats, was reported by Quan et al. Third, the rather large jump in repeat size that a normal allele would need to make in order to expand into the disease range suggests that de novo mutations occur only rarely. A few, such as anticipation, are relatively well understood, whereas others are not so well appreciated. Larger repeats cause earlier disease onset and are associated with faster disease progression than are smaller, disease alleles (Klockgether et al. At the molecular level, there is a tendency for expanded repeats to enlarge during transmission. Several studies have shown no difference in repeat instability with paternally or maternally transmitted alleles, whereas others have shown a small bias toward increased paternal instability (Cancel et al. The molecular mechanism underlying trinucleotide repeat instability is an area of great research interest, but beyond the scope of this review. Excellent reviews of repeat instability can be found elsewhere (Pearson and Sinden, 1998). The actual protein size varies, depending on at least three factors: (1) the length of the glutamine repeat; (2) a single nucleotide polymorphism (nucle- otide 1118 A to C) that converts the original published stop codon to a tyrosine residue when C replaces A, extending the polypeptide by 16 amino acids (Kawaguchi et al. Perhaps the most interesting splice variant occurs near the C-terminus, where alternative splicing replaces the last 17 amino acids of the originally published ataxin- 3 sequence with a different C-terminus of about the same size (Schmidt et al. Which C-terminal isoform is more prevalent in disease tissue is unknown, but studies suggest that both are expressed in disease brain (Paulson et al. Although there is evidence for additional splice variants near the amino-terminus, full-length ataxin-3 appears to be the predominant isoform expressed in brain and elsewhere (Paulson et al. Ataxin-3 has been found in every mammalian tissue and cell line studied so far (Paulson et al. Ataxin-3 does not show extensive homology to known proteins, although there is a predicted ortholog in C. Ataxin-3 is a small hydrophilic protein with the gln repeat (Q) near the carboxyl terminus. Arrow indicates an intragenic polymorphism 1118 A C, that alters the stop codon, extending the protein by 16 amino acids. The protein is predicted to have a high degree of helical secondary structure, including a coiled-coil domain situated just before the polyglutamine domain (Fig. Coiled-coil domains often medi- ate protein protein interactions, but whether it does so in ataxin-3 is not yet known. This difference in an otherwise highly conserved protein suggests that a homopolymeric glutamine repeat is not essential for normal ataxin-3 function. Some reports indicate predominantly cytoplasmic staining for ataxin-3, whereas others suggest nuclear staining (Paulson et al. Ataxin-3 is likely to be both a cytoplasmic and nuclear protein whose subcellular localization is regulated by one or more factors, including the type of cell, the state of the cell cycle, and the presence or absence of particular splice variants. The most detailed study to date suggests multiple isoforms of ataxin-3 with heterogeneous patterns of subcellular localization (Trottier et al. In many cells, a fraction of the ataxin-3 pool is intranuclear, bound to the nuclear matrix (Tait et al. This nuclear pool of ataxin-3 may be important to pathogenesis, in light of the fact that the mutant protein forms intranuclear inclusions in disease brain. However, some generalizations can be made based on numerous reports (Sachdev et al. First, the pathological changes are degenerative, involving neuronal loss and gliosis. The neuropathy is usually symmetric, involving sensory and motor neurons and both unmyelinated and myelinated fibers. Neuronal intranuclear inclusions are now recognized to be a common pathological hallmark of polyglutamine diseases, having been found in all but two of the polyglutamine diseases. Several neurons in both panels contain intranuclear spherical aggregates of the disease protein that are ubiquitin positive. The slow progression of human disease, together with results from transgenic mouse models (Burright et al. Once redis- tributed into polyglutamine aggregates, these proteins might recruit their own interacting partners, leading to deleterious downstream effects. The following discussion highlights recent findings that lead the way toward an understanding of disease mechanism. Protein Misfolding Is Central to Pathogenesis The basis of disease is a dominant, toxic gain of function occurring at the protein level and increasing with longer glutamine repeats. Evidence increas- ingly suggests that this novel toxic property is misfolding of the polyglutamine domain. Unique structural features of polyglutamine cause it to adopt an altered conformation when expanded, perhaps a `-sheet hairpin structure (Perutz, 1999). Direct evidence supporting an altered structure is the existence of antibodies that preferentially recognize and bind expanded polyglutamine (Trottier et al. Accumulating evidence from in vitro studies, animal models, and human disease tissue further argue for misfolding. Numerous studies in transfected cells have shown that expanded polyglutamine forms insoluble aggregates that presumably are derived from misfolded protein (Ikeda et al. Similar aggregates have also been observed in many transgenic animal mod- els, both in mice and in flies (Warrick et al. Test tube studies of recombinant polyQ fragments indicate that polyQ aggregation can be a self-driven process that occurs in a concentration-de- pendent manner and results in the formation of amyloidlike insoluble fibrils (Scherzinger et al. The threshold repeat length for in vitro aggrega- tion closely mirrors the threshold for disease, supporting the view that polyQ-induced misfolding is a central element in pathogenesis.