Here's the other half I promised so ya'll can put them together! Wendy ********************************* Historically, diseases have been named and classified by their clinical symptoms and characteristic pathology. If there is one dramatic consequence of the molecular genetic revolution on contemporary studies of disease, it is the extreme variations in phenotype that can come from similar genetic lesions. Perhaps the most striking examples to date are the divergent phenotypes that result from nearly identical PRPP178 mutations. This mutant prion gene can cause either CJD or fatal familial insomnia (FFI), two distinctly different fatal phenotypes21,36. It appears that a small change in DNA sequence--a polymorphism at codon 129--dictates the phenotype. (Although the prion protein can aggregate and form amyloid plaques, neither PRPP178 disease, CJD, or FFI is characterized by prominent plaque formation.) Another example of similar genotypes and diverse phenotypes is DRPLA22-24. A triplet-repeat variation in the same gene causes one set of disease symptoms in the Japanese cases, which are clinically distinct from the disease manifestations in African Americans, again pointing to the large phenotypic effects of small variations in the genetic background. My view of the future for the study of AD is that, by understanding how different isoforms of ApoE participate in neuronal metabolism and the mechanisms of pathogenesis that lead to the synaptic and neuronal loss characteristic of AD, we can decipher other principles of cerebral pathology and processes that are currently undefined14-16,20-24,37. ApoE may be the "vitamin C" of neurons. As stated above, ApoE is present in neurons of patients with late-onset AD and in age-matched controls who do not have AD19,34 (see figure 3). Although ApoE is made in large quantities outside the CNS, where it contributes to bulk lipid metabolism, the quantity of ApoE that is present in brain neurons is infinitesimal compared with the quantity in glial cells19,38,39. ApoE appears not to be made in neurons, but neurons probably acquire the protein from astrocytes and require its presence. There must be a currently undefined, neuron-specific mechanism that allows small amounts of ApoE--once it is inside a neuron--to escape the intraneuronal endosomal compartment and enter the cytoplasm. APOE-deficient knockout mice develop early and severe abnormalities in the morphology of their cortical-neuron dendrites, presumably as a consequence of having no ApoE in their brains40. Thus, ApoE is similar to a vitamin, such as vitamin C, in human physiology: The neuron does not make it but it is necessary for good health. Our recent studies suggest that the ApoE3 and ApoE2 isoforms may lead to better brain function over time than ApoE4. Studies of fraternal twins have revealed lower cognitive performance in normal (non-AD) older adult male twins who carry the APOE4 allele41. Also, a person's ability to recover neuropsychological functions after stress, such as cardiopulmonary bypass surgery, has been related to the presence or absence of an APOE4 allele42. The neurobiology and hereditary factors that underlie neuropsychological functioning and responses to environmental stress are only beginning to be appreciated and studied. The normal metabolic role of small quantities of cytoplasmic ApoE in neurons and the pathways for regulating the neuronal intake of ApoE may provide new clues to the study of normal brain function and response to metabolic stresses5,42. ApoE seems to function as a neuronal metabolic co-factor for microtubular maintenance and repair and, possibly, for other physiologic functions, and it may play akey role in the selective vulnerability that characterizes some neurodegenerative diseases. The intriguing localization of ApoE to peroxisomes may suggest that oxygen metabolism is altered in several major neurodegenerative diseases, including amyotrophic lateral sclerosis, Parkinson's disease, and the collection of disorders that resemble AD but that involve different brain pathologies17,43. It is natural that the impetus for these basic studies should come from scientists who are interested in the nature of diseases and the possibilities for treatment. The studies of genes that increase susceptibility to disease will need to be verified by epidemiological studies controlled for age, sex, race, and ethnic variables. The association of the APOE4 allele with more rapid progression to late-onset AD is a wonderful example of how a previously known genetic variation that can increase the susceptibility to fatal myocardial infarctions can be extended to another age-dependent disease44. To understand the epidemiology of diseases in different populations with variable frequencies of the APOE alleles, we must focus our attention on the effects of genetic variations as well as of interactions with diet, exercise habits, education, and other environmental factors on the rate of disease expression. Crystal balls do not provide as much light as do data from experiments. Although this commentary may sound speculative, there is nothing more conjectural than being asked to write about the future. I think basic neurobiologists will lead the way in determining the role of ApoE in neurons and that this information will feed back to investigators who are interested in brain diseases. The ApoE-isoform-specific metabolism that leads to AD will be defined and targeted for pharmacologic therapy. As a "long-shot" bet, many of my colleagues in AD research who are firmly engrossed in studying the role of A-beta in AD may come to understand that an individual's genotype explains his or her phenotype, not that phenotype predicts mechanisms of pathogenesis. The concept of several "Alzheimer's diseases" will become more apparent; whether and how they are interrelated will be tested45. Being somewhat of agambler, my "surest bet" is that new concepts of basic science of the brain will emerge from controversial data that cannot now be explained by prevailing hypotheses. If AD is a universal corollary of long life with variations in APOE genotype being responsible for the proportion of individuals who will develop AD during their life span, then nothing needs to be replaced by gene therapy. Indeed, we need to enhance or inhibit by 10-15 percent the rate of relevant critical reactions to push the curve of age of AD onset to the right. 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Comments intended for publication should be addressed to Advice and Dissent, The Journal Of NIH Research, 1444 I St., N.W., Suite 1000, Washington, DC 20005. Allen D. Roses is the Jefferson Pilot Professor of Neurobiology and Neurology in the Departments of Medicine and Neurobiology, Bryan Alzheimer's Disease Research Center, Duke University Medical Center, Durham, N.C. ------------------------------------------------------------------------