Tuesday, January 10, 2012

DANGER - Public Access To Research

I rely quite a bit on public access to research papers in order to better understand ALS and to bring you this blog, for what it's worth. The US Taxpayers, through NIH grants, fund quite a lot of the medical research that is done in the United States. If we paid for this research, we should be able to have access to the results (which, again, we already paid for).

However, a bill is being introduced to take that away. The bill is sponsored by Carolyn Maloney (D - NY) and Darrel Issa (R - CA). Ms. Maloney received the most individual political contributions of the medical publishing giant Elsevier in 2011. Mr. Issa is also on the contribution list. Once again we see that corporate money in politics does not favor the citizens. This is not a political blog so I will cease my digression.

Clearly this is a threat to public access to knowledge which the public already owns. This public knowledge benefits people like me and you as well as institutions such as schools. If you want to retain your rights to access that for which you already paid, action is needed. I urge you to contact your Congresscritter and urge him or her to kill HR 3699. You could also contact Congresswoman Maloney to express your opinion of this bill:

Twitter: @RepMaloney
@CarolynBMaloney

Phone: 202-225-7944

FAX: 202-225-4709

Email: Use this form

Don't let corporations steal from you and charge you for the favor.

Saturday, January 7, 2012

Guest: Persevering On NP001

A few days ago my friend, who goes by the handle Persevering on the TDI Forum, posted an evaluation of the PALS who have been self-reporting their experience with the Neuraltus Phase 2 trial of NP001 (which I have discussed here in the past). While the data looks exciting, I must caution that this isn't official data and makes some assumptions which, if wrong, could totally invalidate the evaluation. However, I have enough faith in Persevering to bring this to your attention. For those who don't have Patients Like Me accounts, I reproduce the graphs here.

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I have analyzed the NP001 phase 2 data from PLM to date.

I am aware of 37 PLM members who have participated in the trial and 34 who have entered sufficient data to track progress. This is roughly 1/3 of the listed full trial enrollment, and offers a great sample to predict actual trial results. The trial consists of 6 infusion cycles over 21 weeks (147 days), followed by 4 follow-up visits adding 16 more weeks. 13 have completed dosing. 11 will complete within 4 weeks, and all within 8 weeks.

In my thinking, since each infusion cycle is 4 weeks total, the first non-dosing follow up at week 25 (175 days) ends the dosing phase, and I have chosen to review data to day 175 in terms of FRS change. The variable of interest is FRS slope, and is very commonly used to evalauate efficacy for ALS clinical trials. For example, it was used in the recent report of Dexpramipexole phase 2 data, and was used for the official Lithium clinical trials in the US.

FRS for all 37 reporting

In my opinion it is possible to review reports of side effects for commonality to approximate those getting drug (either dose) versus placebo. I do not believe it is 100% accurate, and I also expect those getting a higher dose to have more or greater side effects, but it is not entirely possible to segregate the drug groups (high vs. low). Some may not be prone to side effects on drug and others could experience "nocebo" effects, so again this is not a true substitute for unblinding, which should occur later and allow a timely re-analysis of PLM data.

With that assumption/disclaimer, the summary statistics are:

(Green is improved FRS score, yellow is stable FRS down to -0.49/mo, and red is loss of FRS)

With side effects:


  • n = 20
  • Mean ALSFRS-r slope: 0.00
  • Standard Deviation ALSFRS-r slope: 1.24

FRS for those reporting side effects

Without side effects:


  • n = 14
  • Mean ALSFRS-r slope: -1.01
  • Standard Deviation ALSFRS-r slope: 0.68

FRS with no side effects

Comparison: 100.4% mean improvement

2-tailed t-test p-value for difference = 0.0093

The most exciting outcome to me is that the difference in progression rate is very statistically significant (p<0.05), even with only 34 data points! This would be unprecedented for a phase 2 ALS clinical trial. For example, the recent exciting report regarding Dexpramipexole, with a 31% mean improvement versus placebo in the first 12 weeks had a p-value ~ 0.20, a value 4 times higher than acceptable to conclude drug is better than placebo, by convention (based on a sample size of 53).

There is rumor of an official NP001 trial efficacy review soon, based on all data available on January 24, 2012. Let's hope for statistical significance there as well, and potentially FDA accelerated approval, as occurs for cancer and HIV drugs.
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Thanks to Persevering for the work and for the guest-blog!

Thursday, December 15, 2011

Oh, Holy Nerve...

All I Want For Christmas Is My Phrenic Nerve

sung to the tune of:
http://www.youtube.com/watch?v=KyWiiDxbk-A


Everybody pauses and stares at me
My breath is gone as you can see
I don't know just who to blame for this catastrophe!
But my one wish on Christmas Eve is as plain as it can be!

All I want for Christmas
is my phrenic nerve,
my phrenic nerve,
see my phrenic nerve!

Gee, if I could only
have my phrenic nerve,
then I could wish you
"Merry Christmas."

It seems so long since I could say,
"Sister Susie sitting on a thistle!"
Gosh oh gee, how happy I'd be,
if I could only whistle (thhhh, thhhh)

All I want for Christmas
is my phrenic nerve,
my phrenic nerve,
see my phrenic nerve.

Gee, if I could only
have my phrenic nerve,
then I could wish you
"Merry Christmas!"


Happy Holidays to PALS around the world!

Wednesday, November 23, 2011

Nothing Vented Nothing Gained

I have long been an advocate for PALS going on a vent. Many opt out for various reasons, one of which is, surprisingly, discouragement from medical professionals. Horror stories of cost and the difficulty of home care are common.

I beg to differ with that. Cost can indeed be an issue but with creative financing and the possibility of obtaining long-term care insurance before formal diagnosis, cost can be managed. In terms of home care, with a few simple rules adhered to, the risks of complications are minimal. Up until now I had only my own experience to use as proof of my contrarian view. It turns out I was correct all along.

In a study of over 100 PALS 78 were recommended for tracheotomy. 38 underwent the procedure. Of those, the one-year survival rate was approximately 80% (the same as lung transplant) and only one died from respiratory causes. As the study noted:

"Nowadays, starting [home venting] should no longer necessarily be considered as the beginning of the end for these patients. When the appropriate medical resources are in place and the patients wish to continue living, the old mentality of focusing only on palliative care which is still common in the management of this disease must make way for high technology and compassionate care."

Vents today are about the size of a grammar school student's backpack and very quiet. Assisted Communication Computers are covered by insurance and Medicare and are very easily converted to general-use Internet-capable computer systems. Web-based social media platforms give unprecedented communication and social access to today's PALS.

I have cheated The Reaper for 4 years now and others have for longer. In my view the old bastard can piss off until I am good and ready to go. My quality of life is what I make of it. Technology is my friend and has been for most of my life. As the esteemed Steve Saling says, "Until medicine arrives, technology is the cure."

I believe this and urge all PALS to use technology to win the battle against ALS until medicine provides the final victory.

Wednesday, November 9, 2011

Mutants Versus Mitos

There is an excellent article over at the ALZ Forum written by the equally excellent Amber Dance. Rather than (poorly) paraphrase it, I have reproduced it here for your enjoyment. Please also follow the link to the original because the commentary following it is often as informative as the original article. I have highlighted certain portions in bold. After you have read the article I will discuss my opinions on why the bolded portions are interesting to me.
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4 November 2011. If you have wondered about the true importance of mitochondria in motor neuron disease, read on. Researchers from the Weill Medical College of Cornell University in New York corralled mutant superoxide dismutase 1 (mSOD1), a ubiquitous protein that causes amyotrophic lateral sclerosis (ALS), in these powerhouse organelles to prove that mSOD1 damages the mitochondria, and in turn, the cell and the body as a whole. In the November 2 Journal of Neuroscience, the researchers report that limiting the dismutase to the mitochondrial intermembrane space is sufficient to recapitulate much, but not all, of the ALS pathology caused by the SOD1 mutation, which causes a rare form of inherited ALS.

There is plenty of evidence that mitochondria play a part in the motor neuron degeneration that happens in ALS (reviewed in Hervias et al., 2006), but so do defects in many other areas such as RNA processing (see ARF related news story on Kwiatkowski et al., 2009 and Vance et al., 2009), the endoplasmic reticulum (see ARF related news story on Saxena et al., 2009) and Golgi (Urushitani et al., 2008), neighboring glia (reviewed in Ilieva et al., 2009), glutamate uptake (Rothstein et al., 1995), and axonal transport (see ARF related news story). The study authors, led by joint first authors Anissa Igoudjil and Jordi Magrané and senior author Giovanni Manfredi, sought to delineate the cause and outcomes of only the mitochondrial dysfunction. Researchers wondered whether malformed, underactive mitochondria cause some or much of the widespread pathology in ALS—or whether they are simply a symptom of a struggling cell. The current work confirms, as Manfredi’s team and others had also seen in cultured cells (Magrané et al., 2009; Cozzolino et al., 2009), that mSOD1 directly influences mitochondria for the worse, even if all else in the cell is normal.

The researchers designed a mouse model that makes the G93A mutant human SOD1 (an alanine for glycine at position 93), under control of the prion promoter. They linked the dismutase to the amino terminus of mitofilin, which targeted it to the inner mitochondrial membrane, facing the intermembrane space. The mitochondria of these mito-mSOD1 mice contained about the same amount of mSOD1 seen in mitochondria in the standard SOD1-G93A model with unrestricted mSOD1 targeting.

Mice with pan-cellular SOD1-G93A succumb to disease within a year. Male mice with mitochondrial mSOD1, in contrast, lived a nearly normal lifespan of 18 months, Manfredi said. Females suffered more severe disease, and their illness required they be sacrificed for ethical reasons by one year. That may be because the transgene landed in an estrogen-sensitive locus, not due to the mitochondrial mSOD1, Manfredi said. Males and females aged prematurely, hunching over and losing weight before their time. Compared to non-transgenic mice of either gender, females struggled with the motor coordination rotarod test when first examined, at three months of age, while males had near-normal coordination until six months. On a hang test for muscle strength, females performed worse than non-transgenics starting at three months, while males’ muscle weakness was not statistically significant.

When the researchers examined the mitochondria from the mito-mSOD1 mice under the electron microscope, they observed large, empty spaces, or vacuoles, in the normally densely packed organelles. In biochemistry experiments, mitochondria isolated from the brains of mito-mSOD1 mice were more sensitive to an uncoupling agent, failed to retain calcium ions, and had reduced activity of the respiratory enzyme cytochrome oxidase, as compared to mitochondria from non-transgenic mice. These data indicate that while the mitochondria with mutant SOD1 were functional, they were weakened and easily ran out of energy when stressed. Manfredi compared them to a four-cylinder engine firing on only three.

The effects of the mitochondrial mSOD1 extended beyond that organelle.
Compared to normal mice, fewer motor neurons populated the spinal cord of mito-mSOD1 mice, and they suffered a thinning of the motor cortex. The motor neuron loss was not as bad as in standard SOD1-G93A mice, the authors noted. In addition, one hallmark of ALS was decidedly missing: “What was surprising to us is, despite the fact that the mice lost a proportion of the spinal cord neurons and there was atrophy of skeletal muscle, we did not see denervation,” Manfredi said. He noted that just because neuromuscular junctions were intact, it does not mean they were healthy—the sickened neurons could still fail to send proper signals through the junction without completely detaching from it, explaining the poor rotarod performance.

The researchers concluded that mitochondrial mSOD1 is only responsible for part of ALS pathology. “It is now becoming clear that a combination of toxic effects are probably necessary to drive motor neuron disease onset and progression,” wrote Adrian Israelson of the University of San Diego, who was not involved in the study, in an e-mail to ARF.

Precisely how mSOD1 disables mitochondria is unknown. It might interact with proteins or other factors in the respiratory chain, Manfredi suggested, or it might promote the formation of free radicals. The new mito-mSOD1 mouse can help answer that question, commented Piera Pasinelli of Thomas Jefferson University in Philadelphia, Pennsylvania. “This is a powerful tool to really dissect the specific contribution for the mutant SOD1 in these organelles,” said Pasinelli, who also was not involved in the current paper.

One pathological event that is relevant to mSOD1 in mitochondria is production of reactive oxygen species, which generate other toxins, such as peroxynitrite, which can drive apoptosis, or programmed cell death. SOD chemically modifies other proteins in the presence of peroxynitrite. In the October 27 Journal of Biological Chemistry online, researchers from the University of Melbourne, Australia, propose a potential treatment for this mSOD1 effect. They discovered that a copper compound that scavenges peroxynitrite extended lifespan, and reduced inflammation, in a mouse model for ALS that expresses lower levels of SOD1-G93A than Manfredi’s mice. “They do not look at mitochondria directly, but it is possible that there is an effect of the drug at the mitochondrial level,” Manfredi wrote in an e-mail to ARF. In addition, Manfredi noted, this study reports for the first time that their low-expressing G93A mice also exhibit TAR DNA Binding Protein 43 (TDP-43) pathology, which up until now had not been seen in mSOD1 mice. TDP-43 accumulated as fragmented, abnormally phosphorylated protein in the spinal cord of these animals. The study was led by first author Cynthia Soon and senior authors Kevin Barnham and Qiao-Xin Li.—Amber Dance.

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...mitochondrial mSOD1 is only part of ALS pathology...
Previously I had discussed mutant or misfolded SOD1 being found in not just PALS with the genetic mutation but also those with the more common sporadic type. In another new study, it was shown that mSOD1 altered the shape and function of mitochondria prior to symptom onset. This is a very nice clue to a possible pathogenesis of ALS. Damaged mitochondria produce massive amounts of ROS and produce a fraction of the energy the cell requires of each mitochondria. Normally damaged mitochondria are destroyed and recycled by the cell but in ALS the recycling mechanism also appears damaged. Before going too far down this path I should remind readers that astrocytes carrying mSOD1 are sufficient to cause disease in healthy motor neurons. So the answer is never as simple as we would wish.

One pathological event that is relevant to mSOD1 in mitochondria is production of reactive oxygen species, which can drive apoptosis, or programmed cell death.
As discussed above, ROS causes damage to cellular machinery if it overwhelms the ability of the cell to fight it. The lack of energy output is a "bonus" in terms of cellular stress. Once this combination hits the Endoplasmic reticulum the cell is in serious trouble.

In addition, Manfredi noted, this study reports for the first time that their low-expressing G93A mice also exhibit TDP-43 pathology, accumulated as fragmented, abnormally phosphorylated protein in the spinal cord of these animals.
As I discussed in my previous post linked above, mSOD1 has been reported to interact with TDP43. The nature and implications of this interaction is very far from clear. A recent study showed that TDP43 binds to an inflammatory protein called NF-kb p65 in PALS but not controls (people without motor neuron disease) In the microglia, this causes upregulation of inflammatory factors in the CNS. Neuroinflammation is a major factor in progression of ALS.

This is a lot to digest, but are only a few of the clues to the etiology and pathology of ALS. They are like moths circling around a lightbulb that we cannot yet see. However, the more moths we see and the more precisely we can chart their paths, the more we can learn about the bulb. We now have many more moths, with much better understanding of their flight, than even a few years ago. The picture of the bulb is getting much clearer and brighter. One day soon we shall see the light.

Sunday, October 30, 2011

Doggone It!

As my readers might know, I have a PEG tube for feeding. I also have a little dog who is more like a 5-year-old in a dog suit. She is quite devious, even having learned how to stomp the foot lever that opens the lid on the trash can.

For the past few months, ever since I stopped using medical formula to correct the diabetic condition it created, I have been giving her a few tablespoons of my meals. Last Friday, I was working on some email while lunch flowed into me. Out of the corner of my eye I noticed some movement and realized it was the rolling stand from which the feeding bag was suspended.

I didn't feel the earthquake that must be responsible for the stand rocking back and forth and nothing else seemed to be moving (especially my computer which is suspended from the ceiling). A quick mental inventory revealed I wasn't on any drugs that I was aware of. Motor neuron disease doesn't involve hallucinations.

I didn't feel possessed...

Suddenly I felt a tug on the feeding tube and heard the tell-tale clicking of canine toenails on hardwood. That little thieving pooch was chewing the tube trying to get more of the clam chowder I had shared 30 minutes prior! I swear she knew that I couldn't do anything to stop her. But I also knew that, being 17 years old, she is a little hard of hearing. So rather than ring my call bell which she can hear and knows means trouble for her, I made my computer call in my caregiver on the sly.

Busted doggie!

Saturday, October 15, 2011

PEACaboo

Last month I wrote about the Steve Saling ALS Residence. Steve recently posted a video about the technology which is a large part of what makes the Residence so wonderful for PALS. Every PALS should demand a Residence in his/her local community.