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.

Wednesday, October 12, 2011

Chair the Love

Wondering about options for wheelchair-modified vans? My friend over at ALS Everyday Living has a very informative post on the subject. I urge my readers to hop over there and sign up for his updates.

Monday, October 3, 2011

Assaultrocytes

In my post Prion, Garth! I had talked about mutant or misfolded SOD1 (mSOD1) spreading like a prion and infecting neighboring cells. A recently released study from Johns Hopkins shows for the first time in vivo that astrocytes expressing mutant mSOD1 damage the motor neurons they are supposed to protect. In the study, the authors transplanted SOD1G93A glial-restricted precursor cells—glial progenitors capable of differentiating into astrocytes—into the cervical spinal cord of rats to reveal how mutant astrocytes influence WT motor neurons and other cells types (microglia and astrocytes) in an in vivo setting. The G93A mutation of SOD1 is the most studied version of that particular genetic mutation responsible for many inherited (or familial) ALS cases.

This is the strongest evidence to date that "assaultrocytes" are primary culprits in ALS. It also further suggests that even some sporadic ALS can be caused by misfolded SOD1 which escapes proteasomal degradation and gets into the extracellular space. It also suggests that targeting mSOD1 and stem cell implantation of astrocytes can be viable treatment methods.

EDIT: Here is a more in-depth article by Amber Dance at the ALZ Forum.

Saturday, October 1, 2011

Headlines

First off, there is some wonderful news: Diaphragm pacing system receives FDA approval for use with ALS patients. This is a device which extends time until vent by electrically stimulating the diaphragm. Note that this will not replace a vent as the diaphragm muscle needs neurons to release acetylcholine to the muscle fibers in order for them to contract. However, I urge all PALS reading this to immediately begin talking with your neurologist about whether this would be right for you. Here is some good information regarding the DPS.

Next up is the recent news regarding the Neuralstem trial involving stem cells implanted in the spines of PALS. Readers can see a poster-style synopsis of current trial data here. The initial results are encouraging, and one patient has even shown improvement. The next step in the trial is cervical implantation where the cells will have the chance to impact the phrenic nerve (the "money" nerve that serves the diaphragm and breathing). There is still much to learn about this technique before it is available to but a few. Remember that this is still a safety trial. I would urge readers to consider the words of Neuralstem's CEO.

Tuesday, September 20, 2011

Prion, Garth

in a previous post, I had discussed the possibility of misfolded SOD1 aggregating with TDP43 resulting in depletion of TDP43 from the nucleus which caused disruption of cellular processes and cell death. Further, misfolded SOD1 induces glial activation seen in ALS which poisons otherwise healthy neurons. A new study explores the mechanism behind this prion-like behavior, and further indicates that extracellular misfolded SOD1 can be a cause of even sporadic ALS. It also points to a molecular target which could halt progression cold. The study was done at the Brain Research Centre based at the University of British Columbia and the Vancouver Coastal Health Research Institute, in collaboration with researchers at the University of Alberta. The research was supported in part by Amorfix Life Sciences which has a "vaccine" against misfolded SOD1 already in development.

Thursday, September 1, 2011

Now Is The Time

I am a huge believer in staying at home while living with ALS, having done so for 4 years now. However, the financial stress is outrageous. I am personally bankrupt and have critically stressed the finances of my family. This is because there are no institutions which would accept me on a vent. Steve Saling, an architect with ALS, proactively designed a residence for people with advanced ALS and MS which utilizes technology to maximize their remaining independence and comfort. Steve currently resides there happily, and last year another PALS on a vent was rescued from a horrific institution and is now safely and happily living there. If I had a Saling Residence anywhere in this state I would have gone to live there instead. Please read the email message below. Immediate Attention - If you've ever wanted to help, here's your chance. Please spread this to anyone and everyone you can. Please write your letters ASAP. See video here for inspiration: http://www.youtube.com/watch?v=KlQvcw3kQe4 We need your help in establishing a residential living center for those suffering from ALS or MS in Georgia - We need your letter no matter where you are, if we can provide a residence like this here, your state could be next! We really need your help in generating the information requested below no later than September 15th. Forward this email to anyone you think can help. If we are unable to make a persuasive case for this facility it will not be approved and Georgia families (and everywhere) will be left to fend for themselves in supporting their loved ones afflicted with ALS/MS. Thanks for your continued support. Bill Saling Immediate Attention- We need your help in establishing a residential living center for those suffering from ALS or MS in Georgia We are in the final stages of securing approval from the State of Georgia to build a skilled nursing facility that will focus on serving residents with neurological diseases or impairments to include an emphasis on providing care to MS and ALS residents. This state of the art facility will utilize technology to provide the maximum personal independence for each resident. All of the necessary paperwork has been submitted and we are now being asked to provide additional written documentation by September 15, 2011 on the challenges currently being faced by those suffering from these illnesses. We need letters from individuals and families outlining the difficulty they have had in securing residential skilled nursing care for patients with ALS or MS. We need letters from doctors and case workers showing the difficulty families have in Georgia trying to find suitable living accommodations for those living with ALS or MS. We need to hear from families who have had to go outside Georgia to find suitable care for their loved ones suffering from ALS or MS. It would be very helpful to hear from healthcare providers on the difficulties they face in finding suitable housing options for people living on a vent. If we cannot convince the State of Georgia there is a pressing need for this type nursing center which is currently not being met by traditional nursing centers, it will not be approved. Any letters of support, documentation or testimony should be addressed to: Division of Health Planning, Department of Community Health Please EMAIL me your letter as soon as possible. I need to receive them before September 15th, 2011, via my email at kherron@sas-ga.org - Please copy Bill Saling at b.saling@yahoo.com

Tuesday, August 23, 2011

Often Awesome

Today the ALS Community lost yet another member. Tim LaFollette, Mr. Often Awesome, has returned Home. My heart is with his wife Kaylan. While I initially hid my condition for over a year, Tim had the foresight and steel balls to create the Often Awesome video documentary series so that the entire world can see his decline as he battled this disease from start to finish. This is "Tuesdays With Morrie" on steroids -- a very intimate and detailed look into the horror and hope that is ALS. Not only did it show the effect on a young man cut down in the beginning of his prime, but it showed the devastating effect on family, friends, and community. One person may carry the disease, but many suffer irreversible collateral damage. People have told me how brave I am. However, compared to Tim, I merely dabble in ALS. He had the A4V inherited version, the worst and most aggressive possible. Whenever I would feel down about my situation, I would think about Tim and how he dealt with even worse with a fortitude and grace I cannot contemplate. I would like to thank him for unknowingly lending me some of his strength. I never met Tim personally, only having worked with him over Facebook on awareness and advocacy projects. When I heard the news this morning I shed exactly one tear. I then decided to more properly honor his memory by continuing to live with ALS as he did, on my own terms. I also intend to honor Tim by winning my battle and, like he did, help others win theirs. Fuck ALS.

Monday, August 22, 2011

Common Cause?

A sensational bit of news has begun spreading across the ALS Community: A common cause for all forms of ALS has been found!

But has it? Certainly it is a common process but is it really the cause?

The process involved is autophagy. One of the important jobs of autophagy is to break down and recycle misfolded (improperly constructed) proteins marked by another protein called ubiquitin. A proteasome then breaks down the protein into amino acids which are then used to build new proteins It's like tearing a house apart, timber by timber, and reconstructing another from the material. If this process is interrupted or incomplete then you have a pile of junk left laying around which is thought to impede the efficient operation of the cell. An example of this is the amyloid plaques that are thought to cause Alzheimer's. However, removal of those plaques did not affect disease progression.

ALS is now strongly considered to be a "non-cell-autonomous" disease. This means that something outside the cell is causing the disease. Some of the most persuasive evidence for this is a recent study involving cells known as astrocytes become toxic to the motor neurons. This happens in both the inherited form (familial or FALS) and the more common sporadic form (SALS). Previous readers will know about my interest in current research regarding neuroinflammation as a primary cause of ALS and other neurodegenerative disease. This is also a common cause from a variety of triggers. It is, however, upstream of the "cause" identified in the recent news.

The calcium influx from the excitotoxicity created by neuroinflammation damages the mitochondria. In fact, this is a primary event. It is known that the motor neurons "die-back" along the axon, and that mitochondria motility down the axon is one of the first problems in ALS and neuroinflammation models. Once the mitochondria are damaged and cannot be repaired/replaced, pretty much all bets are off inside the cell. The cell becomes starved for energy, the cellular machinery (such as proteasomes) begins to fail, and the mitochondria start producing apoptotic factors which leads to cell death. Normally this wouldn't be a problem as many of the cells in the human body die and are simply replaced (even brain cells). However, the motor neurons you are born with are the very same motor neurons you die with.

I therefore posit that this "common cause of ALS" is too downstream of the actual cause for treatment based solely on it to be effective in and of itself. It's like trying to stop a waterfall at the edge of the cliff rather than building a dam in the stream a mile further behind. I do believe that although this may not lead directly to a single effective treatment, it would nearly certainly be an important part of a "cocktail therapy". The major positive I take away from this is that it answers the question whether the SOD1 model is applicable to all forms of ALS.

Friday, August 5, 2011

Chatterbug

Since I lost the ability to travel and talk, I use Instant Messaging to keep in touch with family and friends all over the world. Everybody seems to have their favorite client, be it MSN, Yahoo, AIM, or Google. Rather than try to force everyone to switch to a client program of my choosing, I installed all of the various programs and created accounts (I did force some to stop using Facebook chat because it doesn't play nicely with my system). This was fine and dandy, but now my boot load time was obnoxiously long and my computer's RAM was getting low, leading to performance issues. Luckily I had bumped my system up to 4GB in anticipation of my higher-than-normal demands. This led me to search for an alternative, where I could combine most or all of my clients into one ("One client to rule them all, one client to find them..."). Prior to disease, most all my computer systems in the house ran Linux. On my personal laptop I used a program called Pidgin which talked to all the major IM services. The Windows port I found a little lacking and probably not a great fit for most users. A friend then suggested Trillian. I installed it, ran through the setup to fill in the login information for my various IM accounts, and launched the application. I was impressed with the sleek interface. All chat sessions are in one tabbed window. The settings are easy to use and customize. And my RAM usage dropped by about half a GB! Trillian doesn't support all of the functionality of the native clients such as video/audio chat and sometimes the file transfer isn't available, but for regular text chat (including the overly-cute emoticons) it works great. If I need the other functions I just pop up the native client and close it when I'm done. To save boot time and RAM I disabled the natives from loading at boot. It also supports a Facebook connection but I found the newsfeed to be annoying; I prefer to leave Facebook on the web browser where it belongs. I would also caution about security: Your IM logins and conversations are not encrypted or secure and possibly subject to inspection by 3rd parties (also quite possible on the natives), so be aware that transmitting sensitive information over this is not advised. If you are a chatterbug like me, I recommend using Trillian on your AAC computer. I would even recommend it for non-disabled people.

Monday, July 25, 2011

G-Whiz

Holy dancing cow! Today I was playing with my Google account and finally set up a G-Mail account. I then noticed a "Call Phone" link that connected me to Google Voice. While this isn't new by any means, since it was free for USA domestic and Canada, I decided to install the web browser add-on. Within a few minutes I was placing phone calls to friends. Imagine their surprise... The default setup comes across as "CLIENT_ONLY" which might be ignored by people with Caller-ID (most of my calls went to voicemail at first). So a few more minutes later I had "upgraded" my Google Voice account with a brand new mobile phone number in my desired area-code and linked it to my house land-line so people can call me if I am offline. Calls to my Google Voice number which go to voicemail are placed in an inbox I can access via my Google Voice or email. The voice quality on both ends was reported to be quite good. Calls were very easy for me to make. I cued up my opening lines so that as soon as the remote end answered I could hit "Speak" on my assisted communication device and identify myself. I had originally intended to use this in emergencies if I couldn't otherwise alert a caregiver (note that this is NOT suitable for dialing 9-1-1) but after my test calls went so well I decided that I have a "new" communication method for talking to my more patient friends. I had used Skype in the past, but Skype is only free for computer-to-computer calls, not to regular cell or land-line phones. I was able to do all of this with my eye-tracking system with relative ease. If you have control over your eye-tracking assisted communication device and can install software, I recommend trying this out to see if it works for you. UPDATE: Configuration instructions are in the Comments section.

Thursday, July 21, 2011

Jury Duty

As many of you know, I have two previous posts about a drug in trial called NP001 (see "Salty Dog" and "All Roads"). In the past few days ALSA released a statement about this trial. I thank ALSA for doing this service for pals in spreading the word about this trial. Recent research seems to finally hold real promise of effective treatment for ALS, the realization of over a century of work. However, until we have the hard data all we have is promise and hope (which while powerful are still ineffective treatments for real disease). It is the responsibility of eligible PALS to become "jurors" in these trials and help us all to find the facts which can free us from the death sentence which Fate has issued.

Monday, July 18, 2011

Brainstorm Coming

Some more very good news for PALS in the USA: Brainstorm is bringing it's stem cell clinical trial to the US! This technology, named NurOwn, uses a patient's own mesenchymal stem cells to produce little factories for neurotrophic factors (proteins that nourish and strengthen neurons). This would provide a constant and lifetime production of support for the neighboring neurons, a much more effective approach than drugs which are only present for a short time or may be reduced or blocked by the Blood-Brain-Barrier. Note that this is not a replacement therapy, but rather one to help feed and protect existing neurons. You can read about the trial protocol here. For recently diagnosed patients they will inject into muscles to try to take advantage of axonal uptake in the hope that this will preserve the axon and its attachment to the muscle (neuromuscular junction). Patients in later stages of disease will have an injection into the spine to treat the neurons' cell bodies directly.

Thursday, July 7, 2011

All Roads

It has been known for some time that chronic neuroinflammation is a primary driver of disease in ALS and its "cousins" Alzheimers, Parkinsons, etc. Many attempts have been made to address it by using anti-inflammation drugs without success. Recently a study was published using a "prodrug" in animal models of Alzheimer's and Huntington's diseases. In this study, the drug 2-(3,4-dimethoxybenzenesulfonylamino)-4-(3-nitrophenyl)-5-(piperidin-1-yl)methylthiazole (JM6) inhibited the action of KMO, which is involved in the metabolism of tryptophan. This causes tryptophan to metabolize into kynurenic acid (KYNA), a neuroprotective substance, instead of quinolinic acid (QUIN), a neurotoxic substance. This degradation of tryptophan is called the kynurenine pathway (KP). It is one of the major regulatory pathways of the immune response and is known to be active in neuroinflammation. In HD, AD, and PD (Parkinson) there is decreased KYNA and increased QUIN. In multiple studies, changing the KYNA/QUIN balance in favor of KYNA is neuroprotective via a variety of methods.

Of interest to the ALS Community is that the same imbalances are seen in ALS. Strong evidence suggests that dysregulation of the KP leads to the type of neuronal damage from chronic neuroinflammation seen in many neurodegenerative diseases. In vitro testing with rodent motor neuron cells revealed a functional KP, that degeneration increased with duration and magnitude of exposure of QUIN, and that KYNA was protective against damage to neurons. It is known that QUIN is an NMDA receptor agonist (activator) and that KYNA is an antagonist (inhibitor). NMDA receptor-mediated excitotoxicity via calcium (Ca+) influx is a known cause of motor neuron death in ALS. This means that inhibition of KMO (aka kynurenine 3-hydroxylase) should be beneficial in ALS as well. Fortunately, K3H/KMO has been characterized for some time. In a study done in 2000, KMO (referred to as K3H) was found to be inhibited by Cl- (chloride). Luckily for PALS, there is already a chlorine drug in trial. This drug creates Taurine Chloramine (TauCl) which modulates the pro-inflammatory response seen in ALS, and also appears capable of rerouting KP to a beneficial product rather than harmful.

From the above it appears that previous attempts at modulating neuroinflammation failed because they were targeting symptoms rather than underlying cause (like treating a headache with aspirin when the cause is a tumor). By boosting the body's endogenous TauCl production a clearly malfunctioning immune response can be guided to its secondary, nurturing, state. At the same time, multiple targets identified in ALS can be struck with a single weapon: Excitotoxic calcium influx from glutamate receptors (currently treated with little effect by Riluzole), mitochondrial distress (currently the target of other drugs in trial), and the neuroinflammation which is one of the main drivers of disease progression in ALS.

While all roads may lead to Rome, it appears that in neurodegenerative disease they may lead to KP moderation by chloramines.

Sunday, June 5, 2011

Growing Grass

A few weeks ago, Professor Stephen Hawking was quoted in The Guardian newspaper saying "there is no Heaven; it's a fairy tale." Shortly after, two radio "shock jocks" in the Houston market decided to take issue with Professor Hawking's words by belittling his condition and questioning his abilities. I won't repeat their attack, but it was immature and offensive to all people affected by ALS. In response to their attack, a Facebook group was formed to boycott the radio personalities and the advertisers on their network of stations. The goal was formed to not just demand an apology but to make this a teachable moment by demanding that the parent company, Clear Channel, also air multiple PSAs. In addition, Clear Channel agreed to a 30-minute interview featuring Steve Perrin, the CEO of ALS-TDI. All of the boycott group's demands were met. This marks a major event in awareness for ALS. An organized grassroots movement was formed via social network tools and used those tools to achieve a goal long-sought in the community. This is only the beginning, and a perfect example of the kind of the cooperative relationship we need to foster with media, local and national.

Wednesday, June 1, 2011

Cell Mates

In 2006, mouse fibroblasts were successfully transformed from a fully differentiated state to a state of pluripotency. These cells were designated induced pluripotent stem cells (iPSC).Since that news, human cells were successfully transformed and techniques to increase the safety and efficiency of production have been found. Other techniques have been developed which can correct genetic defects in iPSCs with the eventual goal of repairing or replacing defective tissues.

iPSCs still have issues to be resolved such as:
  • certain methods of inducing pluripotency are tumorigenic
  • iPSCs appear to have "memory" of their original cell type
  • there is some data showing that iPSCs express certain proteins on their surface resulting in immune rejection even in cells donated from the host's own tissue
  • other complications such as efficiency (allowing sufficient numbers of cells to be generated within a clinically acceptable time at a clinically acceptable cost).
Some of these issues are already being addressed and quite frankly the pace of research has been astonishingly rapid. iPSCs are already being used to model disease and aid drug discovery. Due to the novelty of cell-based therapies and the fact that implanted cells are difficult or impossible to remove (unlike dosages of drugs which can be ceased in the event of adverse reaction), regulatory hurdles are necessarily high. However, as more trials are performed giving more data on safety these hurdles can be lowered somewhat and/or more easily surmounted. There are cell-based therapies already in or going through the regulatory process for trials using a variety of stem cell types. Not only do these prospective treatments face regulatory hurdles, they must also cross the Valley of Death of pharmaceutical research. Some researchers are finding ways of doing this on their own with intellectual property partnerships, and the NIH has been working to bridge the gap with new programs such as TRND.

This is a very exciting time for regenerative medicine.

Wednesday, May 18, 2011

FUS and ALS: What's the Connection?

A very interesting article from the MDA. Discusses some exciting work regarding the role of FUS in ALS. The article also mentions TDP43 and a possible convergence in the pathologies of both.

Friday, May 6, 2011

The Cost of Breath

Despite having a "fatal illness", with a little technology and someone to keep an eye on me for the inevitable adjustments, I can live until age draws the final curtain on the story of my life. My quality of life remains high regardless of my current certain physical limitations. There is nothing wrong with my mind: I am still as intellectually productive as ever. Nothing would please me more than to earn my own keep (and I am not alone in this desire), but people classified as terminally ill don't appear to be considered viable members of the workforce. So I volunteer my time to raise awareness and try to understand relevant research, sharing what I learn with others (a part of my previous career and the genesis of this blog). I find this work fulfilling and it keeps my opinion of my quality of life quite high, focusing on accomplishment rather than loss. Those close to me can attest that I can get cranky between projects when I have nothing to do so I try to stay busy. As I am quadriplegic I must use a computer system that tracks my eye movement to approximate the use of a mouse. With this computer I write and respond to email and online chat offering technical advice and answering questions from other PALS, scour the Web for research information, create videos to promote awareness, created a website (with coding assistance from a friend far more skilled than I), and play with my home computer network among other projects. The decision to vent or not is a highly personal one with many factors contributing to the decision. I chose to live on a vent for a few reasons. First, I had finally recently achieved real happiness in life and didn't want the dream-come-true to end so soon. Second, I saw some hope on the horizon with the state of research into the disease and possible ways to overcome it and I still hold this view more than ever. Last, and important to my perception of quality of life, I still had a contribution to make to the world and I have only grown more intense in that belief. I am simply not done living, with all which that experience entails. But my every breath now comes at a price. Because I cannot move to assist myself I must have an able-bodied person within hearing distance of any alarms or signals from my equipment. The skill requirements aren't high and can be taught in a weekend, but nevertheless someone must be alert and on duty 24/7. Family is often preoccupied by the demands of daily living, volunteers are few and far between, and government assistance is non-existent for people in my condition. The one factor which should NOT be involved in deciding whether to live on a vent is the cost of attendants. Medicare will not provide for in-home attendants. There are even very few institutions which will take people on mechanical ventilation and hospice is not an option due to the vent being a life support device. With the enormous wealth floating around our for-profit healthcare system it is astounding that no insurance (not even my high-end corporate policy) will cover the cost of attendants. So my only option, given my desire to live, is to become a beggar on an offramp of the information superhighway. This is terribly humiliating to me.

Wednesday, April 20, 2011

Nerd Factor Five

As an Information Technology professional I tend to accumulate equipment. I have a couple of old laptops lying around (some dating back to 1998). One of the slightly newer ones I connected to my TV via the external SVGA port (with an associated stereo sound cable connected to the headphone jack). Now I can stream Netflix and other online content to my big flatscreen TV while not using up the resources on my communication system. For independence I installed VNC which gives me full control over the remote machine. All I need is someone to power on the laptop and I am up and running. Currently I am watching live surfing being streamed from Bells Beach, Australia. Think I'll crack a Foster's and enjoy!

Tuesday, April 5, 2011

More Press

As many of you may already know, I was recently featured in an article in the Santa Cruz Sentinel. There was a lot of information to cover and I applaud Laura for getting it all in there. I did want to clarify some points: First (and least), I was the web group sysadmin for Lutris, building and maintaining the internal and external web infrastructure, and the I.T. manager for Mercedes-Benz Research & Development. Second, regarding vents, my point was that due to the costs involved, many never have a choice. Some make a choice not to vent, and I respect that. However, due to the financial expense, for many the choice is made for them regardless of their desire. This deprives the world of many potentially productive and engaged people, and is an ongoing concern of mine.

Wednesday, March 30, 2011

Another Victory

This is why we do it. Olya in the Ukraine needed a biPAP which she couldn't possibly afford. She contacted ALS Guardian Angels. I chat with the ALSGA coordinator quite frequently, heard the story, and donated my old biPAP. ALSGA shipped it to Poland and Olya's friends got it to her from there. Another PALS given more time alive by cooperation and action within the global PALS family. Although I appear in this story, it is not about me: It is about how we as PALS can change our own lives and the lives of each other. Without the new communications technologies now available (and the ability to use them) this could not have happened. The following is an email trail following receipt of the biPAP and a technical issue resolved. Some of the discussions took place over real-time chat and so aren't shown here. Total time from request to receipt and use was less than a month. -------------------------------------------------------------------------- From: Olya@.ru To: @.com Subject: I want to say thank you Date: Thu, 31 Mar 2011 00:19:27 +0400 Hello, Lisa! I can't wait to share my happiness with you. Today I've used the bipap for an hour or so for the first time and I felt excellent. Much better than without it. I learned how to do settings. I find my mask to be comfortable too. I feel deep relief now. I'm not scared any more not being able to breath normally and sleepless nights are the past. I've attached a picture of me while bipap therapy. Now I'm thinking back and understand that is would not be possible without ALS GuardianAngels, Stu and your priceless help. There were obstacles to ship the bipap and receive it, but you were so patient and sympathetic to me and to all this process. I sometimes can't believe it's true. When I tell people, that an American organisation helped me with the bipap and tell them this story,they say: "It's something unbeliveble, it's really hard to believe that miracles do happen". You can't imagine how much your help means for me and my family. I'm writing this and understand that I can't find right words to express how grateful I am.I also want to tell Eric (the donar) that his donation means '"surviving" for one more PALS (for me). That this is more than a gift! That I will always be grateful to him and never forget it. I want to cry out THANK YOU FOR EVERYTHING YOU ARE DOING FOR PALS! IT'S PRICELESS! Happy Olya 29.03.2011, 17:18, "ALS GuardianAngels" <@.com>:YAY, I am so relieved! Here is the companies contact information: Respironics Inc - 6 reviews - Place page www.respironics.com - 1001 Murry Ridge Drive, Murrysville, PA - (724) 387-5200 From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 15:09:30 +0400 Hello Lisa, It was voltage issue (the user guide info was right). My husband bought another adapter and the bipap works with the new one. Actually, at first we used an adapter too (an American one, as we have American product and it does with the device), but the bipap didn't work with it, but Ukrainian adapter is good.Thank you, Lisa, for your help, anyway. I was really worried. But I still need the contact of a provider in case something goes wrong in future.Model ð 1003986PCA1SN:3074661My phone number +38 095 700-68-67 29.03.2011, 02:25, "ALS GuardianAngels" <@.com>;:Also, please send me the model number and serial number...any other information would be great. A detailed reply about what is happening will also be helpful. Send me your phone number again as well. From: @.com To: olya@.ru Subject: RE: Olya: Mission accomplished! Date: Mon, 28 Mar 2011 18:23:01 -0400 For now, bring it in to your doctor at your appointment...they may have some advice. I'm hoping it's not a voltage issue between US and Ukraine products...we looked into that and we were certain it wouldn't be an issue. I can look for contact info, I already called them to see where the device was originally made (needed that for Customs). I will call them tomorrow as they are closed already today. From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 01:59:47 +0400 Picture is attached. This is what I see on the screen, when trying start the bipap. 29.03.2011, 01:07, "ALS GuardianAngels" <@.com>;:Olya, here is the user guide: http://global.respironics.com/UserGuides/UserGuideBiPAPSynchrony.pdf Let me know if this helps or not. Otherwise, I can definitely ask the Donor if he has any suggestions. From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 00:51:09 +0400 Hello Lisa, We have just tried to start the bipap and failed. It does turn on, but in several seconds long alarm sound and red solid and yewllow solid turn on while system self test. I think we should adress the provider, but we don't have one. Could you advice what to do? 28.03.2011, 17:58, "ALS GuardianAngels" <@.com>;:I just received this wonderful update form Olya! Also, since Olya wished to thank the donor I included him on this message. Olya, his name is Eric Valor...and he's a wonderful man and PALS from Santa Cruz, California. Thank you all, and Olya I look forward to more updates on how you are doing! - LisaFrom: olya@.ru To: @.com Subject: Re: Need help to live with ALS Date: Mon, 28 Mar 2011 16:53:01 +0400 Hello, Lisa! I have news. I've just received the bipap and the mask. I didn't try it yet. I'm going to see a doctor tomorrow and she should do all the settings. But I'm very excited I have the bipap. I will do my best to get accustomed to it. There is a nice surprise. When I opened the box, I found a humidifier there.I can't express how grateful I am to you and Stu and the donor and to all the people who helped me to get it and of course to God, who arranged my meeting ALS GuardianAngels. I'd love to thank the donor who agreed to donate it to me. I hope you can deliver my thanks to him. I am really very very excited. I can't believe everything is done.I will write you how I am doing with the bipap. Olya

Monday, March 21, 2011

A Possible Cause

For some time it appeared that the inclusions found in the cytosol of neurons in degenerative disease were causing the disease, likely due to disruption of movement of organelles and proteins up and down the axons. But evidence is now suggesting that may not be the case. With TDP-43, it appears that depletion of it from the nucleus is the cause of disease. With SOD1, an unknown toxic gain of function is still theorized. However, a recent study reported that mutant SOD1 interacts with TDP-43 where normal SOD1 did not. Conflicting previous studies have found and not found misfolded SOD1 inclusions in the motor neuron cytoplasm of sporadic ALS patients, though a study using novel antibodies specific for denatured SOD1 reported small inclusions in all tested SALS patients. SOD1 is a highly complex protein and such are easily misfolded. Usually this is no problem as either chaperones refold the protein or intracellular autophagy destroys the errant protein. But age and stress can cause autophagy to decrease in effectiveness, possibly leaving errant proteins in the cell where they can do damage. So assuming that mutant SOD1 is present either by genetic mutation or routine misfolding not corrected or cleared by the cell, and assuming interactions between mutant SOD1 and TDP-43 where TDP-43 is depleted from the nucleus, it could be held that mutant or misfolded SOD1 causes disease through depletion of nuclear TDP-43.

Activation of the glial cells (astrocytes, microglia, etc.) is a driving force in ALS progression. Experiments where mutant SOD1 was limited solely to the glia demonstrated the ability to drive disease on their own. In the case of inherited forms of ALS where particular mutated genes produce mutated forms of proteins throughout the body it is easy to imagine disease spreading rapidly once initiated. But what drives the more common sporadic forms? A clue might be found by looking at prion disease. In fact, a recent study shows that Huntington's Disease may very well spread this way, and it may be applicable to other neurodegenerative diseases. Indeed another study found that extracellular SOD1 can induce microglia to release pro-inflammatory cytokines and free radicals which promote motorneuron damage. A more recent study showed that introduced mutant SOD1 can induce disease. The biotech company Amorfix makes antibodies against extracellular mutant SOD1 and is now in trials to use these antibodies as a vaccine against ALS.

So with mutant or misfolded SOD1 we have multiple paths for disease as well as a likely pathway for spread of disease. Each of these questions are comparatively easy to test and seemingly easy to intercept in the extracellular space. I look forward to more studies to further illuminate these questions.

Friday, March 18, 2011

Public Service Announcement #2

I have created another PSA to accompany my previous one. Please spread these links everywhere you can to increase awareness. Until we can get a serious advocate we must rely on each other.

Monday, March 7, 2011

Taze Me Bro!

Rob Goldstein of the ALS Therapy Development Institute (ALS-TDI) talks to Dr. Seward Rutkove about his invention of device using Electrical Impedance Myography, which recently won the $1,000,000.00 Prize4Life award for biomarker development for ALS. This is available as an mp3 stream. Very interesting discussion and well worth a listen.

Friday, February 18, 2011

Press Release

This is a press release I created to help us get our story of struggle out to the media. Please cut and paste the text below and put your own contact information in the Contact: line then send to your local media with a cover letter explaining your own struggle and advocacy activities. With enough synchronous distributed local coverage we can generate national interest. If you can't cut and paste then email me and I will send you a copy. YOU are the story. But together we can create the change we demand. --------(cut and paste below)------------ People with ALS Changing Their Own World Contact: Much like the people in the Middle East, people here at home who are subject to another kind of tyranny are using social media such as Facebook, Twitter and Youtube to organize and spread the word about their condition. These people are known as PALS, or Person(s) with ALS. ALS, commonly known as Lou Gehrig's Disease after the famous baseball player who died from it, is a progressive and incurable deterioration of the nerves controlling voluntary muscle movement. This leaves the person totally paralyzed and eventually unable to even breathe. Because the expected lifespan from diagnosis rarely exceeds five years, the population of living PALS is low and those living aren't able to make themselves into public figures. Until now. With the advent of social media, as well as the technology of mobile computers with eye-tracking input systems and text-to-speech synthesis, PALS are able to compete on an even footing in cyberspace with more physically capable people. Many of these PALS are in serious medical conditions such as near total paralysis and some on mechanical ventilation via tracheotomy. As the astrophysicist and PALS Stephen Hawking said, "My body may be crippled but my mind is free." Unsatisfied with the level of advocacy and awareness generated by organizations with that as their claimed mission, PALS are doing it themselves and placing pressure on those representative organizations to change old operating procedures. Other organizations representing other medical conditions are very vocal and aggressive in public awareness (the foundation of funding and national priority for research) and this new group of PALS demand commensurate action from the organizations representing them. Examples of the new paradigm are: • an emergency Facebook movement to transfer one PALS from an abusive institutional care facility to an entirely new fully automated care facility (which was designed by another PALS who was also the first resident) http://www.govostes.com/blog/?page_id=172 http://www.youtube.com/results?search_query=saling+als+residence+&aq=f • the "Often Awesome" serial documentary of a PALS' life with ALS from diagnosis to current time http://www.youtube.com/results?search_query=often+awesome+&aq=f • various Facebook groups including a direct petition to the ALS Association http://www.facebook.com/pages/Petition-Against-ALSA-National/139603146055424?ref=ts • a movement to draft a Hollywood star as a spokesman https://www.facebook.com/alsspokesman • use of the popular video creation site xtranormal.com to craft and distribute their own Public Service Announcement http://www.youtube.com/watch?v=NgNVvHbIIiI Facebook as a corporation is aware of this group of PALS and recently invited a few to its Palo Alto, CA, headquarters to take part in a documentary being aired in March, 2011, on MTV. The documentary will be about how various groups have used Facebook to effect change.

Friday, February 11, 2011

Public Service Announcement

This is a little video I put together. It was a bit of work to do with my optical tracking system. I need your help getting it distributed so please share via Facebook, Twitter, email, whatever. Some may wonder why I didn't mention the ALS Association (ALSA). ALSA to this date refuses to mount a national PSA campaign like other more successful organizations, so I did my own. The two organizations I did mention I feel are more effective. But this is really about awareness so please help me and many others get the word out. Thanks!

Friday, January 21, 2011

Be Yourself

"I'm nobody! Who are you?" The concept of "self" is critically important in the immune system. Each of our cells present a unique set of molecules on their outer walls which signal to our wandering immunity police that they belong ("your papers, please"). Any other cells not presenting the same combination are considered foreign invaders and are attacked ("your papers are not in order!"). This works great for resisting infection but is a major impediment to transplant surgery. Even "tissue matching" is inexact, requiring recipients to have their immune system forever after repressed in order to maintain the graft. Finding a way to allow for a graft of desirable foreign tissue but also maintain a robust immune system is a therefore a major goal. A stem cell research grant by theCalifornia Institute of Regenerative Medicine has a quite novel approach: regenerating the thymus, the "police academy" where the immunity cells learn to recognize the body's own cells from foreign invaders. The thymus atrophies in adulthood, so regenerating it from stem cells from an appropriate HLA line might trick the immune system into accepting the graft with the same HLA type. Quite a clever approach, and yet another reason that I am glad to have voted in favor of forming CIRM (ironically shortly before I was diagnosed with ALS).

Monday, January 17, 2011

Apollo 13

"Houston, we have a problem." Apparently you can't believe everything you read. Whether it is a problem of vanishing results, reliance on unrepeatable or outdated information, or the fact that not all publications are created equally, there seems to be a serious problem with relying on medical publications. While research papers provide valuable clues, only after those results are repeatedly verified can they reach the status of fact. And even that could change over time as the sample set grows beyond what is practical for a single study. It seems that even rigorous science can fall prey to the human failing that people see what they want to see. This results in selective reporting as well as selective publication (rarely do negative results get submitted). And in the pharmaceutical industry there is the ever-present threat of monetary corruption. Note that this should not create a panic of Nihilism, but rather instill healthy skepticism and diminish false hope.