Growth Potential

Two new studies came out that I found rather interesting. The ability to transfer into humans is years off but the progress is still impressive. First up, a team at the University of Toronto developed a new technique to expand stem cells at industrial capacity. Second, Children's Hospital of Philadelphia generated a new human stem cell type called an "endodermal precursor". If the new stem cell technique can also be used to generate ectodermal precursors, it could be a major advancement in regenerative therapy for ALS. Many additional steps would still be necessary but mass-production of teratoma-free cells would be an important contribution.

Letter From The Void

This letter was written in 2010 by another PALS who has since passed. I didn't always agree with him about certain things, but on this we most definitely do: ALSA National is letting us down. They have a nonexistent communication campaign unless it is to beg money from PALS (people already under severe financial stress). They have a basic research program that receives a small portion of the budget and no translational program (to move prospective drugs from the lab to the patient). They purport to provide equipment and services yet quietly refer people to other organizations because they "just don't do that". PALS may have good experience with their local Chapter (the OT in mine is an absolute superwoman) but there is no consistency between each Chapter.

This letter was written in 2010 and is unfortunately still true. ALSA is failing us.

Ms. Jane Gilbert,
I am writing to you as a 48 year old former airline pilot and victim of ALS, now in my fourth year. The purpose of this communication is to convey my terrible disappointment with the performance of the ALS Association at the national level. In my view, ALSA national is not putting the best interest of the patient community first. The game of baseball provides an excellent visual model of the awareness, advocacy, and research dynamics. Awareness is first base, advocacy is second base, research is third base, and a TRULY effective treatment resides on home base. Sadly, although the game has been playing for decades, the patient community has yet to reach first base. We have no unified national voice and no public awareness program. ALSA seems content to send e-mails to the patient community encouraging the purchase of cheap Chinese bracelets and have this serve as a national awareness program, which it clearly is not. The bedrock of an effective national awareness program is a series of public service announcements airing consistently on national networks. Anything less is a waste of time and resources. Here is what I can see during a typical day of television viewing. See if you can discover a pattern. Quite often on ABC at 6:45pm, I see an excellent PSA from the Alzheimer's Association, nothing from ALSA. I see KFC commercials for the "pink bucket" of chicken to support breast cancer initiatives, nothing from ALSA. I see PSAs for the breast cancer walk in DC on May 9th, nothing from ALSA. I see the PSA for the MS walk,nothing from ALSA. I see a PSA for the Epilepsy walk, nothing from ALSA. Earlier this year I saw yogurt commercials highlighting the "pink cap" for breast cancer, nothing from ALSA. Do you see the clear pattern that quickly emerges, Ms. Gilbert? Is this disservice to the patient community something to be proud of? ALS continues to be one of the best kept secrets in America because our national organization stubbornly refuses to initiate a consistent program of FREE public service announcements. Can you explain why ALSA refuses to place PSAs on national television? ALS Canada sets a fine example with their public awareness program, that includes an excellent PSA depicting all the phases of ALS in just a few seconds. After their PSA aired for a while, ALS Canada was pleased to notice a large increase in revenue. The PSA system is proven to increase awareness and donations, but it will not work if ALSA refuses to use it at the national level. Considering the bleak prognosis of the patient group, we need the loudest, most radical national organization to push progressive change. Anything less is a disservice to the ALS community. Because there is no national awareness program, and we haven't reached first base, advocacy is suffering on second base. An effective advocacy program depends upon an effective public awareness program. The public must know the details of ALS in order to support our cause. Likewise for those who control the federal research funds. A new phrase has been circulating on ALS blogs and forums. Anemic Advocacy. The sole use of this new phrase is to describe the advocacy of ALSA at the national level. Last year, we went to the Hill with tin cans to beg for only 5 million dollars from the DOD. This year we are asked to again approach the Hill for only 15 million dollars. While other patient groups demand adequate funding, we are encouraged to move in and sweep up the crumbs. Do you realize that even in 2001, HIV research was supported by 4 billion federal dollars? This year, the Alzheimer's Association is demanding 2 billion dollars. ALSA acknowledges that 95% of ALS research projects will go unfunded. This would not be the case if ALSA demanded real money instead of pocket change. This year, I will spend my time at the Missing Parts display. I will not carry the can to beg for table scraps. I will however, be willing to climb the Hill to demand not less than 250 million dollars in federal research funding. Swift access to investigational new drugs was a listed legislative priority in 2005 and 2006. Now that important priority is gone, and we still cannot access new drugs. When I asked ALSA for help with obtaining Iplex last summer, there was no interest. Why?I realize that ALSA may not be able to correct the many deficiencies in the research community, so I'll not dwell long on the third base of the model. Increased funding will help, as will increased communication between all research efforts. A major victory would be achieved if the conventional clinical trial structure were overhauled to reflect the reality of a fast moving condition such as ALS. The process must be simplified and streamlined. When patients don't live long enough to complete a trial, something is wrong. Just a few more concerns left. I know that a letter was sent to ALSA national some weeks ago asking that all organizations involved in the fight against ALS be welcomed to present at Advocacy Days. The request was denied. As a result, other fine organizations are forced to use the lobby or other hotels. Why is ALSA national so hostile to other organizations that just want to help? We need a unified effort, not political turf wars. What is the issue with signs this year? Last year, my daughter and I carried signs to increase ALS awareness and inform the public of our plight. The signs were very effective and well received at the conference, among the public, and on the Hill. Without signs, you can only bring the message to people next to you, if you still have a voice. You may know that many ALS patients lose their voice, therefor signs are the only means of personal expression and communication. With a sign, I can reach every person within 50' of my chair. I don't appreciate being lied to. ALSA seeks to prohibit free speech citing existing regulations prohibiting signs on the hotel property. Quick communication with the JW Marriott reveals that there is no regulation against signs. The element of trust has been damaged. I will once again bring my signs to communicate with the people. I do not wish to cause a disruption and I ask that ALSA not instigate a confrontation by attempting to take my voice away. I notice that the schedule is open on Sunday until 2 pm. Why are our veterans not being honored with a wreath this year?This is a public letter published on ALS forums. I challenge you to take the stage on Monday morning. Many within the ALS patient community will be interested in what you have to say.

The Mito-Can't-Rias

One of the earliest observations in ALS is a weakening of the energy-producing organelles of the cell called mitochondria. The mitochondria are found to only output about half of the energy as normal while producing more waste in the form of Reactive Oxygen Species (ROS). Think of your car engine horribly out of tune where you don't get your normal acceleration and nasty black smoke pours out of your tailpipe which causes you to fail smog inspection, only this smoke causes your car to rust away from the inside out. In addition to reduced energy output, mitochondria in neurodegenerative diseases also don't repair themselves well and have, in previous research, suffered from axonal transport problems which appeared linked to the "die-back" of the axon and detachment from the neuromuscular junction (NMJ).

However, a recent study that used live imaging of mouse motor neurons showed that axonal transport was independent of mitochondrial density and axonal degeneration. In mice with different SOD1 mutations, axonal transport was affected differently (or not at all). The motor neurons of the mice bred to have the SOD1 G93A mutation, which are used in the majority of studies because they are the model most understood, showed extensive axonal transport problems early on while G85R motor neurons showed very little even up to end-stage. Even mice bred to overexpress (multiple copies of the gene) human wild-type (non-mutant) SOD1 showed axonal transport issues without motor neuron degeneration. The "code" for the mutations refer to nucleotide transpositions at numbered locations in the SOD1 gene that creates the SOD1 protein. Below you can see movies of transport in the various types of neurons relative to controls.

WT-SOD1

G93A-SOD1

WT-SOD1

G85R-SOD1

WT-SOD1

WT-SOD1 (human, overexpressed)

I have previously posted about the role of mitochondria in ALS and discussed various implications. I have also posted about the possibility of a role of SOD1 in both FALS and SALS as well as the possibility of SOD1 as a prion in the propagation of ALS. In all the mutant SOD1, mitochondria show dysfunction early. Mitochondria also have "communication" with the Schwann cells at the NMJ which is an early event in the destruction of the NMJ and commencement of the axonal die-back.

Nothing is as simple as we would like, and ALS exemplifies this axiom. What would seem apparently causal might merely suggest another, as yet undiscovered, mechanism which may underlie other related observed effects. And sometimes what appears to be a related effect may just be something separate. Regardless of any doubt cast on the role of axonal transport in ALS, the mitochondrial dysfunction with which it is associated still appears strongly implicated. The cause of that remains under investigation.

The Fix-Up

To communicate (and do other things like write this blog) I use a computer set up with a special infrared camera and software which allows me to control the computer with my eye. The hardware platform this system runs on is a very nice little tablet PC from TabletKiosk. I chose the ERICA system from ERT specifically because it was based on this tablet which, even 4 years later, is way more powerful than all other competitors I know save one (and the new i500T easily matches that). Being an Information Technology professional I knew that I would be doing quite a bit more than just typing and talking, and would require the computing power and features of the Sahara Slate PC.

After years of heavy, daily, use, the system started having trouble with the sliding power switch. Sometimes the power light would come on but the system would make no noise and the screen would remain blank (it would fail to POST, for my fellow geeks). My assistant would have to hold the power switch for 5 seconds to turn the machine off and then try again. This frequently resulted in a total hang which required pulling the power cable and battery. Because the machine was mounted and had a docking cradle attached, this required some disassembly to get at the battery. Needless to say, as this problem became more frequent I became more worried that each procedure would result in a fried computer.

I looked up support on the TabletKiosk site and saw that they had a nice little online Forum for questions and user support. I posted a message and also emailed tech support in the hope they would answer (mind you this system is over 3 years old). After some anonymous queries back to me for more information I was contacted by the Director of CorpComm who helped me set up a process by which they shipped me a loaner identical to my system, I popped my hard disk in the loaner, shipped my system back to them for evaluation and repair, and then the reverse. This way I was able to keep my heavily-customized work environment during the couple of weeks required to complete the process.

The problem was with the motherboard, which was replaced. I have my system back and it's as good as new. These TabletKiosk PCs are nice and solid with a great list of features. I would recommend these to all my friends who want a reliable and powerful tablet computer that is Linux-ready (hint hint). TabletKiosk was extremely courteous and supportive and got me through what could have been a total disaster in my life.

I would like to thank by name John Kwan for his patient support and Lisa Herbert for getting the ball rolling and overseeing the process. It's not often that CorpComm meddles with TechSupport without tactical nukes being deployed... I would also like to thank the entire TabletKiosk team for making this able to happen. I very much appreciate their products and support

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.

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.

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

Without side effects:

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

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!

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!