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Penn’s Glowing Cancer Tool Illuminates Benign, but Dangerous, Brain Tumors during Pituitary Surgery

Fluorescent, targeted dye illuminates molecular signature of tumor tissue in personalized surgery.

An experimental imaging tool that uses a targeted fluorescent dye successfully lit up the benign brain tumors of patients during removal surgery, allowing surgeons to identify tumor tissue, a new study from researchers at the Perelman School of Medicine at the University of Pennsylvania shows. The tumors, known as pituitary adenomas, are the third most common brain tumor, and very rarely turn cancerous, but can cause blindness, hormonal disorders, and in some cases, gigantism.

Findings from the pilot study of 15 patients, published this week in the Journal of Neurosurgery, build upon previous clinical studies showing intraoperative molecular imaging developed by researchers at Penn’s Center for Precision Surgery can improve tumor surgeries. According to first author John Y.K. Lee, MD, MSCE, an associate professor of Neurosurgery in the Perelman School of Medicine at the University of Pennsylvania and co-director of the Center for Precision Surgery, this study describes the first targeted, near infrared dye to be employed in brain tumor surgery. Other dyes are limited either by their fluorescent range being in the busy visible spectrum or by lack of specificity.

“This study heralds a new era in personalized tumor surgery. Surgeons are now able to see molecular characteristics of patient’s tumors; not just light absorption or reflectance,” Lee said. “In real time in the operating room, we are seeing the unique cell surface properties of the tumor and not just color. This is the start of a revolution.”

Non-specific dyes have been used to visualize and precisely cut out brain tumors during resection surgery, but this dye is believed to be the first targeted, near infrared dye to be used in neurosurgery. The fluorescent dye, known as OTL38, consists of two parts: vitamin B9 (a necessary ingredient for cell growth), and a near infrared glowing dye. As tumors try to grow and proliferate, they overexpress folate receptors. Pituitary tumors can overexpress folate receptors more than 20 times above the level of the normal pituitary gland in some cases. This dye binds to these receptors and thus allows us to identify tumors.

“Pituitary adenomas are rarely cancerous, but they can cause other serious problems for patients by pushing up against parts of their brain, which can lead to Cushing’s disease, gigantism, blindness and death,” Lee explained. “The study shows that this novel, targeted, near infrared fluorescent dye technique is a safe, and we believe this technique will improve surgery.”

Lee says larger studies are warranted to further demonstrate its clinical effectiveness, especially in nonfunctioning pituitary adenomas.

A big challenge with this type of brain surgery is ensuring the entire tumor is removed. Parts of the tumor issue are often missed by conventional endoscopy approaches during removal, leading to a recurrence in 20 percent of patients. The researchers showed that the technique was safe and effective at illuminating the molecular features of the tumors in the subset of patients with nonfunctioning pituitary adenomas.

The technique uses near-infrared, or NIR, imaging and OTL38 fluoresces brightly when excited by NIR light. The VisionSense IridiumTM 4mm endoscope is a unique camera system which can be employed in the narrow confines of the nasal cavity to illuminate the pituitary adenoma. Both the dye and the camera system are needed in order to perform the surgery successfully.

The rate of gross-total resection (GTR) for the 15 patients, based on postoperative MRI, was 73 percent. The GTR with conventional approaches ranges from 50 to 70 percent. Residual tumor was identified on MRI only in patients with more severe tumors, including cavernous sinus invasion or a significant extrasellar tumor.

In addition, for the three patients with the highest overexpression of folate, the technique predicted post-operative MRI results with perfect concordance.

Some centers have resorted to implementing MRI in the operating room to maximize the extent of resection. However, bringing a massive MRI into the operating room theater remains expensive and has been shown to produce a high number of false-positives in pituitary adenoma surgery. The fluorescent dye imaging tool, Lee said, may serve as a replacement for MRIs in the operating room.

Co-authors on the study include M. Sean Grady, MD, chair of Neurosurgery at Penn, and Sunil Singhal, MD, an associate professor of Surgery, and co-director the Center for Precision Surgery.

Over the past four years, Singhal, Lee, and their colleagues have performed more than 400 surgeries using both nonspecific and targeted near infrared dyes. The breadth of tumor types include lung, brain, bladder and breast.

Most recently, in July, Penn researchers reported results from a lung cancer trial using the OTL38 dye. Surgeons were able to identify and remove a greater number of cancerous nodules from lung cancer patients with the dye using preoperative positron emission tomography, or PET, scans. Penn’s imaging tool identified 60 of the 66 previously known lung nodules, or 91 percent. In addition, doctors used the tool to identify nine additional nodules that were undetected by the PET scan or by traditional intraoperative monitoring.

Researchers at Penn are also exploring the effectiveness of additional contrast agents, some of which they expect to be available in the clinic within a few months.

“This is the beginning of a whole wave of new dyes coming out that may improve surgeries using the fluorescent dye technique,” Lee said. “And we’re leading the charge here at Penn.”

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First Long-Term Study on Medical Marijuana’s Impact on Opioid Use for Pain

The National Institutes of Health (NIH) has awarded researchers at Albert Einstein College of Medicine and Montefiore Health System a five-year, $3.8 million grant for the first long-term study to test whether medical marijuana reduces opioid use among adults with chronic pain, including those with HIV.

Millions of Americans experience chronic, severe pain as a result of their health conditions.  Many take prescribed opioids, including Oxycodone, to help relieve their symptoms. But given the dangers of opioid use and misuse, both doctors and patients are seeking safe and effective alternatives to manage pain.

“There is a lack of information about the impact of medical marijuana on opioid use in those with chronic pain,” says Chinazo Cunningham, M.D., M.S., associate chief of general internal medicine at Einstein and Montefiore and principal investigator on the grant. “We hope this study will fill in the gaps and provide doctors and patients with some much needed guidance.”

Compared to the general population, chronic pain and opioid use is even more common in people with HIV. Between 25 and 90 percent of adults with HIV suffer from chronic pain. Previous studies have reported that despite the high risk for misuse of opioid pain relievers, adults with HIV are likely to receive opioids to help manage their pain. In recent years, medical marijuana has gained recognition as a treatment option. Twenty-nine states, plus the District of Columbia, have legalized its use; in those states, chronic pain and/or HIV/AIDS are qualifying conditions for medical marijuana use.

Researchers have never studied—in any population—if the use of medical marijuana over time reduces the use of opioids. Additionally, there are no studies on how the specific chemical compounds of marijuana, tetrahydrocannabinol (THC) and cannabidiol (CBD), affect health outcomes, like pain, function, and quality of life. Most studies that have reported negative effects of long-term marijuana use have focused on illicit, rather than medical, marijuana.

“As state and federal governments grapple with the complex issues surrounding opioids and medical marijuana, we hope to provide evidence-based recommendations that will help shape responsible and effective healthcare practices and public policies,” notes Dr. Cunningham.

Dr. Cunningham will enroll 250 HIV-positive and HIV-negative adults with chronic pain who use opioids and who have received certification from their physicians to use medical marijuana, which is provided through approved dispensaries in New York State. Over 18 months, the study subjects will complete web-based questionnaires every two weeks, which will focus on pain levels and the medical and illicit use of marijuana and opioids. They’ll also provide urine and blood samples at in-person research visits every three months. In addition, in-depth interviews with a select group of these participants will explore their perceptions of how medical marijuana use affects the use of opioids.

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CAR T-Cell Therapy for Leukemia Leads to Remissions in Clinical Trial

In an early-phase clinical trial of an experimental immunotherapy, researchers achieved durable molecular remissions in patients with chronic lymphocytic leukemia who had failed other treatments

Researchers at Fred Hutchinson Cancer Research Center showed about 70 percent of patients with the most common adult leukemia had their tumors shrink or disappear following an experimental chimeric antigen receptor (CAR) T-cell immunotherapy.

The researchers also found that measuring genetic traces of cancer cells taken from bone marrow biopsies might be a better indicator of prognosis than the standard lymph node scan.

The Journal of Clinical Oncology published the results online July 17 of the Phase 1/2 clinical trial, which included 24 patients with chronic lymphocytic leukemia (CLL) who had failed other treatments. Most of the patients had seen their cancer progress despite treatment with ibrutinib, a targeted cancer drug approved in 2014 for CLL by the U.S. Food and Drug Administration.

This history placed them in a high-risk group that was found in previous studies to have short survival with standard therapies.

“It was not known whether CAR T-cells could be used to treat these high risk CLL patients,” said lead author Dr. Cameron Turtle, an immunotherapy researcher at Fred Hutch. “Our study shows that CD19 CAR T-cells are a highly promising treatment for CLL patients who have failed ibrutinib.”

CD19 CAR T-cells are a type of immunotherapy in which a patient’s T cells are extracted from their blood and modified in a lab to recognize CD19, a target on the surface of leukemia cells. The engineered T cells are then infused back into the patient where they multiply and hunt down and kill cancer cells.

In CLL, bone marrow makes too many abnormal lymphocytes, which are a type of white blood cell. The American Cancer Society estimates that in the U.S., there will be about 20,000 new cases and 4,600 deaths from CLL in 2017. Tests of blood, bone marrow and lymph nodes—where lymphocytes congregate to fight infection—reveal the disease.

The 24 patients participating in the study ranged in age from 40 to 73 years, with a median age of 61. They had received a median of five other therapies with as few as three and as many as nine.

Researchers found that 17 out of 24 (71 percent) of patients saw their tumors shrink or disappear following CAR T-cell therapy using the standard measure of lymph node size by CT scans four weeks after treatment.

Of side effects of CAR-T cell therapy, 20 of the 24 patients—83 percent—experienced cytokine release syndrome (grade 1-2, 18 patients; grade 4, one patient; grade 5, one patient) and 8 patients (33 percent) developed neurotoxicity (grade 3, five patients; grade 5, one patient). For the most part the side effects were reversible, but two patients had side effects severe enough to require being admitted to the intensive care unit and one of those patients died.

 (An earlier report on trial results was presented by Turtle in December at the American Society of Hematology annual meeting.)

The new paper expands on the measures used to indicate whether the CAR T-cell treatment is working.

To take a closer look to see if any cancer cells remained after treatment, the research team analyzed samples taken from some of the patients’ bone marrow four weeks after the CAR T-cell infusion. The team used a genetic test called IGH deep sequencing, which is akin to a bar code and enables researchers to track cancer cells in the body.

Turtle and his collaborators did the sequencing analysis in 12 of the patients. Seven of the 12 patients had no malignant copies. All patients without malignant copies were alive and free of disease at a median follow-up of 6.6 months after CAR T-cell infusion.

Compared with the CT scans, having no malignant gene sequences in bone marrow following CAR T-cell therapy was a better predictor of the cancer staying at bay—known as “progression-free survival,” the researchers found.

The study is the first to suggest that deep sequencing might be a superior measure for predicting outcomes four weeks after CAR T-cell therapy for CLL.

The immunotherapy team at Fred Hutch is still enrolling eligible patients with CLL, acute lymphoblastic leukemia and non-Hodgkin lymphoma for treatment on CD19 CAR T-cell trials. The patients are seen at Seattle Cancer Care Alliance, the clinical care partner for Fred Hutch.

Fred Hutch co-authors of the paper are Kevin Hay, Laila-Aicha Hanafi, Shelly Heimfeld, Stanley R. Riddell and David G. Maloney. Other co-authors are Daniel Li, Juno Therapeutics; Sindhu Cherian, Xueyan Chen and Brent Wood, University of Washington; and Arletta Lozanski and John C. Byrd, The Ohio State University.

Funding for the project came from Juno Therapeutics, National Cancer Institute, National Institute of Diabetes and Digestive and Kidney Diseases, Life Science Discovery Fund, the Bezos family, and the University of British Columbia.

Turtle, Maloney and Riddell receive research funding from Juno Therapeutics and are named as inventors on one or more patents or patent applications related to this work. Riddell is a co-founder of Juno Therapeutics and has equity interest in Juno Therapeutics. Li is an employee of and has equity interests in Juno Therapeutics. Fred Hutch receives research funding from Juno Therapeutics.

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Three-Week Radiation Therapy Treatment Given Post Mastectomy Is Safe and Effective

Rutgers Cancer Institute of New Jersey research shows low toxicity in shorter treatment course

A shorter course of radiation therapy given to breast cancer patients following mastectomy is safe and effective and cuts treatment time in half. That is according to data from a phase II clinical trial conducted by Rutgers Cancer Institute of New Jersey investigators and other colleagues who examined a hypofractionated regimen given over three weeks versus the traditional six week course of treatment. The work appears in the current online edition of the Journal of Clinical Oncology (http://ascopubs.org/doi/full/10.1200/JCO.2016.70.7158).

When there is a concern that cancer cells may remain in the chest wall and lymph node regions following a mastectomy, a patient may be given targeted radiation over a five to six week period to further treat the breast cancer. “Receiving radiation for that long of a period becomes a quality of life issue for many patients. This includes the inconvenience of frequent travel to the treatment facility, as well as fatigue and other common side effects that can cause lost time at work and other challenges,” notes the work’s senior investigator Bruce G. Haffty, MD, professor and chair, Department of Radiation Oncology at Rutgers Cancer Institute, Rutgers Robert Wood Johnson Medical School and Rutgers New Jersey Medical School.

Researchers explored an accelerated course of radiation that cut treatment time in half. Currently, there is limited data supporting this type of treatment in this patient population.

From 2010 to 2014, 67 eligible patients with stage II to IIIa breast cancer were enrolled at Rutgers Cancer Institute of New Jersey and Huntsman Cancer Institute at the University of Utah. A dose of 36.63 Gy (a unit of radiation measurement) was given in 11 fractions of 3.33 Gy each.  The fractions were delivered over a three-week period to the chest wall and area lymph nodes.  The treatment also allowed for an optional four fractions (3.33 Gy each) of radiation to the chest wall at the mastectomy scar area, resulting in a total of 15 treatments over three weeks.

The aim was to not have any reported treatment toxicities of grade three or above. After a median follow up of 32 months, no grade three toxicities or higher were reported. There were 29 grade two toxicities reported, with a majority being skin rash followed by fatigue, similar to what may be experienced with the longer five to six week course of treatment. The estimated three-year survival rate of the cancer not coming back to the breast area was 89.2 percent.  The estimated three-year survival rate for the cancer not coming back and spreading beyond the breast was 90.3 percent.

“While shorter courses of radiation therapy have been adopted in patients receiving radiation therapy to the breast alone after lumpectomy, there has not been adoption of shorter courses of treatment to the chest wall and lymph nodes after mastectomy. This trial demonstrated the safety of this shorter course approach in a prospective phase II study,” notes Dr. Haffty.

Based on this study, a larger post-mastectomy randomized trial has been developed through the Alliance Cooperative Group with Haffty and current study investigators Matt Poppe of the Huntsman Cancer Institute and Atif J. Khan of Memorial Sloan Kettering Cancer Center leading the effort.  In this phase III trial, a shorter course of radiation in the post-mastectomy, post-reconstruction setting will be compared to the more conventional five to six week course of treatment.

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Cord Blood Test Might Help Predict Fatal Lung Disease in Preemies

Interventions for babies at risk could be started at birth to prevent disease

Findings published in the Journal of Pediatrics describe growth factors in cord blood that may identify premature infants at risk for bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) – an often fatal lung disease in which the vessels carrying blood from the heart to the lungs become narrowed and dysfunctional. Identifying these babies at birth would allow earlier interventions to prevent the disease that manifests in some preemies two to three months after birth.

“We have many promising interventions and it would be exciting to start them at birth in babies at risk, before they become extremely sick,” said lead author Karen Mestan, MD, a neonatologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and Associate Professor at Northwestern University Feinberg School of Medicine. “Currently we do not use cord blood for prediction of disease, but our study shows that it has tremendous potential to save lives.”

Using a large repository of cord blood and placental tissues from a wide gestational age range, Mestan and colleagues examined 15 biomarkers in cord blood, looking for correlations with lesions in the placenta that cause insufficient blood flow between the mother and fetus. They found that two growth factors – granulocyte colony-stimulating factor (G-CSF) and placental growth factor (PlGF) – were decreased with these placental lesions. They also found that these two growth factors were almost undetectable in extremely premature babies who later developed BPD-PH, as opposed to others who escaped the disease. The team validated these findings in a large sample of babies born at less than 28 weeks of gestation.

“Our findings also have implications for what we do during pregnancy,” said Mestan. “The growth factors we identified potentially could be measured in the mom’s blood, and if they are low, that would signal lesions in the placenta that place the baby at risk for severe lung disease. Better understanding about fetal origins of disease, which is still a mystery, would help us find new ways to improve outcomes even before the child is born.”

While the findings do not establish that deficiency in the two growth factors causes BPD-PH, they suggest a possible mechanism behind the disease. “There are many undifferentiated stem cells in cord blood and these growth factors might help mobilize them to get assigned to specific immune functions involved in the healing process,” said Mestan. “Preemies who are deficient in G-CSF and PlGF might not be able to fight off the development of lung damage. But what if we could replenish these babies with healthier stem cells or even replenish the growth factors? We could then regenerate lung tissue. This is a thrilling area of research that could have huge impact.”

Larger, multicenter studies are needed to validate findings before the growth factors can be used clinically to identify premature infants at risk for BPD-PH in order to initiate earlier interventions.

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How Prenatal Maternal Infections May Affect Genetic Factors in Autism Spectrum Disorder

Researchers find activation of maternal immune system during pregnancy disrupts expression of key genes and processes associated with autism and prenatal brain development

For some infections, such as Zika, the virus passes through the placenta and directly attacks the fetus. For others, such as the H1N1 influenza, the virus induces maternal immune activation (MIA) by triggering a woman’s immune system during pregnancy. Both Zika and MIA mechanisms may lead to potentially disastrous neurological repercussions for the unborn child, such as microcephaly (an undersized, underdeveloped brain and head) in the case of Zika or cortical abnormalities with excess numbers of neurons, patches of disorganized cortex, synapse mal-development and early brain overgrowth in some cases of MIA.

Large population-based studies suggest MIA caused by infection during pregnancy are also associated with small increases in risk for psychiatric disorders, including autism spectrum disorder (ASD). In a new study published today in Molecular Psychiatry, researchers at the University of California San Diego School of Medicine, University of Cyprus and Stanford University map the complex biological cascade caused by MIA: the expression of multiple genes involved in autism are turned up or down by MIA, affecting key aspects of prenatal brain development that may increase risk for atypical development later in life.

“We provide novel evidence that supports the link between prenatal infections and biology known to be important in the development of autism,” said senior author Tiziano Pramparo, PhD, associate research scientist at the Autism Center of Excellence at UC San Diego School of Medicine. “There are different routes of importance. We highlight a specific pathway that seems to be key in driving downstream early abnormal brain development.”

“Our work adds to growing evidence that prenatal development is an important window for understanding key biology of relevance to neurodevelopmental conditions like autism,” added lead author Michael Lombardo, PhD, at the University of Cyprus. “MIA is an environmental route of influence on fundamental biological processes important for brain development. The influence it exerts overlaps with key processes known to be important in how the brain in autism develops.”

Pramparo said the effects are not caused by the infectious agents themselves — virus or bacterium — but from the maternal immune response itself. “Although the mechanisms are not entirely known, it has to do with the cascade of altered events regulating production and function of neurons, their synapses and how they arrange themselves in the brain that are triggered when a mother’s immune system is activated.”

For example, increased levels of maternal cytokines (small signaling molecules driven by the immune response) may directly or indirectly alter gene expression in the fetus’ brain.

“These up- and down-regulated genes may lead to an excess or reduction in the normal amounts of proteins required for normal brain development,” Pramparo said. “Importantly, we have found that MIA-induced effects involve both single genes and pathways (many genes working in a coordinated way to serve some dedicated biological purpose) essential for early fetal neurodevelopment.” Among the large number of genes whose activity is altered by the maternal immune response, are a few that, when mutated, are thought to cause more genetic forms of autism in a small subset of all ASD toddlers.

Pramparo suggested the findings have multiple clinical implications.

“In general, the more we know and understand about a disrupted mechanism, the higher the chance of finding amenable targets for potential therapeutic intervention or for informing how to prevent such risk from occurring in the first place.”

Another implication, he said, is the potential to define the effects and clinical phenotypes based upon the underlying mechanisms: genetic, environmental or both.

“The MIA effects are transient but very potent during fetal development and perhaps even more potent than the effects induced by certain types of mutations in single gene forms of autism. Also, depending on when MIA occurs during gestation, the clinical characteristics may vary. The finding of MIA affecting the expression genes known to be important in autism supports the hypothesis that a genetic-by-environment interaction may lead to amplified effects at the clinical level. For example, more severe cases of autism.”

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Researchers Identify Potential Treatment for Type of Muscle and Brain Degenerative Disease

UCLA researchers have discovered the molecular basis of, and identified potential treatment for, an incurable disease known as inclusion body myopathy, Paget disease with frontotemporal dementia, or IBMPFD. Using both genetically engineered fruit flies that have the fly equivalent of the disease gene as well as cells from people with IBMPFD, the researchers discovered how mutations carried by those with IBMPFD cause cellular damage. They also identified two compounds that are able to reverse the effects of IBMPFD-associated mutations in flies and human IBMPFD cells. The findings suggest potential strategies to combat IBMPFD and other degenerative diseases, including amyotrophic lateral sclerosis, commonly known as ALS.

BACKGROUND
IBMPFD is an inherited disorder that affects the muscles, the brain and bones. Most people with the disorder show progressive muscle weakness, or myopathy, leading to mobility loss or even respiratory failure. Others develop dementia that predominantly affects language and behavior. No treatment is available to halt progression of the disease. Prior studies showed that mutations in a gene that encodes Valosin-Containing Protein, known as VSP, cause IBMPFD and some forms of ALS. Moreover, in people with IBMPFD, mitochondria, the energy-generating powerhouse of the cell, do not produce energy properly. However, it was not clear how VSP mutations disrupt mitochondria and how this disruption leads to disease.

METHOD
The team created fruit flies that are given the disease in their muscles, which results in multiple defects, including muscle cell death, similar to that seen in patients. In addition, abnormally small, fragmented mitochondria appeared, a sign of mitochondrial distress. This led the team to examine a protein called Mitofusin which controls mitochondria fusion, maintaining mitochondrial energy-production capacity in healthy cells. The team showed that VSP normally degrades Mitofusin, but mutant VCP is abnormally overactive, and promotes excessive degradation of Mitofusin. This discovery explains how cellular damage occurs. Most importantly, flies fed VCP-inhibiting compounds showed reversal of muscle wasting and mitochondrial fragmentation. Patient cells treated with the same compounds showed similar positive responses.

IMPACT
Biomedical researchers are increasingly aware that defects in mitochondrial fusion are a hallmark of conditions ranging from Parkinson’s disease, heart disease to diabetes. This paper reveals how mutant VCP can cause cellular destruction seen in IBMPFD by interfering with proteins responsible for controlling mitochondrial fusion. Importantly, VCP inhibitors can reverse the pathology of IBMPFD in flies and in patient cells. VCP inhibitors are currently being studied in clinical trials for cancer. This raises the possibility of using VCP inhibitors for treatments of IBMPFD and other diseases caused by VCP mutations, such as ALS, peripheral neuropathy and hereditary spastic paraplegia.

 

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UW Scientists Find Key Cues to Regulate Bone-Building Cells

The prospect of regenerating bone lost to cancer or trauma is a step closer to the clinic as University of Wisconsin-Madison scientists have identified two proteins found in bone marrow as key regulators of the master cells responsible for making new bone.

In a study published online today (Feb. 2, 2017) in the journal Stem Cell Reports, a team of UW-Madison scientists reports that the proteins govern the activity of mesenchymal stem cells — precursor cells found in marrow that make bone and cartilage. The discovery opens the door to devising implants seeded with cells that can replace bone tissue lost to disease or injury.

“These are pretty interesting molecules,” explains Wan-Ju Li, a UW-Madison professor of orthopedics and biomedical engineering, of the bone marrow proteins lipocalin-2 and prolactin. “We found that they are critical in regulating the fate of mesenchymal stem cells.”

Li and Tsung-Lin Tsai, a UW-Madison postdoctoral researcher, scoured donated human bone marrow using high-throughput protein arrays to identify proteins of interest and then determined the activity of mesenchymal stem cells exposed to the proteins in culture. A goal of the study, says Li, is to better understand the bone marrow niche where mesenchymal stem cells reside in the body so that researchers can improve culture conditions for growing the cells in the lab and for therapy.

The Wisconsin researchers found that exposing mesenchymal stem cells to a combination of lipocalin-2 and prolactin in culture reduces and slows senescence, the natural process that robs cells of their power to divide and grow. Li says keeping the cells happy and primed outside the body, but reining in their power to grow and make bone tissue until after they are implanted in a patient, is key.

The ability to precisely manipulate mesenchymal stem cells in the laboratory dish and keep them poised to divide and form bone on cue helps pave the way for using cell-bearing three-dimensional matrices to reconstruct large swaths of bone lost to tumors or major trauma. Because bone has some natural healing properties, things like breaks and fractures can often mend themselves. But when large pieces of bone are lost, clinical intervention is required.

“We’re seeking better treatments for bone repair,” says Li, who is affiliated with the UW School of Medicine and Public Health.

To engineer the growth of new bone in the body through regenerative medicine first requires generating large amounts of good quality cells in the lab, notes Li. In the body stem cells are rare. But if cell growth, differentiation and quality can be controlled in the lab dish, it may be possible to create stocks of cells for therapeutic applications and prime them for bone regeneration once implanted in a patient.

The Wisconsin team successfully tested human cells treated with lipocalin-2 and prolactin to regrow bone by implanting them in mice with a calvarial defect, where part of the skullcap has been surgically removed to model critical-sized bone loss.

The human marrow used in the new Wisconsin study was donated by patients undergoing hip replacement surgery. Thus, a caveat to the study is that the protein factors identified by Li and his colleague came from donors with osteoarthritis. However, Li expressed confidence that the factors from the marrow used in the study would be similar or identical to what occurs in a healthy patient.

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Tissue Engineering Advance Reduces Heart Failure in Model of Heart Attack

Researchers have grown heart tissue by seeding a mix of human cells onto a 1-micron-resolution scaffold made with a 3-D printer. The cells organized themselves in the scaffold to create engineered heart tissue that beats synchronously in culture. When the human-derived heart muscle patch was surgically placed onto a mouse heart after a heart attack, it significantly improved heart function and decreased the amount of dead heart tissue.

“Our novel technique is the first to achieve resolution of 1 micrometer or less,” the researchers reported in the journal Circulation Research. This tissue engineering advance is an important step toward the goal of preventing heart failure after a heart attack. Such heart failures account for nearly half of the 7.3 million worldwide heart disease-related deaths each year.

The heart cannot regenerate muscle tissue after a heart attack has killed part of the muscle wall. That dead tissue can strain surrounding muscle, leading to a lethal heart enlargement. It has long been the dream of heart experts to create new tissue that could replace damaged muscle and protect the heart from dilatation after a heart attack.

The researchers, led by Jianyi “Jay” Zhang, M.D., Ph.D., the University of Alabama at Birmingham, and Brenda Ogle, Ph.D., the University of Minnesota, modeled the scaffold after a three-dimensional scan of the extracellular matrix of a piece of mouse myocardial tissue. Extracellular matrix is the collection of compounds secreted by cells that gives structural support and cushioning to hold the tissue together.

Using multiphoton three-dimensional printing, the team then created crosslinks among extracellular proteins dissolved in a photoreactive gelatin. When the uncrosslinked gelatin was washed away, the photopolymerized extracellular protein scaffold that remained replicated the shape of the extracellular matrix, with hollows where cells had been.

This native-like scaffold was seeded with a mix of 50,000 cardiomyocytes, smooth muscle cells and endothelial cells derived from human-induced pluripotent stem cells, or hiPSCs. This cardiac muscle patch, about four one-thousandths of an inch thick and eight one-hundredths of an inch square began beating within one day of seeding, and the speed and strength of contractions increased significantly over the next week.

Researchers found that the scaffold had aligned the muscle cells properly, similar to native heart tissue, and the cells showed a smooth wave of electrical signal moving across the patch, a vital part of the electrophysiology that propagates contraction of the heart across the atria or ventricles. It appeared that the native-like structure of the scaffold contributed to the healthy electrical and mechanical function of the cells.

When two of the patches were transplanted onto an infarcted mouse heart, there was significant improvement in measures of cardiac function, blood vessel density and cell proliferation, and reduced infarct size and programmed cell death, or apoptosis.

“Thus, the hiPSC-derived cardiac muscle patches produced for this report may represent an important step toward the clinical use of 3-D-printing technology,” Zhang, Ogle and colleagues wrote. They also said, “To our knowledge, this is the first time modulated raster scanning has ever been successfully used to control the fabrication of a tissue-engineered scaffold, and consequently, our results are particularly relevant for applications that require the fibrillar and mesh-like structures present in cardiac tissue.”

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Precision Medicine: UAB Study Creates ‘Mini-Lung’ to Study Effect of Pulmonary Fibrosis Drugs

Pulmospheres, three dimensional multicellular spheroids composed of lung cells from individual patients, were shown to be effective in predicting the efficacy of medications for idiopathic pulmonary fibrosis, according to findings from University of Alabama at Birmingham scientists presented today in JCI Insight, a journal of the American Society for Clinical Investigation.

Pulmospheres are tiny spheres — about one millimeter in diameter — which contain all the various cell types found in a human lung and are grown from tissue obtained from a surgical lung biopsy. Pulmospheres give researchers a 3D model to study various aspects of cell biology and disease mechanisms.

“Our results suggest that pulmospheres simulate the microenvironment in the lung and serve as a personalized and predictive model for assessing responsiveness to antifibrotic drugs in patients with IPF,” said Veena Antony, M.D., professor in the Division of Pulmonary, Allergy and Critical Care Medicine within the Department of Medicine, and primary investigator of the study.

The UAB research team grew pulmospheres from 20 patients with idiopathic pulmonary fibrosis — a devastating lung disease — and nine control patients. They then examined whether the pulmospheres reacted to one of two commonly used medications for IPF.

“There is no cure for IPF, but there are two FDA-approved drugs that can help slow the rate of decline caused by the disease and improve quality of life,” said Antony. “Not all patients respond to both drugs, and some don’t respond to either. Having a reliable clinical test that can predict which drug works best for which patient is urgently needed.”

The pulmospheres were grown to useable size in about 24 hours following the biopsy, then exposed to the two medications, pirfenidone and nintedanib. Within about 16 hours, researchers were able to observe if the spheres responded favorably to one, both or neither of the medications.

“This is a wonderful example of precision medicine,” said Victor Thannickal, M.D., professor and director of the Division of Pulmonary, Allergy and Critical Care Medicine and a study co-author. “Using pulmospheres derived from a patient’s own cells may allow clinicians to tailor specific drugs to an individual patient without exposing that patient to potential side-effects or harm from treatments that are unlikely to be effective.”

Of the 20 subjects enrolled in this study, three patient’s pulmospheres responded only to nintedanib and the pulmospheres of four patient’s responded only to pirfenidone. Eleven patient’s pulmospheres responded to both drugs and two patient’s pulmospheres did not respond to either drug.

Researchers confirmed the findings by following the patients over time, establishing that the response predicted by the pulmospheres was clinically observed in the patients.

Antony says there is a critical need for a better predictive model for IPF. Animal models of the disease are disappointing, and more traditional two dimensional cellular models are insufficient.

“The lungs are three dimensional organs and to truly understand the dynamics of IPF medications on the disease we require a 3D model, one that contains all the cell types found in a lung and that is able to function as a microcosm of the lung,” Antony said. “Many drugs have shown promise in pre-clinical studies, only to fail in subsequent clinical trials. Three dimensional modeling might change that.”

Antony says pulmospheres were developed in cancer research as a means of targeting potential drugs. A hallmark of IPF is an aggressive invasion by cells known as myofibroblasts, which mirrors the invasive phenotype of malignant cells, giving researchers reason to think that pulmospheres might work in IPF. The UAB trial was the first to study pulmospheres in IPF.

Antony also hopes that modern drug discovery techniques, using high throughput screening technology to quickly screen numerous compounds for disease-modifying properties, will be enhanced by the use of pulmospheres.

“There are many potential therapeutic agents for IPF in the discovery pipeline now, and this technique might prove to be a very effective way to determining which are the most promising,” she said.

Thannickal serves as the program director of a translational program project grant, sponsored by the National Heart, Lung and Blood Institute, that is focused on identifying novel diagnostic and therapeutic approaches to fibrotic lung disease.

“Without support of the NHLBI, and in particular the tPPG funding mechanism, the tissue biorepository which was critical to developing these innovative screening methods would not have been possible,” he said.

Funding for the study came from the National Institutes of Health. NIH describes IPF as a disease in which tissue deep in the lungs becomes thick and stiff, or scarred, over time. As the lung tissue thickens, the lungs are unable to properly move oxygen into the bloodstream.

IPF is a serious disease that usually affects middle-aged and older adults. IPF has no cure and many people live only about three to five years after diagnosis.

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Johnson & Johnson Innovation, New York State and New York Genome Center Collaborate to Launch JLABS in New York City

Johnson & Johnson Innovation LLC, New York State and the New York Genome Center today announced a collaboration to launch a new JLABS in New York City. Called JLABS @ NYC, the 30,000-square foot facility will be located at the New York Genome Center (NYGC) in SoHo and will open in 2018. The project is receiving $17 million in New York State funding. The site will be open to biotech, pharmaceutical, medical device and consumer health companies. A QuickFire Challenge seeking companies working in these areas, particularly startups working on cross-sector solutions to prevent, intercept or cure diseases, will be launched by Johnson & Johnson Innovation, with the winner(s) eligible for one year of residency at JLABS @ NYC.

The ever-evolving life science sector is discovering solutions to the most pressing problems of our time, helping to cure disease and save lives around the world,” said Governor Cuomo. “New York is poised to be a global leader in this industry, and the new, vital incubator JLABS will be the catalyst that pushes our state into the forefront of this exciting field. I look forward to working with Johnson & Johnson and the New York Genome Center to build momentum in the life science industry and establish New York as the home of discoveries that will drive the economy and create a better future for all.”

“The New York Genome Center is excited to be a partner with Johnson & Johnson Innovation, Governor Cuomo and New York State in bringing JLABS to New York,” said NYGC President and COO Cheryl A. Moore. “JLABS’ support of talented scientists in New York as they take their innovative ideas to market aligns with our mission of fostering intellectually vibrant collaborations that advance the development of new treatments, therapies and therapeutics against human disease. This initiative would not have been possible without the leadership of the Partnership for New York City and the Partnership Fund for New York City. We are grateful for the commitment of all of our business and academic partners to enhance the life sciences infrastructure in New York.”

Johnson & Johnson Innovation seeks to find the best science and technology, no matter where it is located, to solve the greatest unmet medical and healthcare needs of our time. JLABS, in addition to offering emerging life science companies modular lab units, office space, shared core laboratory equipment and business facilities, will link the entrepreneurs of New York with the full breadth of Johnson & Johnson Innovation, including opportunities for funding, third-party services, educational events and R&D experts from medical technology, consumer healthcare product and Janssen pharmaceutical teams. In addition to providing access to scientific, industry and capital funding experts from across the industry, JLABS @ NYC will also follow the same no-strings attached approach currently in operation in San Diego; San Francisco; South San Francisco; Boston; Lowell, MA; Houston; and Toronto.

“Expanding the JLABS model to New York City, home to world-class academic and medical institutions, furthers Johnson & Johnson Innovation’s commitment to providing resources that catalyze and foster the growth of life science ecosystems around the world,” said Paul Stoffels, M.D., Chief Scientific Officer, Johnson & Johnson. “Our hope is that JLABS @ NYC will provide a resource-rich environment for innovators throughout the New York region where today’s ideas can become healthcare products that truly impact patient’s lives.”

JLABS facilities have incubated more than 200 companies to date and are currently home to over 140 companies advancing biotech, pharmaceutical, medical device, consumer and digital health programs. To date, a total of 33 collaborations have been formed between companies residing at JLABS and the Johnson & Johnson Family of Companies.

“Home to more than 100 research foundations and nine medical centers, New York City has the foundational elements for a thriving biomedical ecosystem, yet lack of infrastructure and commercialization support has been a roadblock for entrepreneurs in the life sciences in the greater New York region,” said Melinda Richter, Head, JLABS. “By providing healthcare startups with the laboratories, equipment, expertise, tools and capabilities that they need to build and grow their companies, we believe JLABS @ NYC will fill a key gap in resources and remove a barrier to growth for the region’s life science innovation ecosystem, providing well-paying jobs and allowing potentially transformative solutions for patients to advance.”

Applications to join JLABS @ NYC and other JLABS sites are currently being accepted from biotech, pharmaceutical, medical device, consumer and digital health companies.

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The Lancet Diabetes & Endocrinology: Gastric Bypass Helps Severely Obese Teenagers Maintain Weight Loss Over Long Term

Two studies show surgery leads to significant weight loss and health benefits over 5-12 years, but may lead to more surgery and vitamin deficiency in some.

Gastric bypass surgery helps severely obese teenagers lose weight and keep it off, according to the first long-term follow-up studies of teenagers who had undergone the procedure 5-12 years earlier. However, the two studies, published in The Lancet Diabetes & Endocrinology, show some patients will likely need further surgery to deal with the complications of rapid weight loss or may develop vitamin deficiencies later in life.

Severe obesity is classified as having a BMI of 40 or over (around 100 pounds overweight) and affects around 4.6 million children and teenagers in the USA. Obesity causes ill health, poor quality of life and cuts life expectancy.
The studies are the first to look at long-term effects of gastric bypass surgery in teenagers. Until now, it has been unclear how successful the surgery is in the long-term and whether it can lead to complications. Despite this thousands of teenagers are offered the surgical treatment each year.
Both papers showed that gastric bypass dramatically reduced the teenagers’ weight and helped them maintain weight loss over more than five years of follow-up. However, the surgery was associated with the development of vitamin D and B12 deficiencies and mild anaemia, and some of those who had a bypass needed further surgery to deal with complications. While the surgery resulted in dramatic weight loss and BMI reductions, many of the teenagers remained obese, meaning that earlier intervention may be needed coupled with lifestyle changes such as diet and exercise.

In the first paper, researchers studied 58 American teenagers aged between 13 and 21 who were severely obese and had a gastric bypass.

Average BMI was reduced from 59 before surgery to 36 a year after surgery. Eight years later, average BMI was 42, equivalent to a loss of 50 kilos per person or a 30% weight reduction. Although the weight loss was significant, almost two-thirds of cases (63%, 36/57) remained very obese (BMI over 35) and only one person became a normal weight (BMI 18.5-25) at follow-up.

The number of teenagers with diabetes dropped from 16% to 2%, those with high cholesterol reduced from 86% to 38%, while the number with high blood pressure decreased from 47% to 16% as a result of the surgery. However, some had low levels of vitamin D (78%, 39/50), B12 (16%, 8/50) and mild anaemia (46%, 25/54), which could be a result of lower food consumption or impaired gut absorption.

Given the long-term weight loss and health benefits that result from the surgery, the researchers note that these benefits outweigh the small and manageable risk of nutritional deficiencies.

“Weight loss is crucial for severely obese patients who face poor health and shorter lifespans,” said lead author Dr Thomas Inge, Cincinnati Children’s Hospital Medical Center, USA. “These two manuscripts clearly document long-term benefits of adolescent bariatric treatment, but also highlight several nutritional risks. Now it is important to focus on delivery of the substantial health advantages of surgery while minimizing these risks. Since there are currently two effective bariatric procedures, namely gastric bypass and vertical sleeve gastrectomy, we are currently examining the outcomes of both procedures to determine what is best for adolescents.” [1]

The second study included 81 obese teenagers (average BMI 45) and 81 adults (average BMI 43) in Sweden who had a gastric bypass and 80 teenagers who did not have surgery.

Five years after surgery, the teenagers and adults who had a gastric bypass had a reduced BMI (by 13 points for teenagers, a weight reduction of 28%; 12 points for adults), whereas teenagers who did not have surgery had an increased BMI (by three points from 42 to 45).

Of the teenagers who underwent the gastric bypass, a quarter (25%, 20/81) had further surgery to treat complications from the bypass or as a result of rapid weight loss, including bowel blockage (11 cases) and gallstones (nine cases).
During the five year follow-up, teenagers who had the surgery spent an average of six and a half days in hospital (including the time spent in hospital for their surgery) compared to one and half for those who didn’t have the surgery, and had an average of five extra visits to an outpatient clinic than those who didn’t have the surgery (15 visits compared with 10).

Despite the additional care and resources needed to offer the surgery, overall, the cost of prescriptions for teenagers who had surgery did not differ (US$2317 and $2701). In addition, a quarter of those in the control group (20 of 80) went on to have a gastric bypass as an adult during the study follow-up.
“Gastric bypass results in substantial weight loss as well as cutting heart and metabolic problems and improving quality of life into the long-term for severely obese teenagers. While some patients may face complications, those given non-surgical treatment often continue to put on weight, putting them at higher risk of poor health throughout life,” said lead author Dr Torsten Olbers, University of Gothenburg, Sahlgrenska University Hospital, Sweden. “To reduce risk of complication it’s important that gastric bypass for teenagers is done in centres that can provide the full care needed and long-term follow-up and support.” [1]

Writing in a linked Comment, Professor Geltrude Mingrone, Catholic University, Italy, said: “Unfortunately, hypocaloric diet, lifestyle modification, and medical treatment do not have much of an effect in adolescent populations because of poor adherence. Additionally, intensive behavioural weight loss interventions that are effective at reducing BMI in adolescents who are overweight or obese have diminished effectiveness for those with severe obesity… Before now, only a few short-term studies of bariatric surgery in adolescents have been reported; therefore, these studies provide important data and shed new light on the use of bariatric surgery in young people… Undoubtedly, no other approaches but bariatric surgery are able to provide such considerable weight loss, with only relatively small weight regain, over time… In view of the significant vitamin D deficiency reported by both Inge and colleagues and Olbers and colleagues, and the possibility of early surgery affecting growth, it is important that future national guidelines address the matter of the age at which bariatric surgery should be performed in adolescents.”

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Pregnancy leads to changes in the mother’s brain

Pregnancy involves radical hormone surges and biological adaptations, but the effects on the brain are still unknown. In this study a team of researchers compared the structure of the brain of women before and after their first pregnancy. This is the first research to show that pregnancy involves long-lasting changes – at least for two years post-partum – in the morphology of a woman’s brain.

Using magnetic resonance imaging, the scientists have been able to show that the brains of women who have undergone a first pregnancy present significant reductions in grey matter in regions associated with social cognition.

The researchers believe that such changes correspond to an adaptive process of functional specialization towards motherhood. “These changes may reflect, at least in part, a mechanism of synaptic pruning, which also takes place in adolescence, where weak synapses are eliminated giving way to more efficient and specialized neural networks”, says Elseline Hoekzema, co-lead author of the article.

According to Erika Barba, the other co-lead author, “these changes concern brain areas associated with functions necessary to manage the challenges of motherhood”.

In fact, researchers found that the areas with grey matter reductions overlapped with brain regions activated during a functional neuroimaging session in which the mothers of the study watched images of their own babies.

In order to conduct the study, researchers compared magnetic resonance images of 25 first-time mothers before and after their pregnancy, of 19 male partners, and of a control group formed by 20 women who were not and had never been pregnant and 17 male partners. They gathered information about the participants during five years and four months.

The results of the research directed by Òscar Vilarroya and Susanna Carmona demonstrated a symmetrical reduction in the volume of grey matter in the medial frontal and posterior cortex line, as well as in specific sections of, mainly, prefrontal and temporal cortex in pregnant women. “These areas correspond to a great extent with a network associated with processes involved in social cognition and self-focused processing”, indicates Susanna Carmona.

The analyses of the study determine with great reliability whether any woman from the study had been pregnant depending on the changes in the brain structure. They were even able to predict the mother’s attachment to her baby in the postpartum period based on these brain changes.

The study took into account variations in both women who had undergone fertility treatments and women who had become pregnant naturally, and the reductions in grey matter were practically identical in both groups.

Researchers did not observe any changes in memory or other cognitive functions during the pregnancies and therefore believe that the loss of grey matter does not imply any cognitive deficits, but rather: “The findings point to an adaptive process related to the benefits of better detecting the needs of the child, such as identifying the newborn’s emotional state. Moreover, they provide primary clues regarding the neural basis of motherhood, perinatal mental health and brain plasticity in general”, says Oscar Vilarroya.

 

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Mayo Clinic researchers identify how liver fat stores provide energy source during fasting

In a recent Science Advances article, Mayo Clinic researchers show how hungry human liver cells find energy. This study, done in rat and human liver cells, reports on the role of a small regulatory protein that acts like a beacon to help cells locate lipids and provides new information to support the development of therapies for fatty liver disease.

“Between 30 and 40 percent of our population have, or are leading toward getting, nonalcoholic fatty liver disease,” says Mark McNiven, Ph.D., senior author on the paper and director of Mayo Clinic’s Center for Biomedical Discovery. “And that is not including those with alcohol-induced fatty liver; that is also quite prevalent.”

While the mechanisms involved in fat accumulation are the usual targets of research for fatty liver disease, clarifying the cell’s mechanism for breaking down fat also could provide valuable information to fuel the discovery of breakthrough treatments in the future.

Fueling the hungry cell

In a well-fed cell, fat deposits, called lipid droplets, are nutritional insurance. They are ignored by the cell as it fuels growth and division via its normal pathway. But, in a starving cell, the normal pathway switches off, and a recycling process, called autophagy, switches on. Autophagy is a way for cells to break down macromolecules, such as protein and fat, into their component parts to be used in cell processes.

Under starvation conditions, the cell’s recycling pathway directs specialized vessels to engulf lipid droplets. These vessels, called autophagosomes, then link with another organelle, called a lysosome, which is filled with acidic enzymes. When these two merge, the resulting structure is called an autolysosome. Within the autolysosome, the enzymes break apart the fat droplet free fatty acids.

How does a hungry cell find the fat? It follows the beacon

Zhipeng Li, first author and a student at Mayo Clinic Graduate School of Biomedical Sciences, noticed that, within the hungry cells, one protein, called Rab10, was intimately associated with many of the lipid droplets. Rab proteins operate like switches; when bound to a substance, they switch on and facilitate interactions in the cell. There are more than 60 different Rab switches, or small regulatory GTPases, in the human genome.

“In this paper, we show that, when Rab10 is switched on, it will bind to a lipid droplet and cause the autophagosome to dock on the droplet surface, recruit other proteins, and digest the lipid into a free fatty acid energy source,” says Li.

Dr. McNiven explains that cells have sensors that detect low energy levels and respond.

“Rab10 switches on and builds up around the lipid droplet,” says Dr. McNiven. “Then, the cell activates its lysosomes that then targets these lipid droplets and goes after them. So this was an important step that we provided between the sensing mechanism of starvation and how that is signaling to this switch to go after lipid droplets.”

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New Evidence That Testosterone May Explain Sex Difference In Knee Injury Rates

In studies on rats, Johns Hopkins Medicine scientists report new evidence that the predominance of the hormone testosterone in males may explain why women are up to 10 times more likely than men to injure the anterior cruciate ligament (ACL) in their knees.

Specifically, they found that normal male rats with natural supplies of testosterone had stronger ACLs than those that had been castrated and no longer produced the hormone. The results are described online Sept. 20 in the journal The Knee.

“The primary implication of the study is that testosterone may contribute to the ACL’s ability to withstand tensile loads and may be one of multiple factors response for the disparate ACL injury rate between men and women,” says William Romani, Ph.D., M.H.A., a physical therapist and sports medicine researcher who was a visiting faculty member in The Johns Hopkins University’s Department of Biomedical Engineering from 2009 to 2015.

Senior study author Jennifer Elisseeff, Ph.D., a biomedical engineer at The Johns Hopkins University, says the new finding could eventually lead to techniques that use circulating sex hormone levels to identify athletes at higher risk for ACL injury who may benefit from training strategies to strengthen the ligament.

The ACL is a flexible, stretchable tissue that tunnels through the knee, connecting the femur, or thigh bone, with the tibia, or shin bone. More than 200,000 people in the U.S. get ACL injuries, ranging from partial to full tears, most often while playing sports. Previous studies have found that girls and women are anywhere from two to 10 times more likely to tear an ACL than men doing similar activities. Explanations for the sex differences include differences in anatomy, strength, reflex times and hormones.

Romani, who now works with the AARP Foundation’s Experience Corps, conducted previous research on rats showing that that estrogen — a predominantly female hormone — reduces ACL strength, but he also found that knee ligaments in both sexes contain receptors for testosterone.

“Our thought was that while estrogen may make the female ACL weaker and more prone to injury, the male hormone testosterone may act to strengthen the ACL and protect it from injury,” says Romani.

In the new research, Romani and Elisseeff removed the ACL — still connected to the tibia and femur — from 16 healthy, 12-week-old male rats. Eight of the rats were normal, with testosterone levels averaging 3.54 nanograms per milliliter, and eight had been castrated, giving them nearly undetectable levels of the hormone, at 0.14 nanograms per milliliter. The researchers measured the cross-sectional area of each ACL and then connected the bones — with the ACL stretched between them — to a machine that could pull the bones apart, tugging on the ACL. Then, they tested the strength of the ligaments by measuring how much force it took to tear each ACL.

The researchers found that it took more force — 34.5 newtons, compared to 29.2 newtons — to tear the ACLs from mice with normal levels of testosterone, indicating that the ligaments were stronger. Since researchers have generally accepted that a stronger ACL is less prone to injury, the results support a link between testosterone and ACL injuries.

More work is needed to explain exactly which pathways and molecules testosterone and estrogen act through to influence ligament strength, and whether the hormones have the same impact on other ligaments in the body.

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Simple Procedure Could Improve Treatment for Common Eye Disease

A new, minimally invasive procedure appears to be effective for many patients with Fuchs endothelial dystrophy (FED), a common eye disease, without the potential side effects and cost of the current standard of care, a cornea transplant.

In a proof-of-concept study, published in the journal Cornea, researchers led by Kathryn Colby, MD, PhD, the Louis Block professor and chairman of the Department of Ophthalmology and Visual Science at the University of Chicago, showed that removing a few square millimeters of a single layer of cells on the inside of the cornea allowed rejuvenation of the surrounding tissue, without the need for a corneal transplant. This simple procedure restored clear vision to three out of four patients suffering from FED, the most frequent cause for corneal transplantation in the United States.

Over the past two years while at Harvard Medical School, Colby performed the new procedure, known as Descemet stripping, on 11 patients, aged 51 to 91. Two patients had the procedure in both eyes, one at a time.

When assessed six months after the operation, ten of the treated eyes (77 percent) had clear corneas and eight had 20/20 vision or better (two patients had retinal disease that limited their final vision). The other three eyes did not respond and required a standard cornea transplant.

“It’s too soon to call this a cure,” Colby said. “We performed the first operation just over two years ago. But when it works, it’s a wonderful thing. It’s quick, inexpensive and it spares patients from having someone else’s cells in their eyes, which requires local immunosuppression.”

The first patient to undergo Descemet stripping, 69-year-old Eric Thorp of the Boston area, was pleased. “It’s quite a breakthrough,” he said. His vision, now 20/20 in that eye, “is equivalent to what I had as a boy,” he said. “Amazing.”

“It’s kind of an honor to have been the first,” he added. “It was worth doing.”

Descemet stripping involves removing a small patch of the corneal endothelium (the pumping cells that stop working in FED) attached to an underlying layer (the Descemet membrane). In patients with FED, water accumulates in the cornea, the clear front window of the eye, because of the dysfunction of the pumping cells, causing reduced vision, glare and haloes. If left untreated, the condition progresses to painful blindness.

Removal of the central dysfunctional cells enables healthier peripheral cells to migrate to the center of the cornea, where they reestablish pumping capacity and removal of fluid from the layers above. This gradually restores clear vision.

“Although Descemet stripping is a relatively simple procedure, its potential is revolutionary,” Colby said. In 2015, 14,000 corneal transplants were performed in the United States, just for FED, the most common reason for this operation. The transplants work well, but the tissues are expensive and there is a limited supply in some areas of the world. Because the corneal transplant tissue is foreign, patients must apply topical steroids for the rest of their lives to dampen their immune response and prevent rejection of the transplanted cells. Steroid eye drops are known to cause glaucoma and cataract and can predispose to infection.

The researchers classified patients into four groups based on how they responded to Descemet stripping. Fast responders regained clear vision within a month after surgery. Responders recovered within three months. Slow responders took more than three months. Nonresponders had persistent corneal edema and required endothelial keratoplasty—a streamlined cornea transplant.

Of the 13 eyes treated, four were fast responders, four were responders and two were slow responders.

The next step is to try to understand why some patients, about one out of four, don’t respond to removal of the dysfunctional cells. Fuchs dystrophy is a polygenic disease, but in the last few years researchers have found connections between the extent of a repeating nonsensical genetic abnormality seen in other neurological diseases and the severity of FED. Colby hopes to find genetic clues that predict which patients are most likely to respond to this approach.

Thorp, the first patient treated, had 20/20 vision when last assessed in January of 2016 at the University of Chicago, 24 months after his operation. He was first diagnosed with FED and had a cornea transplant in his right eye in 2002, a two-stage operation. It was successful, but the recovery process meant “foggy vision” in that eye for nearly a year. This prevented him from driving.

That eye slowly recovered, but by 2013 vision in the left eye began to decline. After Colby offered her new procedure and explained the logic behind it, Thorp felt “a great deal of confidence and understanding in what she was doing,” he said. He volunteered to go first.

“It certainly turned out to be worth it,” Thorp said. His operation, removal of a cataract plus Descemet stripping, took less than 30 minutes. That was “about 20 minutes for the cataract and one minute for the stripping,” he recalled.

“After I performed Mr. Thorp’s surgery, I waited eight months to make sure nothing unexpected happened to his cornea,” Colby said, “then I started offering the procedure to patients whom I felt could benefit.”

“Few things remind you as constantly as deteriorating vision,” Thorp recalled. “Your world steadily narrows as you lose the ability to see. But mine expanded again at the other end. I remember walking the dog at night right after the operation. Each night, the streetlights would be a little more in focus. You could see the improvement, night after night over the course of a few weeks, like the fog lifting out of London. It was cool. Really cool.”

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Changes Uncovered in the Gut Bacteria of Patients with Multiple Sclerosis

A connection between the bacteria living in the gut and immunological disorders such as multiple sclerosis have long been suspected, but for the first time, researchers have detected clear evidence of changes that tie the two together. Investigators from Brigham and Women’s Hospital (BWH) have found that people with multiple sclerosis have different patterns of gut microorganisms than those of their healthy counterparts. In addition, patients receiving treatment for MS have different patterns than untreated patients. The new research supports recent studies linking immunological disorders to the gut microbiome and may have implications for pursuing new therapies for MS.

“Our findings raise the possibility that by affecting the gut microbiome, one could come up with treatments for MS – treatments that affect the microbiome, and, in turn, the immune response,” said Howard L. Weiner, MD, director of the Partners MS Center and co-director of the Ann Romney Center for Neurologic Disease at Brigham Women’s Hospital, . “There are a number of ways that the microbiome could play a role in MS and this opens up a whole new world of looking at the disease in a way that it’s never been looked at before.”

Weiner and colleagues conducted their investigations using data and samples from subjects who are part of the CLIMB (Comprehensive Longitudinal Investigation of Multiple Sclerosis) study at Brigham and Women’s Hospital. The team analyzed stool samples from 60 people with MS and 43 control subjects, performing gene sequencing to detect differences in the microbial communities of the subjects.

Samples from MS patients contained higher levels of certain bacterial species – including Methanobrevibacter and Akkermansia – and lower levels of others – such as Butyricimonas – when compared to healthy samples. Other studies have found that several of these microorganisms may drive inflammation or are associated with autoimmunity. Importantly, the team also found that microbial changes in the gut correlated with changes in the activity of genes that play a role in the immune system. The team also collected breath samples from subjects, finding that, as a result of increased levels of Methanobrevibacter, patients with MS had higher levels of methane in their breath samples.

The researchers also investigated the gut microbe communities of untreated MS patients, finding that MS disease-modifying therapy appeared to normalize the gut microbiomes of MS patients. The researchers note that further study will be required to determine the exact role that these microbes may be playing in the progression of disease and whether or not modifying the microbiome may be helpful in treating MS. They plan to continue to explore the connection between the gut and the immune system in a larger group of patients and follow changes over time to better understand disease progression and interventions.

“This work provides a window into how the gut can affect the immune system which can then affect the brain,” said Weiner, who is also a professor of Neurology at Harvard Medical School. “Characterizing the gut microbiome in those with MS may provide new opportunities to diagnose MS and point us toward new interventions to help prevent disease development in those who are at risk.”

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Parkinson’s disease biomarker found in patient urine samples

For more than five years, urine and cerebral-spinal fluid samples from patients with Parkinson’s disease have been locked in freezers in the NINDS National Repository, stored with the expectation they might someday help unravel the still-hidden course of this slow-acting neurodegenerative disease.

Now, research by Andrew West, Ph.D., and colleagues at the University of Alabama at Birmingham has revealed that the tubes hold a brand-new type of biomarker — a phosphorylated protein that correlates with the presence and severity of Parkinson’s disease. West and colleagues, with support from the National Institutes of Health, the Michael J. Fox Foundation for Parkinson’s Disease Research and the Parkinson’s Disease Foundation, are digging deeper into these biobanked samples, to validate the biomarker as a possible guide for future clinical treatments and a monitor of the efficacy of potential new Parkinson’s drugs in real time during treatment.

“Nobody thought we’d be able to measure the activity of this huge protein called LRRK2 (pronounced lark two) in biofluids since it is usually found inside neurons in the brain,” said West, co-director of the Center for Neurodegeneration and Experimental Therapeutics, and the John A. and Ruth R. Jurenko Professor of Neurology at UAB. “New biochemical markers like the one we’ve discovered together with new neuroimaging approaches are going to be the key to successfully stopping Parkinson’s disease in its tracks. I think the days of blindly testing new therapies for complex diseases like Parkinson’s without having active feedback both for ‘on-target’ drug effects and for effectiveness in patients are thankfully coming to an end.”

A biomarker helps physicians predict, diagnose or monitor disease, because the biomarker corresponds to the presence or risk of disease, and its levels may change as the disease progresses. Validated biomarkers can aid both preclinical trial work in the laboratory and future clinical trials of drugs to treat Parkinson’s. West and others are paving the way for an inhibitor drug that prevented neuroinflammation and neurodegeneration in an animal model of the disease, as reported last year by West and colleagues.

The new biomarker findings were published in Neurology in March and Movement Disorders in June. The biomarker, LRRK2, has been shown to play a role in hereditary Parkinson’s, and the most common of these mutations — called G2019S — causes the LRRK2 kinase to add too many phosphates to itself and other proteins. Why this leads to Parkinson’s disease is not yet clear.

The key to West’s biomarker approach was the recognition that LRRK2 can be purified from a new type of vesicle called exosomes found in all human biofluids, like urine and saliva. Cells in the body continually release exosomes that contain a mixture of proteins, RNA and DNA derived from different kinds of cells. West and colleagues were able to purify exosomes from 3- or 4-ounce urine samples donated by patients, and then measure phosphorylated LRRK2 in those exosomes.

The findings

In the Neurology study, they found that elevated phosphorylated LRRK2 predicted the risk for onset of Parkinson’s disease for people carrying a mutation in LRRK2, which is about 2-3 percent of all Parkinson’s disease patients. These findings were first tested with a preliminary, 14-person cohort of urine samples from the Columbia University Movement Disorders Center. That was followed by a larger replication study of 72 biobanked urine samples from the Michael J. Fox Foundation LRRK2 Cohort Consortium. All samples were provided to UAB in a blinded fashion to ensure the approach was rigorous.

The follow-up Movement Disorders paper — the first study of its type — expanded the scope to people without LRRK2 mutations, which is most Parkinson’s disease patients. Using 158 urine samples from Parkinson’s disease patients and healthy controls enrolled in the UAB Movement Disorder Clinic as part of the NIH Parkinson’s Disease Biomarker Program, West and colleagues found that approximately 20 percent of people without LRRK2 mutations but with Parkinson’s disease also showed highly elevated phosphorylated LRRK2 similar to people with LRRK2 mutations, and this was not present in healthy controls. The study speculates that people with elevated phosphorylated LRRK2 may be particularly good candidates for future drugs that reduce phosphorylated LRRK2.

Next steps

Questions remain for this evidence of biochemical changes in LRRK2 in idiopathic Parkinson’s disease. One is finding out where the urinary exosomes come from. Given a suspected role for inflammation in Parkinson’s disease, it is interesting that LRRK2 is highly expressed in cells of the innate immune system. A possible explanation for the phosphorylated LRRK2 in patients with more severe disease may be an increased inflammation in those patients who have aggressive progression of disease.

In May, West was awarded a new U01 collaborative grant from the National Institute of Neurological Disorders and Stroke to further explore urinary exosomes and extend the observations to cerebral-spinal fluid as a marker for disease prediction and prognosis.

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JAMA Article Summarizes FSMB Marijuana Recommendations

The Journal of the American Medical Association (JAMA) has published in its online edition a summary of new policy adopted by the Federation of State Medical Boards (FSMB) that provides recommendations about marijuana in patient care and a cautionary note advising actively licensed physicians to abstain from using marijuana while practicing medicine.

The online “Viewpoint” summary, published June 16, was written by FSMB President and CEO Humayun J. Chaudhry, DO, MACP; FSMB Chair Arthur S. Hengerer, MD; and FSMB Chair-Elect Gregory B. Snyder, MD.

Heightened public interest in marijuana and marijuana-infused products for medicinal and recreational purposes led the nation’s state medical and osteopathic boards to issue the recommendations during the FSMB’s 2016 House of Delegates meeting in April.

This is the first time that the dispensing or use of marijuana in patient care have been highlighted in a policy recommendation of the FSMB, whose members include 70 state and territorial medical licensing boards of the United States. In addition to summarizing the FSMB’s ten recommendations, the authors examine the dilemma of physicians practicing today, who they say are “caught between increasingly permissive local statutes and prohibitive federal regulations” regarding the use of marijuana.

Although there is little evidence for the efficacy of marijuana in treating certain medical conditions, marijuana has been variously suggested for alleviating some or all symptoms of a range of debilitating medical conditions – from certain types of cancer to glaucoma.

The “prescribing” of marijuana, however, remains illegal under federal law, where it is classified as a Schedule I substance under the Controlled Substances Act of 1970. Therefore, under federal law, marijuana cannot be knowingly or intentionally distributed, dispensed, or possessed, and an individual who aids and abets another in violating federal law or engages in a conspiracy to purchase, cultivate, or possess marijuana may be punished to the same extent as the individual who commits the crime.

With the increasing number of jurisdictions permitting the use of marijuana in patient care, the U.S. Department of Justice updated its marijuana enforcement policy in 2013, advising states and local governments that authorize marijuana-related conduct to implement strong and effective regulatory and enforcement systems to address any threat those laws could pose to public safety, public health, and other interests.

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New Clues to COPD Linked to Proteostasis Imbalance Caused by Cigarette Smoke

Few threats to public health are as perilous as cigarette smoking, with more than 435,000 Americans dying each year of tobacco-related pulmonary illnesses such as chronic obstructive pulmonary disease (COPD). COPD ranks as the third-leading cause of tobacco-related morbidity and mortality worldwide in 2012 and the global cost of illness related to COPD is expected to rise to $4.8 trillion by 2030, yet there are currently no effective medical treatments to cure COPD or stop its progression.

Since the identification of factors contributing to the development of COPD is crucial for developing new treatments, a team of scientists including Anna Blumental-Perry, PhD, from the department of surgery, and Xing-Huang Gao, PhD, from the department of genetics and genome sciences, at Case Western Reserve University School of Medicine embarked on a study to examine COPD development at the cellular level. Specifically, Blumental-Perry and her team sought to better understand the mechanisms of a relatively new scientific concept – the smoke induced collapse of protein homeostasis and its contribution to age-dependent onset of COPD. Knowing that upon inhalation of cigarette smoke (CS), the free radicals in it can reach the interior of lung cells where they react with a wide variety of cell proteins and affect their functions, the scientists formed the hypothesis that CS-free radicals can interfere with proper folding of the proteins within the cell.

The scientists’ findings, recently published in The Journal of Biological Chemistry, demonstrated that free radicals—small, unstable molecules present in CS—can reach the endoplasmic reticulum, a cellular organelle that is critical in manufacturing and transporting fats, steroids, hormones and various proteins, and alter its function by oxidizing and damaging its most abundant and crucial to protein folding chaperone, Protein Disulfide Isomerase (PDI).

Determining that PDI is a critical factor in the development of COPD, the researchers identified for the first time how cells adapt to the presence of less functional PDI, which is by increasing the levels of it through a novel mechanism at the protein synthesis level, as opposed to the level of gene transcription. Since adaptation wears off with age, the researchers have now identified one of the first clues to age-dependency in COPD onset.

“Understanding the mechanisms of the collapse of protein homeostasis in COPD allows us to focus on maintaining functional levels of PDI. This could improve outcomes for the many patients with COPD as well as potentially giving us clues to improve health with aging.” said Blumental-Perry. “We discovered that PDI is a critical new factor in the pathogenesis of COPD, and that protein collapse in COPD is age dependent and unpredictable. Based on these fascinating findings, we plan to conduct future research targeting failed adaptive systems in an effort to maintain functional levels of PDI, and prevent it from acquisitions of ‘bad’ functions – discoveries that could ultimately help us to identify new therapeutic approaches for COPD.”