Inside Gross Hall

Posted November 3, 2012 by katewillette
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It’s not gross at all, so far. ¬†ūüôā ¬†One of the young post-docs is showing us how he designs equipment to test and train rats and monkeys. ¬†The animals get trained before injury on this equipment, which lets them use a baseline to see whether or not treatments are working. ¬†The device is called the autoGSN.

One of the things they want animals to be able to do is make a choice to grab a bar. ¬†They need them to have volitional control because anything that isn’t coming from the animal can’t be trusted — it might be a result of something the investigator is doing. ¬†They’re currently working with 22 rats, who got 3 weeks of training before their injuries.

(This is one of the things that’s hard to remember about the research process — how bloody much time and thought and effort has to go into figuring out how to get reliable, true measurements that mean what you hope they mean.)

Now showing a suspended gait thing that’s on a curved overhead track — the usual ones only go forward. ¬†They need ways to measure trunk strength and stability . . . the idea is to translate standing trunk balance to sitting balance. ¬†Kelly’s strapping an AB assistant into the harness so that she can show us how a Wii-style game works. ¬†There’s a sky scene projected on the wall in front of her with a floating balloon in it. ¬†Her job is to use her body (trunk muscles) to pop the balloon. ¬†At this point they only do this with incompletes, mostly due to IRB issues (gov’t control of risk stuff) but have just submitted a protocol for permission to work with completes.

Their incomplete studies have been successful, meaning, they were safe. She did mental practice and gait training with incomplete sci and looked at brain active before and after task.

They showed that people with incomplete injuries had cortical changes in the brain after training.  Low level Asia Cs to Ds who are incomplete can have rehab patterns set to take advantage of the parts of their brains that MRIs show are helping them.

Another area of focus is motivation. ¬†Music, gaming, etc., are areas they’re working on as ways to get people to do the tedious and repetitive work that constitutes training.

Robotrunk is another thing they have in development . . . they want reliable and valid tools that can go quickly into the clinic. ¬†What matters here is two things — one is reliable measuring tools so that treatments can be shown to be effective. ¬†The other is to make devices that can become home-based rehab tools that are cheap and simple to use.

Guy is showing a brain interface system (not cheap, simple or home-based for sure!) . . . they’ve succeeded in wiring an AB person, asking that person to imagine walking as they look at an avatar on a computer screen, and seeing the avatar walk. ¬†New paper published showing the success of this. The idea is to (eventually) use brain signals to activate (internal) prosthetics so that people with injuries can walk just by imagining that they are.

The music glove . . . it’s kind of like Guitar Hero, if you’ve ever seen that. ¬†The subject wears a wired glove on one hand while music plays on an attached laptop. ¬†Right now there’s an AB young man (who turned out to be Dr. Steward’s grandson) operating the thing to the sound of I Heard It Through the Grapevine. ¬†He has to touch thumb to finger in time with the beat, and on the screen there are icons like little guitars floating up a fret board that show which finger to tap when . . . the idea is to motivate users to do their OT by making it challenging and game-like ‚Äď more or less the same principle that gets AB people into the gym for aerobics classes . . . hit the beat, follow the instructions. More fun than doing reps with a set of weights.

And, another machine that works in a similar way, except that it has a ramp-up function for people with minimal ability to move their fingers. ¬†At first it will do all the work for the hand, and then gradually ‚Äď very gradually ‚Äď back off as the fingers are able to work on their own.

And, another one — (people, this is like being a super-amazing toyland) ‚Äď this time a small highly wired and sensitive package that sits on the subject’s back like a papoose. It’s attached to a computer that shows in realtime how successfully the person is using their trunk muscles. It knows if you’re not sitting up straight, and it knows if you’re not trying hard, and it knows exactly which muscles you’re pushing with, and god knows what other stuff. Seems like a highly useful tool to me.

Okay, half my roam-around time is gone already, and I haven’t even been in any of the basic science labs. ūüė¶ Hate to leave this building!

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Morning at the Reeve Irvine Research Center

Posted November 3, 2012 by katewillette
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Dr. Os Steward is describing how the place works . . . there are senior scientists, post grad fellowship people, grad students, technicians.

The technicians are all dressed up today, which they’re laughing about because most of the time they’re very much dressed down; one of them is talking now.

Her normal day is making rats pee, morning and night. ¬†All our days are spent in the basement; we don’t see the sun much, don’t know what the weather is. ¬†Every day of the year, no exceptions, because the animals need to be cared for. ¬†An operation like this requires a LOT of people.

The plan for us today is to meet with the postdoc fellows, hearing about what they’re working on, getting a chance to ask them how what they’re doing is going to help US. ¬†The grad students are the ones who are just starting their projects. ¬†We’re going to see how labs work . . . from the cellular ¬†level to animal models to human performance labs, where they’re looking at what kinds of rehab work best for people with impaired function.

He asks for questions, but we don’t know what to ask yet . . .

Kelly Sharp steps up to explain the logistics. ¬†The senior scientists will be arranged around the various labs, ready to explain and take questions as needed. ¬†We’re free to roam around and see what there is to see for about an hour and a half, then come back to eat. ¬†They’ve set up their most intriguing equipment so that we can see what it is and how it works.

Hmmmm. ¬†Not sure how I’m going to do this blog thing in that scenario. ¬†Probably go around and find the most crazy-interesting things & try to describe as we go.

Some background — Reeve Irvine Research Center got started because an elderly woman with a lot of money and a love of horses saw Chris Reeve being interviewed on television not long after his injury. ¬†She was touched and impressed that he didn’t blame the horse, and she sent him a note volunteering to hand over a million dollars to establish a center here. ¬†The story is that Dana and a friend were opening the piles of mail and came across that note, almost dismissing it as impossible.

But here we are. ¬†It’s a 4-story building that’s obviously built for access. ¬†Off we go.

Breakout: Dr. Justin Brown

Posted November 2, 2012 by katewillette
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He’s talking about the surgery that can restore hand function — nerve grafts described earlier this morning.

Limit to one or two nerve transfers, don’t expect to be able to play the guitar, do expect to be able to use a pen and pick up a fork and hold a cup. ¬†Expect to have to work at it, all day long, all the time until the connection kicks in.

Just had a long chat with him about how this works . . . he’s done 3 patients, and the interesting thing is that he gets tons of inquiries but most of the people don’t follow through.

To be clear, he’s talking about a minimal surgery that takes a working nerve from the elbow or arm of a quad and uses it to restore their hand function. ¬†People don’t like the idea of losing anything that they’ve got left . . . and they don’t like the idea of having their normal routines interrupted even for a little while, which is what a four-week no-stress period would be like. ¬†You’d have to be ready for that.

And then there’s a months-long grind of re-training those re-enervated fingers. ¬†But in the end you have function that you didn’t before.

Okay. ¬†Just to be clear, this is about taking an elbow or arm nerve that’s still enervated from the cord and attaching its end to a peripheral nerve in the hand so that the connection gets made from brain to fingers. ¬†It’s a solution that Justin has shown works better than the tendon transfer; the surgery is simpler, the non-use time is shorter, and the results are better.

He’s in San Diego, looking for patients right now. ¬†You all should have a look at the video that u2fp will put up from his talk this morning if you’re interested. ¬†There’s a news story on youtube right now, and his contact information is here.

And with that, friends, we’re wrapping up another day. ¬†Tomorrow morning there will be a tour at the RIRC, and then it’s back to the real world for all of us funsters. ¬†I’ll bring the laptop and see what I can capture on the fly.

Hans Keirstead

Posted November 2, 2012 by katewillette
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Roman Reed is introducing Dr. Keirstead as the best stem cell scientist in the world. ¬†“He’s like a brother to me. ¬†He’s a pioneer. ¬†He’s going to win the Nobel prize one day. ¬†We’re lucky to have him here.”

Hans: ¬†I’m going to go through a couple of the things I’ve developed with my teams.

(Background . . . Keirstead’s lab famously was first to coax embryonic human stem cells into differentiating into the exact kind of neural cell he wanted, which was oligodendrocyte precursors (OPCs). ¬†He tested those pure OPC cells in both acute and chronic animal models, and in the acutes ONLY, was able to show that the OPCs did their job, which is to remyelinate naked axons. ¬†The company Geron took that work to the FDA and asked permission to do human acute trials . . . which were then delayed for years. ¬†The trials finally did start, but then Geron backed out.)

Hans: Geron . . . we had developed highly pure oligodendrocytes and gave 5 patients 1/10th of what we thought would be an effective dose. ¬†The regulatory bar was extremely high, and there was a very long patient followup — 15 years before release to the public. ¬†All of it worked, which is great, but the company was burning a LOT of money for what would be a small market size. ¬†It’s on hold for financial reasons.

I’ve been intimately involved in the analysis and it’s my belief that the program will be resurrected.

(More background . . . he then goes on to talk about the status of his human motor neuron trials, which he has been working for years to see happen in the USA with Spinal Muscular Atrophy (SMA) babies, who suffer from a terminal congenital condition that mimics in some ways the loss of motor function people with SCI have. ¬†He’s told us in the past that it would be faster to try this therapy with SMA than with SCI because there’s much more urgency in the former.)

The high purity human motor neurons for sc disease was placed on clinical hold at the FDA. ¬†We went to the UK with it ¬†. . . using these cells, we’ve established a long body of evidence that it works to restore all kinds of motor function. ¬†We expect to see it go into trial in 2013.

(So apparently the US FDA didn’t go for the idea, but its counterpart in the UK did . . . )

Hans moves on from updates on old work to new stuff . . . we have made high purity human neuronal progenitors for SCI — these cells don’t make anything but neurons — no astrocytes, no oligodendrocytes.

What I decided to do is manipulate the pten gene. ¬†We looked at a couple of pten inhibitors. If we block pten, we get bigger, faster, better, longer axon growth — a 40-50% increase in growth. ¬†Neurons grow, and pten-inhibited ones grow much better. ¬†You also get a lot more secondary neurite growth.

Pten inhibition promotes outgrowth beyond cAMP levels . . we know exactly how that works, i.e., which pathway is being employed.

But, you can’t add pten to people . . .what we can do is add it to cells in a dish and then add the cells to people. ¬†It’s a temporary thing, which is good. ¬†You don’t want it in you for a long time.

In animal models, we’re looking at double the outgrowth in vivo.

pten is big all over the regenerative medicine world . . . many labs exploring what it means to have found a gene that controls whether or not a neuron can regenerate.

Another major effort is to reprogram the astroglial scar.  This is different from development, which is a process of differentiation.  Pluripotent reprogamming is a process of doing that in reverse, and lineage reprogramming is turning one cell into another kind altogether.

What this means is taking astroglial cells from an SCI scar and turning back the clock so that they become like they were when they were young. ¬†In their aged, scar phase they’re inhibitors — but in their young phase they’re ¬†promoters of growth.

They started by establishing astrocyte cultures. ¬†Then they chose some outcome measures, which in itself took a lot of doing. (He’s saying they needed reliable ways to know if they’d succeeded in turning back the clock.) ¬†They landed on markers of proliferation, and what happens when ROCK is added to them, and laminin expression, and dorsal root ganglion neurite outgrowth, and migration — all of which show clear differences between old and young.

They treat their old astrocytes with factors that make them think they’re young, look young, act young. ¬†The factors work.

This is evidence that they’ve succeeded — in a dish — in the goal of taking astroglial scars backwards and turning them from regeneration blockers to regenerations supporters.

(Next would be taking those newly rejuvenated astrocytes and seeing what happens when they’re given to animals with SCI.)

Mark Tuszynski

Posted November 2, 2012 by katewillette
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Axonal Sprouting and Regeneration in the Central Nervous System

Going to talk with you about neural stem cells, which we hadn’t worked with much until recently. ¬†My colleague Paul Lu came to me with a plan to look at neural stem cells . . . I discouraged him, but he was right, and his work has changed the direction of what we do in our lab.

Giving credit to funders, including the VA, CIRM,  and the Roman Reed foundation.

Showing a 9-year-old injured cord. What keeps it broken?

No permissive substrates in the lesion cavity, not enough neurotrophic support, and inhibition.  (My translation of this for the non-scientists would be: nothing for the axons to lie on as they grow, not enough fertilizer to help them grow, and too much toxic shit in the way.)

Inhibitors include myelin-asociated inhibitory proteins, like nogo, mag, omgp, semaphorin, netrin, and ephrin. (That’s some of the toxic shit.)

Then there are neuron-intrinsic factors like regeneration-related gene expression and or production of proteins (this isn’t really toxic shit . . . it’s shit that relates to the way your genes magically know when they’re allowed to help neurons regenerate and when they’re forbidden to do that. ¬†Neurons in an embryo can regenerate, but neurons in an infant can’t. ¬†Same cells, different rules coming from your genes.)

This talk is going to be about that last item . . . if you take an embryonic neural stem cell that IS growing and put into the adult spinal cord injury, will it grow?

Many years of efforts say, not really. ¬†BUT, if you take E14 (E14 is shorthand for a 14-day-old embryo) cells from a developing rat and isolate the stem cells, they’re pluripotent in terms of neural cell types. (Meaning, they can still be turned into all three kinds of ¬†neural cells: neurons, astrocytes, and glial cells.) ¬†Hans Keirstead was able to take human stem cells and grow them in such a way that he got pure oligodendrocytes, but we’re not doing that . ¬†. we’re taking them before they’re differentiated and putting them into the site.

They put trackers on their cells so they could see what happened to them once they were transplanted.

We grafted them two weeks post, because we wanted as much clinical relevance as possible. (“Clinical relevance” means being able to actually do this in human beings.) ¬†We spent more than a year figuring out how to include a gel — a fibrin/thrombin matrix — that would let the cells survive and stick together, and we added some growth factors. (So, they had a good surface for the axons to lie on while they were growing across empty space, and they added some good fertilizer along with their undifferentiated, embryo-style neural cells.)

We used a T3 complete transection . . . six weeks later, the transplanted cells had completely filled the injury site.  Our tissue stains let us see what the cells had become.  A lot of them were neurons.  (Showing a slide with the section lit up)  Some cells turned into astrocytes, and others into oligodendrocytes.  All 3 types were there . . .

The truly remarkable thing was that axons emerged at very high densities over extremely long distances. ¬†Until this experiment, the best we’d ever seen was about a hundred. ¬†We have a thousand times more than that.

Not only that, but they’re growing much further than anything we’d ever seen, all the way up to c4 and down to lumbar. ¬†When we did c5 hemisection models, the cells went all the way to the brain stem and then back down to the t8 level. ¬†Some axons even grew out of the roots to exit the cord and head into the nerve roots.

We could follow the rate of growth over time . . . growth started right away and went at a rate of 1-2 millimeters per day, same rate as peripheral nerves.

This wasn’t just a few extra good results — it’s 80% of the time. ¬†The stem-cell derived axons form connections with host motor neurons. ¬†And they’re being remyelinated as they go.

So . . . a lot of axons grow out and grow for long distances — something I never thought I’d see.

But that’s only half the story. ¬†You need axons to grow into the site as well, and that’s what we saw. ¬†The host axons from the brain stem can penetrate the graft. ¬†This means they could be forming new relays, new connections between the brain stem and the motor neurons.

We measure whether that’s happening, and it is. ¬†Take a t3 graft, stimulate at c7, measure at t6 . . . and got a measurable electrical response, not quite normal, but real. ¬†(To make sure they weren’t fooling themselves, they cut the cord again, just above the graft — and saw what would be expected, namely that the response vanished.)

The BBB score went from about 2 to about 7 with the grafts. ¬†All of which supports the idea that you’re getting functional new relays across the injury.

These were the most potent results we’d ever seen. ¬†So we looked at two human stem cell lines, one from neural stem cells and another from neuronal cells grown at Harvard from human stem cells.

(okay, to be clear . . . he’s saying that they started by putting rat embryo neural cells into transected rat cords, and then did the same experiment two more times, once with human embryo-derived neural cells put into transected rat cords, and then with human neural cells grown in the lab from human stem cells, again placed in rats.)

When we did the human neural cells, it looked a lot like what we saw with the rat neural cells when we put those cells into transected rats.  I have to say that for someone who has worked in this field for a very long time, these results are simply astonishing.

When we did the human stem-cell-based neural cells, we again got axons growing over very long distances, and lots of them.

As part of the CA consortium about 10 years ago, we set up a primate lab, so that was in place for the next phase of testing.

We did C7 hemisection lesion on the primates, and again delayed the graft for 2 weeks. ¬†This time we used the human neural stem cells and have shown — again — axons growing robustly through white matter and gray matter.

This work with the monkeys is just beginning; it’s very important to do it. ¬†The gels we used in the rats didn’t work in the monkeys . . . we have to devise a whole new matrix to fill that much larger cavity. ¬†95% of rat-to-human models fail. ¬†(95%!)

We need to see this work if (when!) we get to human trials. ¬†We’re seeing many scientists from other labs come to see what we’re doing in the hope that it can be extended.

Progress with Neural Stem Cells

Posted November 2, 2012 by katewillette
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This afternoon there are just two speakers — but they’re stars.

First will be Dr. Mark Tuszynski, from UC San Diego and next an old friend of w2w, Dr. Hans Keirstead, from the RIRC.

We’re all kind of excited after listening to the morning group, so it’s a little hard to get people settled down and ready to listen up.

Mark’s talk is called “Neural Stem Cells for Severe Spinal Cord Injury”

Hans’ is Stem Cell-based Approaches to Treat SCI

Justin Brown, MD: Peripheral Nerve Surgery

Posted November 2, 2012 by katewillette
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Slide show is called Building Bridges to Restore Function

When you cut a peripheral nerve, Schwann cells go to work, attracting axons like a magnet. ¬†How do you repair nerves that are too damaged? ¬†You can do grafting by building an effective bridge, usually with nerve cells swiped from a place on the body where you don’t care much about sensation (side of the foot, e.g.) ¬†it works pretty well.

Obstacles are distance, time, complexity, and age.  Closer is better.

The traditional way is to try to recreate what it used to look like . . . results are often mediocre. And sometimes you pop the nerve right out of the spinal cord (this is called avulsion).

A new idea was to do nerve transfer, which is a way of redistributing nerves that doesn’t try to reproduce what used to be there but rather invents a new system. ¬†The peripheral nerve system is just as plastic as the CNS . . . showing a guy who survived a bad motorcycle crash and ended up with a fully paralyzed arm. ¬†They did a graft . . . video from 3 months later, and he’s got some function back, 2 years later he’s got a normal arm with full range of motion, and you can’t tell which of those arms was injured.

You can take nerves that used to have a whole other destination and put them where you want them . . . and make them work. ¬†And it doesn’t always take high end rehab.

Another example — guy got shot in the arm and lost use of his hand. ¬†After the graft, video of his hand working normally while running off completely new nerve set.

So what about SCI? ¬†You have a similar situation to a peripheral nerve loss. ¬†Even years after injury, you should be able to take nerves still connected to the brain and use them in exactly the same way. ¬†You’re transferring axons.

New video of a hand that was rewired.  Can you redistribute axons and restore grip?  Worked with a typical c5 patient, regrafted some nerves that were connected to the brain to replace those that had lost that connection . . . (Arghhhh, showing the surgery itself.  Okay.  Very bloody.)

Ha ha, Jerry Silver says from the audience, “You know, 2 shots of ChABC would really help!”

Justin says, “Let’s do it!”

They find the target with electronics, and — the guy can extend his fingers. ¬†He has brain connection to fingers– connection that didn’t exist before this surgery. ¬†“You can’t come into this game passive. ¬†You have to work to get what you get. ¬†It’s really dependent on how hard you work.”

What about incomplete injuries . . . There are classifications of EMG activity that show level of spasticity.  Turns out you can do peripheral neurotomies to deal with that.  Showing a video of man who had this treatment and went from needing a walker to being able to free-walk, and that was 15 years post.

The thing is, once these stem cell and other strategies get up and running, there’s going to be a tuneup phase. ¬†Things won’t go back to the way they were; there will probably be a need for these kinds of targets.

We’re also working now on restoring the bladder. ¬†With dogs, we’ve already been able to get that working.