“The annals of ALS clinical trials is strewn with failed studies. Only two out of more than 70 clinical trials have been positive, and even these showed only very modest benefit. Is this dismal record strictly due to the extraordinary complexity of neurodegenerative disease in general, and ALS in particular? Or is it due to methodological flaws that could be repaired?”
Robert G Miller, Professor of Neurology, Stanford University
Although there is not much we can do about disease complexity, improving the way treatments are trialed is something that can be achieved. Imagine a world without clinical trials, where independent companies or individuals would be allowed to sell their self-made ‘drugs’ without any evidence that they were ever used on anyone with the disease, let alone that they would improve one’s condition. No one would know what the drug is (which could simply be a water solution), how it works and whether as soon as the drug is taken, we would be poisoned.
Thankfully, this is not the case and clinical trials, although not perfect, are considered the gold standard for approving any treatment. However, there are still some improvements that can be done to make trials easier to access and provide more accurate estimates of drugs’ effectiveness much faster.
MND Association-supported clinical fellow Dr Johnathan Cooper-Knock, and a PhD student Tobias Moll, report mutations in a new MND gene which has uncovered a previously unknown disease mechanism. The new MND causing gene holds instructions for a class of proteins, called glycosyltransferase (GLT8D1), which has not previously been associated with neurodegeneration.
During the experiments, published in the journal Cell Reports, the research team read the genetic code from two related patients with an unknown familial (inherited) form of MND and found a change in the gene that makes an enzyme called GLT8D1. They went on to examine a larger sample of 103 people with inherited MND and found that five of these also had this gene abnormality, indicating that this change causes MND. Because the enzyme and its mechanism have never previously been associated with MND, this study has uncovered a new genetic and biological cause of the disease.Read More »
To mark International Clinical Trials Day (20 May) we reflect on the ALS Clinical Trials Guidelines workshop that took place in March. The MND Association co-sponsored this successful meeting, held at Airlie House in Virginia USA. Approximately 140 delegates from across the world attended, including 11 MND researchers and doctors from the UK.
Why was this meeting held?
The meeting was a key stage in the process to update (and improve) international guidelines for clinical trials in amyotrophic lateral sclerosis (ALS, the most common form of MND).
The first international ALS clinical trials guideline workshop took place in 1998. The guidelines were designed to improve the quality of clinical trials in ALS, and provide evidence based recommendations to those designing and carrying out all stages of clinical trials.Read More »
Professor Winston Hide gave his inaugural lecture on 17 March, during Brain Awareness week, entitled ‘breaking the human genome code – opening Pandora’s box’, which you can watch in full at the end of this blog post.
Professor Hide recently joined the University of Sheffield, and MND Association/ Medical Research Council (MRC) Lady Edith Wolfson Clinical Research Fellow, Dr Johnathan Cooper-Knock has written a blog below about Professor Hide’s research and how they are working together towards a world free from MND: Read More »
“On the seventh day of Christmas MND research gives to you… our SEVEN research strategy themes”
It’s New Year’s eve, a time to look back and celebrate on 2014 and our MND research achievements. It’s also a time to look to the future; in 2015 we will be funding new MND research in line with our research strategy.
The exact cause of the majority of cases of MND is still unknown. Therefore identifying the causes is our first step in understanding MND and developing future treatments.
In 2014 we identified two new inherited MND genes and also announced funding for the UK Whole Genome Sequencing project to better identify the rarer genetic factors involved in causing the disease. Read more.
2) Create and validate new models
Once we identify a genetic cause of MND, we need to find out how this gene causes MND. Animal and cellular models help us to find out how the gene affects the motor neurones and how this causes disease in a complex animal system. Read More »
Medical Research Council (MRC)/ MND Association Lady Edith Wolfson Clinical Research Fellow, Dr Johnathan Cooper-Knock, is based at the Sheffield Institute for Translational Neuroscience (SITraN), at the University of Sheffield. The Tour de France ends up in Sheffield a week today, so to get you into the cycling spirit, John blogs about the Sheffield to Leuven ENCALS cycling challenge!
The great idea
A few weeks ago Richard Mead and I had a chat in the lab. We wondered whether it would be possible to cycle to Leuven for the forthcoming European Network for a Cure of ALS (ENCALS) conference (22 – 24 May 2014). Well of course it would be possible, but given finite resources, time and training could we do it? When we discovered the overnight ferry from Hull to Zeerbrugge (which we were reliably informed only resulted in sea-sickness 60% of the time) we realised the dream could become a reality. Read More »
It’s been six months since the UK MND DNA Bank (DNA Bank) opened its doors to researchers around the world, so what has been happening to all those samples? Dr Lucy Smith, Research Information Administrator at the MND Association, explains:
The DNA Bank is the first UK biobank dedicated to MND and has 3000 samples under its roof. Over an 8 year period, blood samples were collected from people living with MND and their family members, together with unrelated controls. The DNA was extracted, and the entire collection is now stored and managed in partnership with BioBanking Solutions (BBS) at the University of Manchester. Important clinical information, such as gender and the age of onset of the people who gave the sample is also stored within the collection.
Alongside DNA, the DNA Bank also stores some cells lines at the European Collection of Cell Cultures (ECACC), Public Health England. The cell lines were made as a guarantee that the DNA supply wouldn’t run out, however the cell lines have become hugely important over recent years and are now a valuable resource themselves.
There’s a scene in the 1969 film Battle of Britain where Laurence Olivier, who plays the Air Chief Marshal, is in a meeting with his two Vice Marshals. One of them complains that they don’t have enough planes; the other is more concerned with keeping the airfields working. Olivier silences them both by telling them that the fight will be won or lost on one key factor – the number of trained pilots.
It’s a rather cheesy film, but I used that story earlier this month to illustrate the importance of investing in bringing through the next generation of researchers in our battle to defeat MND. We organised a ‘get together’ of our Lady Edith Wolfson Clinical Fellows at the Sheffield Institute for Translational Neuroscience (SITraN) to share their research findings with the donor who has so generously supported the scheme. The ‘get together’ also provided a wonderful opportunity for them to exchange information and expertise with each other, as well as all the staff of SITraN, who over the course of the day were frequently shuttling between the lecture room and their labs.
The Fellowships are aimed at attracting and training the brightest and the best Clinician-Scientists (or ‘Doctor-Doctors’ as I sometimes call them – with both a medical degree and a science PhD). Even so, I couldn’t resist using this cartoon in my introduction, although the reality is very different for our Fellows – the bar is set very high and even applicants for the Junior Fellowships need to have considerable research experience and be fully ‘lab tested’.
Our host for the day was one of the world’s most respected MND ‘Doctor-Doctors’, SITraN Director Prof Pam Shaw, who welcomed everyone to the meeting and provided an overview of the multidisciplinary expertise and collaborative philosophy that underpins SITraN. Prof Shaw also has a great belief in the importance of nurturing the next generation of talent and it is no surprise that almost half of the Clinical Fellows in the programme are based at SITraN.
Are fit and active people more likely to develop MND?
Our first research presentation was from Dr Ceryl Harwood (Sheffield) who is carrying out research on the epidemiology of MND. Specifically, she is addressing the question of whether physical activity is a risk factor for MND. As she explained, this has been a long standing theory, showing us a quote from a medical journal written over 50 years ago which stated:
”Nothing has been said about the possible role in aetiology of a previous habit of athleticism. I have the uncomfortable feeling that a past history of unnecessary muscular movement carried out for no obvious reason may be followed in later life by the development of motor neurone disease in a statistically significant number of cases”
She outlined the plausibility that physical activity may contribute to a complex interplay between biological and genetic processes that may predispose an individual to develop the disease. Generating the evidence, however, is no easy matter, but she has developed and validated a novel questionnaire to measure physical history in adulthood, using data from a diabetes study in the 1990s where over 1,000 people had detailed measures taken of their actual energy expenditure.
A hundred of these participants have recently agreed to undergo rigorous face-to-face interviews and their responses were correlated with actual physical measures from over 15 years previously. In other words, she can now assess how accurately peoples’ recollection of their physical activity – both day to day work and vigorous exercise – links with their actual energy expenditure at the time. This questionnaire is now being used to compare the physical activity profiles in up to 350 people with MND and 700 control participants in Yorkshire and surrounding counties.
Should the results support the theory that physical activity is a predisposing factor in MND, she will be perfectly placed to delve into the genetic factors that underpin the selective vulnerability of motor neurons.
Repetition is bad….
Next up to the lectern was Dr Pietro Fratta, (University College London) who has been immersing himself in the mysteries of how the C9orf72 gene can cause neurodegeneration – especially MND and a related condition called Frontotemporal Dementia (FTD).
Like a needle on a vinyl record can sometimes stick and repeat the same fragment of music again and again, this gene sometimes carries a repeat in its genetic code – specifically with the letters GGGGCC occurring again and again. Dr Fratta has examined many DNA samples from MND and FTD patients and finds that these ‘repeat expansions’ are very large indeed, occurring between 700 and 4000 times!
The process through which these repeat expansions cause nerves to die is still a mystery, but Dr Fratta showed results from his lab which suggests that rather than losing its normal function, the C9orf72 gene gains some additional activity, turning it into a ‘rogue’ gene. He and his colleagues have recently shown that the repeat expansions can lead to the formation of very stable chemical structures called G-quadruplexes that have been implicated in causing nerve damage in other disorders.
He is currently studying how these structures interact with other cellular components, interfering with normal neuronal function. He is also starting to look at possible therapeutic approaches in a collaboration with the UCL School of Pharmacy to develop compounds that will bind to and hopefully inactivate these structures.
Over lunch, we were given a guided tour of the superb SITraN labs by Prof Shaw. Although I strongly believe that research is only as good as the researchers doing the work, there’s no doubt that having a purpose built institute filled with state-of-the art technology certainly doesn’t do any harm!
Then it was back into the lecture room for our afternoon presenters.
A Sheffield double act
The post-lunch session was kicked off by Dr Robin Highley, a neuropathologist who has recently completed his Fellowship and now divides his time equally between pathology duties and MND research. Dr Highley’s area of expertise is in how neurons edit the genetic instructions into precise ‘blueprints’ to make proteins, the essential building blocks of every cell in our body.
He used an entertaining analogy of making dresses form a pattern to describe the process of how DNA is made into RNA copies which can be ‘tailored’ into slightly different protein designs (to find out more about how DNA makes RNA and subsequently proteins see our earlier blog post).
Using a variety of approaches he has looked at gene expression (which genes are being switched on and off) and gene splicing (how the RNA copies are edited) patterns in both inherited and non-inherited MND, as well as in non-MND states. He finds changes occurring in thousands of genes, but by performing searches on databases of the ‘function’ of each gene he can then sort them into different groups (which are then involved in key cellular processes). This provides important clues as to which cellular pathways are altered in MND, which will help researchers around the world to focus their attention on the most common changes and hopefully start addressing the question of how these may be slowed or stopped.
Dr Highley focused his talk mainly on the TDP-43 and SOD1 forms of inherited MND, with his colleague and fellow ‘Fellow’(!) Dr Johnathan Cooper-Knock, concentrating on the C9orf72 form (the most common cause of inherited MND). Through the MND Association’s DNA Bank he has been able to obtain a large number of cell lines from patients with C9orf72 MND, along with detailed clinical information, which will allow him to compare patterns between those with fast progressing and those with more slowly progressing disease.
Although at a much earlier stage in his research, having started only 6 months ago, Dr Cooper-Knock has already identified some specific gene expression effects that may be distinct to the C9orf72 form of the disease. For more details about Dr Cooper-Knock’s work see our earlier blog post about his fellowship.
BioMOx and beyond
It was fitting that Dr Martin Turner (Oxford) gave the closing presentation. Not only was Dr Turner the first recipient of a Lady Edith Wolfson Fellowship, but he has recently been awarded a new five-year Senior Clinical Fellowship through the programme – these are highly prestigious awards, with only one in seven applicants successful.
Titling his talk ‘BioMOx and beyond’ Dr Turner outlined the challenge of identifying a specific signature of MND. He showed that whilst there is unlikely to be a single test for MND, a combination of tests (involving brain scanning and eye tracking techniques together with chemical analysis of blood, urine or cerebrospinal fluid) are showing some promise in aiding and speeding up the diagnosis, as well as predicting how the disease is likely to progress within an individual.
He highlighted the importance of international collaboration, such as the new formal link with Dr Mike Benatar in Miami, who for several years has been studying people at risk of developing inherited MND. Indeed, Dr Turner apologised for missing the morning speakers at Sheffield as he had been busy with one of Dr Benatar’s study participants in his MRI scanner at Oxford!
On the subject of international collaboration, our most recent Clinical Fellow, Dr Jemeen Sreedharan, was unfortunately unable to attend as the first two years of his Fellowship is based at the University of Massachusetts, returning to the University of Cambridge to complete his research. We look forward to having him at the next Fellows get-together!
In 2011 an international team of scientists, including three MND Association-funded researchers, identified the elusive C9orf72 gene located on Chromosome 9. Since this ground-breaking discovery, researchers from around the world have been trying to find a way to open-up and reveal more about this MND-causing gene.
Determined to get inside and unravel the secrets behind C9orf72, the Association is funding a number of new and exciting research projects to help solve the mystery. These projects look at, not one, but a number of different aspects to try and understand more about C9orf72.
In order to solve this mystery our C9orf72 researchers are following the clues using zebrafish, mice, flies and DNA samples.
How the C9orf72 MND mystery began
We each contain copies of 23 pairs of chromosomes, including the X and Y sex chromosomes. These chromosomes contain thousands of genes that portray our characteristics such as hair and eye colour. These genes are made up of DNA which can either be ‘coding’ to make a protein, or ‘non-coding’. For details of how genes make a protein see our earlier blog post.
Before C9orf72 was identified researchers had focused on an area on Chromosome 9 that appeared to be connected with both the rare inherited form of MND and the related neurodegenerative disease frontotemporal dementia (FTD).
Using a number of cutting-edge techniques the international team isolated the C9orf72 gene expanded GGGGCC hexanucleotide repeat as being a crucial player in both inherited MND and FTD. Not only did the researchers find a link between MND and FTD, they also found that C9orf72 was found in approximately 40% of cases of inherited MND (where there is a strong family history). This means that we now know 70% of the genes that cause the rare inherited form of MND. For more details on C9orf72 see our earlier blog post.
So, researchers found C9orf72. The next question was ‘What does it do? Is the gene defect repeat itself, or the protein it makes responsible for causing MND? And what goes wrong in MND?’
Two recent research clues
Since 2011 researchers have been trying to answer these questions and find out more about C9orf72. This has led to a dramatic increase in research, including two papers published in February and March this year!
Prof Christian Haass (Munich Centre for Neurosciences, Germany), who recently presented at our 23rd International Symposium on ALS/MND in December 2012, published a paper on the 7 February in the journal Science. The second paper lead by Prof Leonard Petrucelli (Mayo Clinic, USA) was published open access in the journal Neuron on the 20 February.
In a big surprise, both researchers found that the presumed ‘non-coding’ C9orf72 GGGGCC repeat expansion actually made a protein. Normally these ‘non-coding’ regions do not make proteins so this was a very big surprise indeed!
The researchers found that these proteins formed large clumps in the brains, and throughout the central nervous system (CNS), of people with C9orf72 MND and/or FTD. Importantly, they did not find these clumps in healthy individuals or those with other neurological disorders.
It is currently unknown as to whether these protein clumps are involved in MND and/or FTD, but they may be a potential biomarker or a therapeutic target in this most common type of MND. The next step is for the researchers to find out whether these proteins actually cause MND and/or FTD.
Finding more evidence to piece together the clues
In addition to these two papers looking into the mystery behind C9orf72, the Association is funding some exciting new research projects, each looking at different things, to further understand more about this gene.
Dr Johnathan Cooper-Knock (Sheffield Institute for Translational Neuroscience, UK) is already trying to identify how C9orf72 causes MND by utilising a genetic technique known as gene expression profiling. He is using samples from the Association’s DNA bank which are positive for the C9orf72 genetic mistake. Gene expression profiling is a technique which allows researchers to understand how the activity of genes contributes towards causing MND. (Traditional genetic studies are designed to look at which genes are affected, rather than their activity – ie when and how). Read more about Johnathan’s project here.
Developing new disease models enables us to understand the causes of MND and to test new therapies. One way to understand the function of C9orf72 and how this goes wrong in MND is to create a model. Our current research projects are developing new C9orf72 models in flies, mice and zebrafish.
Dr Frank Hirth (Kings College London, UK) will be producing a fly model, Dr Javier Alegre Abarrategui (University of Oxford) will be making a mouse model and Dr Andrew Grierson (University of Sheffield, UK) will be creating a zebrafish model.
All of our C9orf72 Association-funded research projects are using different approaches to look at C9orf72 in different ways as we are still unsure whether the protein or the repeat is the problem. From mice to flies all of these research projects together are helping to solve the mystery of C9orf72 and MND.
With the proteins formed by C9orf72 likely to be a potential biomarker or therapeutic target the two recent papers are adding to the growing number of clues, pointing researchers in the right direction to unravelling and solving the secrets of C9orf72.
Mori, K. et al. The C9orf72 GGGGCC Repeat Is Translated into Aggregating Dipeptide-Repeat Proteins in FTLD/ALS. Science. 339(6125): 1335-1338.2013 DOI: 10.1126/science.1232927
Ash, P. E. A. et al. Unconventional Translation of C9ORF72 GGGGCC Expansion Generates Insoluble Polypeptides Specific to c9FTD/ALS. Neuron. 77(4): 639-646. 2013 DOI: 10.1016/j.neuron.2013.02.004
Dr Johnathan Cooper-Knock from the Sheffield Institute for Translational Neuroscience (SITraN) has been awarded with the fifth Medical Research Council (MRC)/MND Association Lady Edith Wolfson Clinical Research Fellowship.
Through his three-year fellowship, Dr Cooper-Knock will use the MND Association’s DNA bank to study how recently discovered mistakes (known as mutations) in a gene called C9ORF72 can cause the disease.
Dr Johnathan Cooper Knock explains, “I believe that the genetics of MND are a key to understanding both the cause of the disease and how to treat it. The discovery of mutations in C9ORF72 are a great opportunity to get a hold on mechanisms of disease which has so far been elusive. I am excited by the opportunity my fellowship will give me to pursue this important discovery.
“By the end of my fellowship I aim to have contributed significantly to the understanding of disease mechanisms related to C9ORF72 dysfunction in MND. As a result I hope to have identified a number of therapeutic targets for development into new treatments by myself and others.”
C9ORF72: the facts so far
We know that a repeated six-letter code within a gene called C9ORF72 can cause MND and a related condition called fronto-temporal dementia (FTD) for approximately 40% of cases with a positive family history of MND and/or FTD.
Most genetic mistakes found in MND to date have been swaps of genetic letters, which can change the meaning of that part of the gene. The C9ORF72 genetic mistake on the other hand, is a repeat expansion. This means that six letters within the genetic code (CCCCGG) are repeated hundreds of times for people with C9ORF72 MND. In healthy individuals, this repeat is found about 30 times. We already know that the exact size of the repeat varies substantially between people with this genetic mistake. How this repeat causes MND and how the size of the repeat may affect disease progression is currently unknown but this is something that Dr Cooper-Knock wants to find out.
We also don’t know what role C9ORF72 normally has in the body. Even its name, which stands for ‘chromosome 9 open reading frame 72’ refers to where it is in the genetic code and not what it does. This isn’t unusual as it’s currently estimated that we have over 20,000 genes, and understandably, researchers haven’t yet found out what every one of these does – including C9ORF72.
So far, 96 journal articles have been published about C9ORF72 (by searching on Pubmed for C9ORF72). The oldest of these was published in 2011, and describes the original MND/FTD C9ORF72 finding. All subsequent articles on C9ORF72 have been of a direct consequence from this pivotal genetic discovery in the past year.
These 96 studies were focused on finding out how many people have the C9ORF72 genetic repeat and finding out what this mistake ‘looks like’ both clinically in terms of progression rates, age of onset and symptoms; and in terms of post-mortem findings to compare with other forms of MND. Coincidently, the most recent post-mortem and clinical C9ORF72 finding was authored by Dr Cooper-Knock (when searching for C9ORF72 and post mortem on PubMed).
It’s reassuring to know that researchers aren’t resting on their laurels with this genetic finding. There’s a huge international research effort in place to push forward our understanding of C9ORF72, with a number of our own newly funded projects, starting later this year, dedicated to creating new laboratory models of this genetic mistake to better understand how it can cause the disease.
How do we currently think C9ORF72 causes MND?
Due to the sheer size of the repeat expansion in C9ORF72, it’s thought that it causes MND by disruption of the editing process of genetic information.
I’ll explain: In real life terms, our DNA can be thought of as being held within a library, which is the control centre of the cell (the nucleus). Each book (gene) is stored on a particular shelf (chromosome). Gene ‘books’ aren’t allowed to be taken out of the nucleus, but they can be photocopied. These copies (RNA) are edited and transported out of the nucleus to be used as instructions to create proteins that perform specific roles in and sometimes out of the cell.
Unlike real life books, genes are fraught with errors, variations and nonsense from one person to the next. It looks messy, but it’s normal. Genetic editors are needed to edit and chop the RNA into a readable format so that it can be understood by the parts of the cell that use RNA as instructions.
As normal, healthy copies of C9ORF72 hold approximately 30 repeats to be chopped out as RNA, the effect of having much larger repeats may be having a knock-on effect on the efficiency of the editing process. This could then lead to a much higher risk of developing MND.
Finding out exactly how C9ORF72 can cause MND, and whether this theory is right, will provide us with a deeper insight into MND and potentially provide therapeutic targets that can be further investigated.
Dr Cooper-Knock’s fellowship
Dr Cooper-Knock will be using a cutting-edge genetic technique called ‘gene expression profiling’ to study the various levels of RNA in samples provided by people with the C9ORF72 genetic mistake. From this, he’ll find out which genes are switched on and off because of the C9ORF72 repeat expansion.
He will also study whether the size of the C9ORF72 repeat expansion has an effect on symptoms or progression rates to identify factors that may modify disease progression and may therefore be targets for future therapies.
Technology specialised for identifying misassembled RNA will also be applied to skin cells donated by people with the C9ORF72 repeat expansion who have MND/FTD and healthy controls. This will help to elucidate what the C9ORF72 protein does.
As well as skin cells from people with MND/FTD, this study will use post-mortem brain and spinal cord tissue from people with the C9ORF72 repeat expansion and healthy controls within the Sheffield tissue bank; as well as cells from the blood of C9ORF72 patients and healthy controls obtained from the MND Association’s DNA Bank.
Talking about the importance of people with MND having provided these numerous samples Dr Cooper-Knock said “Without the participation of patients and their families MND research will get nowhere; and equally with their participation, doors are opened towards new and exciting treatments. At this time, with discoveries like the mutations in C9ORF72 to build from, we can do even more with the participation of those who have been affected by this disease, who like us are passionate to see it cured.”