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Wednesday, August 21, 2013

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First pre-clinical gene therapy study to reverse Rett symptoms

Aug. 20, 2013 — The concept behind gene therapy is simple: deliver a healthy gene to compensate for one that is mutated. New research published today in the Journal of Neuroscience suggests this approach may eventually be a feasible option to treat Rett Syndrome, the most disabling of the autism spectrum disorders. Gail Mandel, Ph.D., a Howard Hughes Investigator at Oregon Health and Sciences University, led the study. The Rett Syndrome Research Trust, with generous support from the Rett Syndrome Research Trust UK and Rett Syndrome Research & Treatment Foundation, funded this work through the MECP2 Consortium.

In 2007, co-author Adrian Bird, Ph.D., at the University of Edinburgh astonished the scientific community with proof-of-concept that Rett is curable, by reversing symptoms in adult mice. His unexpected results catalyzed labs around the world to pursue a multitude of strategies to extend the pre-clinical findings to people.

Today's study is the first to show reversal of symptoms in fully symptomatic mice using techniques of gene therapy that have potential for clinical application.

Rett Syndrome is an X-linked neurological disorder primarily affecting girls; in the US, about 1 in 10,000 children a year are born with Rett. In most cases symptoms begin to manifest between 6 and 18 months of age, as developmental milestones are missed or lost. The regression that follows is characterized by loss of speech, mobility, and functional hand use, which is often replaced by Rett's signature gesture: hand-wringing, sometimes so intense that it is a constant during every waking hour. Other symptoms include seizures, tremors, orthopedic and digestive problems, disordered breathing and other autonomic impairments, sensory issues and anxiety. Most children live into adulthood and require round-the-clock care.

The cause of Rett Syndrome's terrible constellation of symptoms lies in mutations of an X-linked gene called MECP2 (methyl CpG-binding protein). MECP2 is a master gene that regulates the activity of many other genes, switching them on or off.

"Gene therapy is well suited for this disorder," Dr. Mandel explains. "Because MECP2 binds to DNA throughout the genome, there is no single gene currently that we can point to and target with a drug. Therefore the best chance of having a major impact on the disorder is to correct the underlying defect in as many cells throughout the body as possible. Gene therapy allows us to do that."

Healthy genes can be delivered into cells aboard a virus, which acts as a Trojan horse. Many different types of these Trojan horses exist. Dr. Mandel used adeno-associated virus serotype 9 (AAV9), which has the unusual and attractive ability to cross the blood-brain barrier. This allows the virus and its cargo to be administered intravenously, instead of employing more invasive direct brain delivery systems that require drilling burr holes into the skull.

Because the virus has limited cargo space, it cannot carry the entire MECP2 gene. Co-author Brian Kaspar of Nationwide Children's Hospital collaborated with the Mandel lab to package only the gene's most critical segments. After being injected into the Rett mice, the virus made its way to cells throughout the body and brain, distributing the modified gene, which then started to produce the MeCP2 protein.

As in human females with Rett Syndrome, only approximately 50% of the mouse cells have a healthy copy of MECP2. After the gene therapy treatment 65% of cells now had a functioning MECP2 gene.

The treated mice showed profound improvements in motor function, tremors, seizures and hind limb clasping. At the cellular level the smaller body size of neurons seen in mutant cells was restored to normal. Biochemical experiments proved that the gene had found its way into the nuclei of cells and was functioning as expected, binding to DNA.

One Rett symptom that was not ameliorated was abnormal respiration. Researchers hypothesize that correcting this may require targeting a greater number of cells than the 15% that had been achieved in the brainstem.

"We learned a critical and encouraging point with these experiments -- that we don't have to correct every cell in order to reverse symptoms. Going from 50% to 65% of the cells having a functioning gene resulted in significant improvements," said co-author Saurabh Garg.

One of the potential challenges of gene therapy in Rett is the possibility of delivering multiple copies of the gene to a cell. We know from the MECP2 Duplication Syndrome that too much of this protein is detrimental. "Our results show that after gene therapy treatment the correct amount of MeCP2 protein was being expressed. At least in our hands, with these methods, overexpression of MeCP2 was not an issue," said co-author Daniel Lioy.

Dr. Mandel cautioned that key steps remain before clinical trials can begin. "Our study is an important first step in highlighting the potential for AAV9 to treating the neurological symptoms in Rett. We are now working on improving the packaging of MeCP2 in the virus to see if we can target a larger percentage of cells and therefore improve symptoms even further," said Mandel. Collaborators Hélène Cheval and Adrian Bird see this as a promising follow up to the 2007 work showing symptom reversal in Rett mice. "That study used genetic tricks that could not be directly applicable to humans, but the AAV9 vector used here could in principle deliver a gene therapeutically. This is an important step forward, but there is a way to go yet."

"Gene therapy has had a tumultuous road in the past few decades but is undergoing a renaissance due to recent technological advances. Europe and Asia have gene therapy treatments already in the clinic and it's likely that the US will follow suit. Our goal now is to prioritize the next key experiments and facilitate their execution as quickly as possible. Gene therapy, especially to the brain, is a tricky undertaking but I'm cautiously optimistic that with the right team we can lay out a plan for clinical development. I congratulate the Mandel and Bird labs on today's publication, which is the third to be generated from the MECP2 Consortium in a short period of time," said Monica Coenraads, Executive Director of the Rett Syndrome Research Trust and mother of a teenaged daughter with the disorder.

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How sleep helps brain learn motor task

Aug. 20, 2013 — Sleep helps the brain consolidate what we've learned, but scientists have struggled to determine what goes on in the brain to make that happen for different kinds of learned tasks. In a new study, researchers pinpoint the brainwave frequencies and brain region associated with sleep-enhanced learning of a sequential finger tapping task akin to typing, or playing piano.

You take your piano lesson, you go to sleep and when you wake up your fingers are better able to play that beautiful sequence of notes. How does sleep make that difference? A new study helps to explain what happens in your brain during those fateful, restful hours when motor learning takes hold.

"The mechanisms of memory consolidations regarding motor memory learning were still uncertain until now," said Masako Tamaki, a postdoctoral researcher at Brown University and lead author of the study that appears Aug. 21 in the Journal of Neuroscience. "We were trying to figure out which part of the brain is doing what during sleep, independent of what goes on during wakefulness. We were trying to figure out the specific role of sleep."

In part because it employed three different kinds of brain scans, the research is the first to precisely quantify changes among certain brainwaves and the exact location of that changed brain activity in subjects as they slept after learning a sequential finger-tapping task. The task was a sequence of key punches that is cognitively akin to typing or playing the piano.

Cap of Sensors

In a sleep lab on Brown's campus researchers use now using caps of EEG sensors in studies of how the brain works to consolidate learning visual tasks. Here graduate student Aaron Berard models the cap.Specifically, the results of complex experiments performed at Massachusetts General Hospital and then analyzed at Brown show that the improved speed and accuracy volunteers showed on the task after a few hours sleep was significantly associated with changes in fast-sigma and delta brainwave oscillations in their supplementary motor area (SMA), a region on the top-middle of the brain. These specific brainwave changes in the SMA occurred during a particular phase of sleep known as "slow-wave" sleep.

Scientists have shown that sleep improves many kinds of learning, including the kind of sequential finger-tapping motor tasks addressed in the study, but they haven't been sure about why or how. It's an intensive activity for the brain to consolidate learning and so the brain may benefit from sleep perhaps because more energy is available or because distractions and new inputs are fewer, said study corresponding author Yuka Sasaki, a research associate professor in Brown's Department of Cognitive, Linguistic & Psychological Sciences.

"Sleep is not just a waste of time," Sasaki said.

The extent of reorganization that the brain accomplishes during sleep is suggested by the distinct roles the two brainwave oscillations appear to play. The authors wrote that the delta oscillations appeared to govern the changes in the SMA's connectivity with other areas of the cortex, while the fast-sigma oscillations appeared to pertain to changes within the SMA itself.

Meticulous measurements

Possible roles for fast-sigma and delta brainwaves and for the SMA had suggestive support in the literature before this study, but no one had obtained much proof in part because doing so requires a complex experimental protocol.

To make their findings, Sasaki, Tamaki and their team asked each of their 15 subjects to volunteer for the motor learning experiments. For the first three nights, nine subjects simply slept at whatever their preferred bedtime was while their brains were scanned both with magnetoencephalography (MEG), which measures the oscillations with precise timing, and polysomnography, which keeps track of sleep phase. By this time the researchers had good baseline measurements of their brain activity and subjects had become accustomed to sleeping in the lab.

On day 4, the subjects learned the finger-tapping task on their non-dominant hand (to purposely make it harder to learn). The subjects were then allowed to go to sleep for three hours and were again scanned with PSG and MEG. Then the researchers woke them up. An hour later they asked the subjects to perform the tapping task. As a control, six other subjects did not sleep after learning the task, but were also asked to perform it four hours after being trained. Those who slept did the task faster and more accurately than those who did not.

On day 5, the researchers scanned each volunteer with an magnetic resonance imaging machine, which maps brain anatomy, so that they could later see where the MEG oscillations they had observed were located in each subject's brain.

In all, the experimenters tracked 5 different oscillation frequencies in eight brain regions (four distinct regions on each of the brain's two sides). Sasaki said she expected the most significant activity to take place in the "M1" brain region, which governs motor control, but instead the significant changes occurred in the SMA on the opposite side of the trained hand.

What was especially important about the delta and fast-sigma oscillations was that they fit two key criteria with statistical significance: they changed substantially after subjects were trained in the task and the strength of that change correlated with the degree of the subject's performance improvement on the task.

After performing the experiments, the team of Sasaki, Tamaki and co-author Takeo Watanabe moved from MGH to Brown, where they have set up a new sleep lab. They have since begun a project to further study how the brain consolidates learning. In this case they're looking at visual learning tasks.

"Will we see similar effects?" Sasaki asked. "Would it be with similar frequency bands and a similar organization of neighboring brain areas?"

To find out, some volunteers will just have to sleep on it.

In addition to Tamaki, Sasaki and Watanabe, other authors on the paper were Tsung-Ren Huang and Yuko Yotsumoto of Boston University, Matti Hämäläinen of MGH, Fa-Hsuan Lin of National Taiwan University and Jose Náñez Sr. of Arizona State University.

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Infection during newborn's first week of life associated with bacterial infection in the mother

Aug. 20, 2013 — Infection during a newborn's first 7 days of life is associated with bacterial infection or colonization in the mother

Early-onset neonatal infection, defined as infection in the first 7 days of life, is associated with maternal infection and colonization, a systematic review and meta-analysis by Grace Chan (Johns Hopkins School of Public Health) and colleagues found in this week's issue of PLOS Medicine.

Newborns of mothers with laboratory-confirmed infection had an odds ratio of 6.6 (95%CI 3.9-11.2) for laboratory-confirmed infection themselves compared with newborns of mothers without laboratory-confirmed infection. Newborns of mothers with colonization had an odds ratio of 9.4 (95%CI 3.1-28.5) of laboratory-confirmed infection compared with newborns of non-colonized mothers. Furthermore, newborns of mothers with risk factors for infection (prelabour rupture of membranes, preterm <37 weeks prelabour rupture of membranes, and prolonged rupture of membranes) had an odds ratio of infection of 2.3 (95%CI 1.0-5.4) compared with newborns of mothers without risk factors.

The authors searched medical literature databases through March 2013 for studies meeting their criteria, conducted hand searches, and had two researchers independently identify studies for inclusion. Two researchers also independently assessed study quality. They identified 448 full-text articles of which 83 studies met the criteria to be included in their study and 67 were able to be combined in meta-analyses.

According to the authors, past reviews have evaluated the effect of antibiotics for maternal Group B streptococcal colonization and maternal risk factors of infection on neonatal sepsis, but have not assessed the risks of infection and colonization for other bacterial types. The authors specifically excluded studies of nonbacterial infections, tetanus infections, sexually transmitted infections such as chlamydia or other TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex, Syphilis) infections, because they have different mechanisms of transmission. Limitations of the systematic review included heterogeneity and high or unclear risk of bias of the included studies.

Discussing the study's implications, the authors state, "The risk of early neonatal infection among women with maternal infections is high and presumably even higher in low-resource settings where most women deliver at home without access to health care. Intrapartum antibiotic prophylaxis could reduce the incidence of maternally acquired early-onset neonatal infections…Development of a simple algorithm that combines clinical signs and risk factors to diagnose maternal infections would be useful in settings where lab facilities (culture or colonization) are not available."

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