>> GOOD AFTERNOON, EVERYBODY. MY NAME IS JOHN GALLIN, DIRECTOR OF THE CLINICAL CENTER AND I WANT TO WELCOME EVERYBODY TO THE 14th ANNUAL ASTUTE CLINICIAN LECTURE. THIS IS PART OF THE NIH DIRECTOR'S WEDNESDAY AFTERNOON LECTURE SERIES AND I BRING MY WARMEST GREETINGS FROM FRANCIS COLLINS WHO REGRETS HE COULD NOT BE HERE TODAY DUE TO SOME OTHER PRESSING ISSUES. THE ASTUTE CLINICIAN LECTURESHIP WAS ESTABLISHED IN 1998 THROUGH A GIFT FROM THE LATE ROBERT W MILLER AND HIS WIFE. MS. MRS. MILLER REGRETS SHE IS NOT ABLE TO JOIN US TODAY BUT I'M HONORED TO ACKNOWLEDGE THE ROLE THAT SHE AND HER LATE HUSBAND PLAYED IN ESTABLISHING THIS LECTURESHIP AND YOU CAN READ ABOUT HIS ROLE IN THE PAMPHLETS THAT WAS DISTRIBUTED. THE SERIES HONORS A U.S. SCIENTIST WHO OBSERVED AN UNUSUAL CLINICAL OCCURRENCE AND BY INVESTIGATING IT, HAS OPENED AN IMPORTANT NEW AVENUE OF RESEARCH. CERTAINLY OUR SPEAKER TODAY IS AN EXCELLENT EXAMPLE OF SUCH A RESEARCHER. DR. KENNETH FISCHBECK WHO GOES BY THE NAME, KURT, IS AN NIH DISTINGUISHED INVESTIGATOR AND CHIEF OF THE NEUROGENETICS BRANCH AT THE NATIONAL INSTITUTE OF NEUROLOGIC DISEASES AND STROKE. HE IS A GRADUATE OF HARVARD AND EARNED MD DEGREE TO THE JOHN'S HOPKINS SCHOOL OF MEDICINE. HE THEN WENT ON AND IN TENDER AT K SWISS AND REVERB UNIVERSITY, COMPLETED NEUROLOGY RESIDENCY AT THE UNIVERSITIESY OF CALL NORTHERNIA AND SAN FRANCISCO AND WENT ON FOR RESEARCH FELLOWSHIP AT THE UNIVERSITY OF PENNSYLVANIA. IN 1982, HE JOINED THE NEUROLOGY DEPARTMENT THERE SERVING AS A PROFESSOR FROM 1995 TO 1998. HE CAME TO THE NIH AND IS CURRENT NINDS POSITION IN 1998. KURT IS THE A FELLOW OF THE AMERICAN ACADEMY OF NEUROLOGY AND WAS ELECTED TO THE INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES IN 2000. HIS LABORATORY IS STUDYING THE MECHANISMS OF HEREDITARY NEUROLOGICAL AND NEUROMUSCULAR DISORDERS, PARTICULARLY THE POLYGLUTAMINE EXPANSION NEURODEGENERATIVE DISEASES. PLEASE JOIN ME IN WELCOMING DR. FISCHBECK WHO WILL SPEAK ON DEVELOPING TREATMENT FOR HEREDITARY NEUROMUSCULAR DISEASE. KURT? [APPLAUSE] >> I'M REALLY PLEASED TO BE HERE WITH THOSE WHO ARE HERE F. AND FOR THE HOME VIEWING AUDIENCE, WE HAVE THE WEBCAM. AND IT'S A REAL HONOR. IT'S KD OF HUMBLING FOR ME TO BE RECOGNIZED AS AN ASTUTE CLINICIAN. BEFORE I GO MUCH FURTHER, SOME DISCLOSURES, AS AN NIH EMPLOYEE, I DON'T TAKE MONEY FOR OUTSIDE ACTIVITIES, BUT I DO SERVE AS AN UNPAID ADVISOR AS A MEMBER OF THE ADVISORY BOARD FOR SEVERAL ORGANIZATIONS, INCLUDING NONPROFIT VOLUNTARY ORGANIZATIONS LIKE MUSCULAR DYSTROPHY ASSOCIATION AND A COUPLE OF EUROPEAN NONPROFIT ORGANIZATIONS, THE FRENCH MUSCULAR DYSTROPHY ASSOCIATION AND EUROPEAN UNION CONSORTIUM AND A COUPLE OF COMPANIES BIOGEN AND OTHERS. I'LL MENTION PROSENSA LATER IN THIS TALK. ALTHOUGH I DON'T TAKE MONEY FROM THESE ORGANIZATIONS, I'M SUMMERY SYMPATHETIC WITH THEIR GOAL OF REDUCING THE BURDEN OF THE DISEASES I WILL BE TALKING ABOUT TODAY. SO MAYBE THIS IS SOMETHING TO KEEP IN MIND AS I GO THROUGH MY TALK. NOW, WHEN I THINK OF AN ASTUTE CLINICIAN, HAVING SPENT TIME AS A STUDENT AND ON THE FACULTY, THE PERSON WHO REALLY COMES TO MIND AS THE MODEL OF AN ASTUTE CLINICIAN AND WILLIAM MOSLER. IN THE TIME I WAS ATOPEN, I LAB OR OFFICE LOOKED OUT ON THE SITE OF THE OLD PHILADELPHIA GENERAL HOSPITAL, CIVIL WAR-ERA HOSPITAL WHERE HE SAW PATIENTS, WHICH WAS TORN DOWN AND REPLACED BY A COMPLEX OF MEDICAL RESEARCH BUILDINGS INCLUDING THE ABRAMSON BUILDING. AND IN THE LOBBY OF THAT BUILDING IS A CARVED IN STONE, IS THIS SAYING FROM WILLIAM, A GOOD ONE TO SIT WITH TO THE TALK I'M GIVING HERE ... AND OVER THE LAST 25 YEARS NOW, WE HAVE BEEN ABLE TO FULFILL OSLER'S AMBITIONS FOR THOSE DISEASES WHICH ARE HEREDITARY AND DISEASES THAT HAVE GENETIC CAUSES. THROUGH THE FRUITS OF THE HUMAN GENOME PROJECT AND ALL THE WORK THAT HAS GONE ON THROUGH THE GENOME INSTITUTES HERE, WE HAVE TOOLS AT OUR DISPOSAL WHICH ALLOW US TO MAP AND IDENTIFY DISEASE GENES AS NEVER BEFORE. THIS IS A PROCESS MAPPED OUT HERE IN A CYCLICAL WAY. IT STARTS AND ENDS WITH PATIENTS. THE FIRST STEP IN THIS CYCLE OVER HERE IS TO SEE THE PATIENTS AND CHARACTERIZE THE DISEASE MANIFESTATION, THE PHENOTYPE, AND TO COLLECT SAMPLES TO USE THESE SAMPLES, DNA SAMPLES FROM BLOOD AND SALIVA, TO MAP AND IDENTIFY THE DISEASE GENE. THIS HAS BEEN DONE WITH SEVERAL THOUSAND HUMAN DISEASES, SEVERAL HUNDRED NEUROLOGIC DISEASES, AND EACH ONE IS A GREAT DISCOVERY REALLY. IT'S INVOLVING THE KIND OF EXPERIMENT OF NATURE, FIGURING OUT HOW SPECIFIC LESIONS IN THE GENOME CAUSE A SPECIFIC MANIFESTATION IN PATIENTS. AND IT GIVES US VERY USEFUL AND RELIABLE DIAGNOSTIC TESTS. BUT IT STARTS US BACK ON THE LOWER PART OF THE CURVE BECAUSE WITH THE DISEASE GENE IN HAND, WE CAN START TO FIGURE OUT HOW, IF IT'S A MUTATION, AFFECT THE NORMAL FUNCTION? WHAT IS THE NORMAL FUNCTION OF THE GENE? DOT MUTATIONS CAUSE A LOSS OR GAIN OF THAT FUNCTION AND NEUROTOXIC ACTIVITY? WE CAN RE-CREATE THE DISEASE MANIFESTATIONS IN CELL CULTURE AND ANIMAL MODELS AND WE CAN USE THESE CELL CULTURE IN ANIMAL MODELS TO WORK OUT THE DISEASE MECHANISM AND TO DEVELOP ASSAYS THAT CAN BE USED TO TEST POTENTIAL TREATMENT. IT COULD BE SMALL MOLECULE TREATMENT OR BIOLOGICAL TREATMENTS, CORRECTION GENE REPLACEMENT OR SMALL MOLECULES THAT MITIGATE THE DISEASE MANIFESTATION. WE CAN TEST TREATMENTS IN ANIMAL MODELS AND SELECT FROM THOSE TREATMENTS, THOSE AGENTS WHICH LOOK TO BE SAFE AND EFFECTIVE, TAKE THEM INTO THE CLINIC IN EARLY-PHASE AND LATER-PHASE CLINICAL TRIALS. THE GOAL IS EVENTUALLY COMING BACK TO THE PATIENTS WITH THE SAFE AND EFFECTIVE TREATMENT. NOW WE MADE PROGRESS AROUND THIS CYCLE AND IDENTIFIED DISEASE GENES AND WORKING OUT DISEASE MECHANISMS. THE STEP WHICH REMAINS TO BE CLOSED FOR THE DISEASE I'M GOING TO TALK ABOUT, THE MUSCULAR DYSTROPHY AND SPINAL MUSCULAR ATROPHY, IS THIS LAST STEP. WE HAVE TREATMENTS NOW THAT WORK VERY WELL IN ANIMAL MODELS. IF WE WERE TALKING CARE OF MICE AS PATIENTS, WE WOULD BE QUITE WELL OFF, BUT WE HAVE TO BE ABLE TO CONVERT THAT TREATMENT, THAT EFFECTIVE TREATMENT IN ANIMALS TO EFFECTIVE TREATMENT IN PATIENTS. THERE IS A LOT OF WORK TO BE DONE BUT WE ARE GETTING CLOSE. YOU CAN SEE THAT GOAL. IT'S ALMOST IN SIGHT. WE ARE INTOjo CLINIC NOW WI TH SPECIFIC TREATMENT, RATIONAL TREATMENT BASED ON THE DISEASE GENE. THIS IS WHERE THE CHALLENGE REMAINS TO GET BACK TO PATIENTS WITH TREATMENT THAT HAS BEEN PROVEN TO BE SAFE AND EFFECTIVE. SO, LET ME GO THROUGH THAT STORY NOW WITH TWO DISEASES, WE HAVE BEEN INVOLVED IN FOR A LONG TIME, MUSCULAR DYSTROPHY AND SPINAL MUSCULAR ATROPHY. HERE IS A PATIENT WITH MUSCULAR DYSTROPHY I SAW SEVERAL YEARS AGO AT CHILDREN'S HOSPITAL IN PHILADELPHIA. I FOLLOWED THIS PATIENT FROM 3-4 THROUGH HIS DEATH IN HIS 20s, THROUGH THE COURSE OF THE DISEASE. PATIENTS WITH DUCHENNE ARE USUALLY NEGOTIABLE AT BIRTH AND START TO BECOME WEAK AS AROUND THAT AGE, 3-4 AND WEAKENS PROGRESSIVE, IT EFFECTS PRIMARILY THE PROXIMAL MUSCLES AT FIRST, THE HIP AND SHOULDER MUSCLES AND AS THE DISEASE PROGRESSES IT AFFECTS THE VOLUNTARY MUSCLES AND RESPIRATORY MUSCLES AND THERE IS ALSO CARDIOMYOPATHY. THE PATIENTS TYPICALLY BECOME WHEELCHAIR BOUND AROUND AGE 10 OR 12 AND SURVIE INTO THEIR EARLY 20s OR MID TO LATE 20s NOWADAYS. AND THEN DIE FROM PROGRESSIVE DISABILITY, DIFFICULTY EATING AND DIFFICULTY BREATHING. THE PATHOLOGY THAT UNDERLIE THIS IS DISEASE IS A DEGENERATION OF THE MUSCLE. WE SEE OUR MUSCLE BIOPSY HERE IN THE PICTURE TAKEN FROM ALLEN FROM THE WASHINGTON UNIVERSITY OF ST. LOUIS, A TYPICAL IMAGE OF MUSCLE FIBER DEGENERATION. THE NORMAL MUSCLE FIBERS IN ROSS SECTION LIKE THESE AROUND THE PERIPHERY, BUT IN THE MIDDLE ARE MUSCLE FIBERS THAT ARE BREAKING DOWN. YOU SEE THE PRODUCT FIBERS WITH BACKUALS AND INFLUX OF INFLAMMATORY CELLS THAT GOBEL UP THE DEBRIS. MUSCLE HAS A REMARKABLE REGENITIVE CAPACITY AND WE SEE ON THE RIGHT HERE, REGENERATING FIBERS. SMALL FIBERS WITH CYTOPLASM THAT ARE PROLIFERATING AND FORMING NEW MUSCLE FIBERS. THE MUSCLE GOES THROUGH REPEATED CYCLES OF DEGENERATION AND REGENERATION BUT THE REGENITIVE CAPACITY OF THE MUSCLES DEPLETED AND THE MUSCLE REPLACES BY FAT AND CONNECTIVE TISSUE AND THE PATIENTS BECOME WEAKER AND EVENTUALLY SUCCUMB TO THE DISEASE. WELL, 25 YEARS AGO NOW, IN 1986, THE GENE FOR THIS WAS IDENTIFIED. THIS WAS ONE OF THE FIRST DISEASES TO BE IDENTIFIED BY CLONING. IT'S AN X LINKED RECESSIVE DISEASE. THE GENE R. GENE WAS FOUND ON THE X CHROMOSOME. IT'S A GENE FOUND FOR THE PROTEIN DIST FEN, A MUSCLE PROTEIN AND THE MUTATION NO, SIR THIS GENE CAUSE A LOSS OF THE PROTEIN IN THE MUSCLE.u! THE DIST FEN GENE IS ONE OF THE LARGEST KNOWN. IT'S NEARLY 2 1/2 MEGABASES. IT TAKES UP 1% OF THE WHOLE X CHROMOSOME. .1% OF OUR DNA CONTAINS 79 CODING AXONS, SOME OF COME ARE DISBURSED WITH NONCODING DNA IN BETWEEN. THIS IS A MILDER DISEASE CAUSED BY MUTATIONS IN THE SAME GENE BUT MUTATION THAT IS HAVE LESS SEVERE EFFECTS ON DIST FEN CAUSE REDUCTION IN DIST FEN WITHOUT A COMPLETE ASSAY AND THE DISEASE MANIFESTATIONS ARE CORRESPONDINGLY SEVERE. NOW, DIST FEN IS KNOWN NOW TO BE PART OF A STRUCTURAL COMPLEX THAT UNDERLIES THE MUSCLE PLASMA MEMBRANE AND CONNECT TO THE PLASMA MEMBRANE PROTEINS IN THE MUSCLE PLASMA MEMBRANE THAT CONNECT UP TO THE BASAL LAMINA ON THE OUTSIDE OF THE CELL. THIS DIST FEN FORMS IMPORTANT LINK IN THIS STRUCTURAL COMPLEX WHICH HOLDS THE MUSCLE PLASMA MEMBRANE TOGETHER AS THE MUSCLE FIBER CONTRACTS AND RELAXES. IN THE ABSENCE OF DIST FEN, THIS LINK BETWEEN THE INTERNAL CYTOSKELETON AND THE EXTERNAL MATRIX OF THE CYTOSKELETON, THE STRUCTURAL PROTEINS ON THE OUTSIDE OF THE CELL, THE LOSS OF THIS LINK CAUSES THE PLASMA MEMBRANE TO BE UNSTABLE AND THIS IS WHAT LEADS TO THE MUSCLE FIBER REGENERATION AND THE DISEASE. SO DIST 77 A IMPORTANT STRUCTURAL PROTEIN IN MUSCLE PLASMA MEMBRANE. MUTATIONS IN THESE OTHER MEMBERS OF THE COMPLEX, THE MEMBRANE PROTEIN THAT FORM THE COMPLEX AND THE PRONE TEENS THAT FORM A LINK WITH THE BASAL LAMINA, MUTATIONS IN THESE OTHER PROTEINS THESE OTHER FORMS OF MUSCULAR DYSTROPHY. SO IT'S A IMPORTANT COMPLEX FOR MUSCLE INTEGRITY. NOW MOST OF THESE MUTATIONS ARE DELETIONS. INTERNAL DELETIONS. DELETIONS AS PART OF THE GENE. ONE OF SEVERAL AXONS AND THE DELETIONS ARE NOT DISTRIBUTED UNIFORMLY ACROSS THE GENE. HERE IS AN EARLY STUDY THAT WAS DONE IN THE NETHERLANDS SHOWING WHERE MUTATIONS ARE LOCATED AND WE SEE HERE FROM ONE END OF THE GENE TO THE OTHER, THAT THERE IS A CLUSTER NEAR THE 5 END AND A CLUSTER IN THE MIDDLE. THESE MAY BE PARTS OF THE GENE PARTICULARLY PRONE TO MUTATION OR THOSE THAT SHOUGH UP WITH THE PHENOTYPE OF MUSCULAR DYSTROPHY. NOW THE DELETIONS TAKE OUT AN ODD NUMBER OF NUCLEOTIDES SUCH THAT THEY SHIFT THE TRANSLATIONAL MEETING PLACE AND THE RESULT IS THAT THE MESSENGER RNA, THE 3 PRIME END OF THE MESSENGER RNA, THE MESS SAGE LOST. PART OF THE MESSAGE THE TRANSCRIPT FROM THIS PART OF THE GENE, ENCODES AN IMPORTANT PART OF THE PROTEIN THAT IS RESPONSIBLE FOR LINKAGE TO THE MUSCLE PLASMA MEMBRANE COMPLEX AND A LOSS OF COMPLIANCE MEANS THE PROTEIN IS TRUNCATED AND UNSTABLE AND RAPIDLY DEGRADED. NOW, THE C TERMINAL PART OF THE PROTEIN IS IMPORTANT FOR PROTEINS STABILITY AND FUNCTION. SO BECKER MUTATIONS TYPICALLY DO NOT SHIFT THE TRANSLATIONAL READING FRAME THAT LEAD TO A PRODUCT WHICH IS SHORTER BUT STILL FUNCTIONAL. BECKER DYSTROPHY. SO WE KNOW NOW THAT THE DIST FEN GENE DEFECT LEADS TO INSTABILITY OF MUSCLE PLASMA MEMBRANE AND MUSCLE DEGENERATION. THERE IS A COMPENSATORY PROCESS OF MUSCLE REGENERATION WHICH EVENTUALLY GETS DEPLETED AND THIS LEADS TO PROGRESSIVE DISEASE. SO WITH THIS KNOWLEDGE IN HAND, HOW DO WE APPROACH TREATMENT FOR THIS PROGRESSIVE AND ULTIMATELY FATAL DISEASE? WELL, ONE APPROACH IS TO֜ REPLACE THE DEFECTIVE GENE. A CHALLENGE BECAUSE THE GENE IS SO LARGE HERE. BUT THEY ARE TRUNCATED VERSIONS OF IT WHICH COULD WORK. OR TO CORRECT THE GENE DEFECT. USUALLY IT'S A MESSENGER RNA LEVEL, AND I'LL BE DISCUSSING EACH OF THESE IN TURN. ANOTHER APPROACH IS TO BLOCK THE GENES TO SLOW PERHAPS THE PROTEASE IN LIB TORS AND PROCESS OF MUSCLE DEGENERATION OR TO ENHANCE THE MUSCLE REGENERATION. AND I'LL SAY A LITTLE BIT ABOUT EACH OF THESE APPROACHES. FIRST IN TERMS OF WORKING DOWNSTREAM AND APPROACH THAT IS INCREASE THE REGENERATION OF MUSCLE, SOMETHING WOULD BE USEFUL NOT ONLY FOR DUE SHEN DISK FEE BUT FOR ANY MUSCLE DISEASE, PERHAPS CHOOSING -- INCLUDING THE AGE-RELATED, WE ALL GET AS WE GET OLDER. SARCOPENEIA. WE AUTUMN GET THIS AS WE GET OLDER AND A TREATMENT THAT PROMOTES MUSCLE REJEN AND SLOWS MUSCLE DEGENERATION COULD BE BENEFICIAL TO ALL OF US. BUT MUSCLE IS NOW KNOWN THAT MUSCLE GROWTH AND REGENERATION ARE ENHANCED BY SPECIFIC FACTOR, INSULIN-LIKE GROWTH FACTOR 1 IS A FACTOR WHICH STIMULATES MUSCLE REGENERATION AS IS TOL STAT IN AND THERE IS AN ENDOGENOUS FACTOR CALLED MYOSTAT IN WHICH BLOCKS MUSCLE REGENERATION. IT'S ALSO SOMETHING WE NEED TO PREVENT OUR MUSCLES FROM OVERGROWING. INCREASING IGF1 AND TOL STAT IN OR DEGREESING MYOSTAT IN HAS BENEFICIAL EFFECTS IN THE MOUSE MODEL AS WE SHOWN. SO YEARS AGO, A MOUSE STRAIN WAS IDENTIFIED CALLED THE MDX OR MUSCULAR DYSTROPHY MOUSE. IT HAS BEEN AVAILABLE AS A DISEASE MODEL. THESE MICE ARE LESS SERIOUSLY AFFECTED THAN PATIENTS WITH DUE SHEN DYSTROPHY BUT IT'S A VERY GOOD FAITHFUL ANIMAL MODEL FOR WHAT HAPPENS WITH MUSCLE OR TO MUSWELAN ABSENCE OF A LOSS OF DIST FEN. AND MYOSTAT IN INHIBITION AND IGF1 AND TOL STAT IN OVEREXPRESSION HAS BENEFICIAL AFFECTS IN THESE MICE. NOW MYOSTAT IN IS A FACTOR OF THE SUPPRESSOR GROWTH. AND ANIMALS HAVE BEEN IDENTIFIED, A SERIES OF ANIMALS, DOGS AND CATTLE HAVE BEEN IDENTIFIED THAT HAVE MUTATION NO, SIR MYOSTAT IN AND EVEN HUMANS, ONE FAMILY HAS BEEN REPORTED WITH A MUTATION IN MYOSTAT IN THAT LEADS TO AN OVERGROWTH OF MUSCLE. BUT THIS LOSS OF MYOSTAT IN IS WELL TOLERATED IN THIS FAMILY. IT'S A REPORT FROM GERMANY IN NEW ENGLAND JOURNAL SEVERAL YEARS AGO SHOWING I A BABY WITH A COMPLETE LOSS OF MYOSTAT IN WHO HAS OVER GROWTH OF MUSCLE. SO, THE MYOSTAT IN INHIBITION WELL TOLERATED IN HUMANS, INCREASES MUSSEL MASS AND STRENGTHENS THE MDX MICE. BASED ON THESE FINDINGS, A MAJOR PHARMACEUTICAL COMPANY, UNDERTOOK A MULTI-CENTER TRIAL OF MYOSTAT IN ANTIBODY IN THE ADULT PATIENTS, MILDLY AFFECTED MUSCULAR DYSTROPHY PATIENTS, AND DID NOT SHOW A BENEFIT IN TERMS OF CHANGE IN MUSCLE STRENGTH. SO THIS IS A STUDY OF OVER 100 PATIENTS. BUT, WYETH, AND A BIOFEC COMPANY HAS BEEN WORKING SINCE THEN TO DEVELOP SAFE AND POTENTIALLY MORE EFFECTIVE, MORE POTENT AGENTS TO WORK ON THIS PATHWAY FOR MYOSTAT IN SO STILL POSSIBILITY FOR TREATMENTS. ANOTHER APPROACH WHICH HAS BEEN PURSUED BY US AND OTHERS OVER THE YEARS IS TO USE DRUGS TO CORRECT THE TRANSLATION OF NUTANT MESSENGER RNA. SO IT'S BEEN KNOWN FOR A WHILE THAT THERE ARE DRUGS THAT WILL PROMOTE THE LEAD THROUGH֜ OF PREMATURE STOP MUTATIONS. SO THESE ARE NOT DELETIONS THAT NONSENSE MUTATIONS THAT LEAD TO A PREMATURE STOP SIGNAL, THESE DRUGS ARE COMMONLY USED AS GLYCOSIDES, KNOWN TO HAVE THIS EFFECT. AND KIND OF LIKE YOU SEE HERE, NOT SO MUCH ON CAMPUS BUT WHEN THE CARS HIT THE STOP SIGN, THEY JUST KEEP GOING. THESE ARE DRUGS THAT INDUCE TRANSLATIONAL INFIDELITY THAT INDUCE A MISREAD OF THE STOP SIGNAL AND PROMOTE A READ THROUGH THAT LEADS TO THESE PROTEINS. NOW A COMPANY IN NEW JERSEY, THERAPEUTICS DEVELOPED A COMPOUND SPECIFICALLY DEVELOPED A COMPOUND MUCH MORE POTENT THAN GRIKEOCIDES ACTIN DEUCING TRANSLATIONAL READ THROUGH AND THEY FOUND THAT THIS WAS REPORTED REPORTED IN NATURE A FEW YEARS AGO. THIS DRUG WAS REMARKABLY EFFECTIVE IN MDX MICE. HERE ARE CONTROL MICE. HERE IS STAINING FOR -- THEY ARE STAINING FOR DIST FEN AROUND EACH MUSCLE FIBER. YOU SEE GREEN CIRCLES HERE. MDX WITHOUT TREATMENT HAS VERY LITTLE STAINING. AND OCCASIONAL FIBER WITH SOMATIC MUTATION WITH STOP SIGNAL BUT THEN A TREATMENT VERY NICE EXPRESSION OF DIST FEN IN SKELETAL MUSCLES, LEG MUSCLE AND DIAPHRAM AND LESS SO BUT SOME EXPRESSION IN THE HEART. SO AGAIN, BASED ON THESE FINDINGS, IN THE MICE, PTC ENTERED INTO A MULTI-CENTER CLINICAL TRIAL AND AGAIN UNFORTUNATELY DIDN'T SEE AN AFFECT ON THE PRIMARY UNPUT -- INPUT OF THAT TRIAL, THE SIX MINUTE WALK TEST. THERE IS SOME AFFECT AT LOWER DOSES. THEY LOOK AT TWO DOSES WITH HIGHER DOSE DID NOT SHOW AN EFFECT, THE LOWER DOSE DID, BUT IT'S OVERALL NOT A SIGNIFICANT CONFIRMATION OF EFFICACY OF THIS APPROACH TO TREATMENT BUT FURTHER STUDIES ARE ONGOING. INTERESTINGLY, THIS APPROACH OF PROMOTING READ THROUGH OF MUTATION THAT IS LEAD TO A PREMATURE STOP SIGNAL IS SOMETHING THAT COULD BE APPLIED AND IT HAS BEEN DEVELOPED BY PTC AS AN APPROACH TO TREATMENT TO OTHER HEREDITARY DISEASES WITH THIS KIND OF MUTATION. SO, WHAT ABOUT MORE BIOLOGICAL APPROACHES TO TREATMENT? WHAT ABOUT GENE REPLACEMENT? REPLACING THE WHOLE GENE IS DIFFICULT IN DUE SHEN MUSCULAR DYSTROPHY BECAUSE THE GENE IS SO LARGE. THERE WERE ATTEMPTS EARLY ON IN MOUSE MODEL, BACK IN THE EARLY 90s, NOT LONG AFTER THE GENE WAS DISCOVERIES, USING ADNO-VIRUS TO DELIVER THE GENE, ADNO-VIRUS HAS A LARGE CAPACITY AND IT LEAD TO SOME DELIVERY OF THE GENE IN A FUNCTIONAL WAY SUCH THAT SOME LOW LEVELS OF DIST FEN COULD BE EXPRESSED IN THE MUSCLE. BUT AS WE HAVE COME TO LEARN SUBSEQUENTLY, ADNO-VIRUS IS REMARKABLY IMMUNOGENIC. IMMUNE SYSTEMS ARE WELL DESIGNED TO DEVELOP TO DEAL WITH ADNO-VIRUS TO ATTACK CELLS WHICH ARE EXCESSING ADNO-VIRUS. NOT VERY SAFE FOR DELIVERY IN HUMANS. WHAT HAS BEEN SHOWN AS A KIND OF PROOF OF CONCEPT LARGELY TO WORK ON UNIVERSITY OF WASHINGTON SEATTLE, HAS SHOWN THAT IF YOU TAKE A TRUNCATED VERSIONS OF DIST FEN, SO THESE ARE SMALLER VERSIONS OF DIST FEN THAT COMPLETE OTHER SAFER VIRAL PACKAGES, AND OVER EXPRESS THEM IN THE MDX MICE, SO GENETICALLY CORRECT, YOU CAN GENETICALLY CORRECT THE DISEASE WITH OVEREXPRESSION OF TRUNCATED DIST FEN, AND THEY WENT ON TO USE ADD NO ASSOCIATED VIRUS, LESS IMMUNOGENIC VIRUS AND SO THEY COULD DELIVER A TRUNCATED DIST FEN WITHY INTERVENOUS DELIVERY IN THE MDX MICE, HERE SHOWN AGAIN THE MDX MOUSE WITHOUT TREATMENT AND WITH TREATMENT. YOU SEE WITH TREATMENT, NICE RINK OF DIST FEN STAINING BY IMMUNOHISTOCHEMISTRY AROUND EACH MUSCLE FIBER. UNFORTUNATELY, WHEN THEY TRIED TO SCALE THIS UP TO DOGS, THERE IS ALSO A DOG MODEL FOR DID YOU SHEN MUSCULAR DYSTROPHY, THEY GOT ENORMOUS INFLAMMATORY RESPONSE. THERE IS SOMETHING ABOUT THE DIST FEN ITSELF OR THE AAV DELIVERY THAT LED TO A REAL PROBLEM WITH INFLAMMATION IN THESE DOGS. AND THAT SLOWED DOWN THE ADAPTATION OF THIS APPROACH TO HUMANS. THERE HAVE BEEN HUMAN TRIALS WHICH HAVE SHOWN SOME INDICATIONS OF EFFICACY. FIRST THERE WERE EARLY VERSIONS OF CELLULAR THERAPY, MYOBLAST TRANSFER THAT WAS DONE IN THE 90s USUALLY GATHERING CELLS FROM AN UNAFFECTED FAMILY MEMBER INJECTING CELLS INTO THE MUSCLE. YOU CAN SEE THAT THAT WOULD REPLACE DYSTROPHIN TO SOME LEVELS BUT AT A VERY LOW-LEVEL AND THEN AN EXPERIMENT WITH DIRECT INJECTION OF THE DNA INTO THE MUSCLE. A GROUP IN FRANCE HERE PUBLISHED A PAPER WITH INJECTION OF THE GENE INTO THE MUSCLE, BIOPSYING THE MUSCLE AFTERWARDS. SHEAR A CONTROL MUSCLE. HERE IS A MUSCULAR DYSTROPHY PATIENT MUSCLE AFTER THE INJECTION. A SINGLE MUSCLE FIBER HERE. THEY SHOW THIS WAS A FIBER THAT WAS POSITIVE IN EXPRESSING DYSTROPHIN THAT HAD COME FROM THE INJECTION BUT THEY WERE VERY FEW OF THEM. I'D LIKE TO POINT OUT THIS PAPER WHICH HAD 20 AUTHORS HAD FEWER THAN 20 MUSCLE FIBERS. THE AAV CONSTRUCTS THAT WERE DEVELOPED BY THE GROUP IN SEATTLE INITIALLY HAVE NOW BEEN USED IN CLINICAL TRIALS. THE ISSUES IN THESE TRIALS WERE FIRST SAFETY, WE DON'T WANT TO HAVE THE KIND OF THING HAPPEN TO PATIENTS THAT HAPPEN WITH DOGS BUT THE EARLY TRIALS AND THE DOGS, THE IMMUNE RESPONSE, WHICH IS A BIG FACTOR IN THE SAFETY IMMUNE RESPONSE TO THE VECTOR, VIRAL VECTOR OR GENE PRODUCT, AND THEN THE DELIVERY EFFICIENCY AND STABILITY OF EXPRESSION AND THE DOSE REQUIREMENT. SO THE DOSE REQUIRED FOR HUMAN IS A LOT MORE THAN THE DOSE REQUIRED FOR A MOUSE AND THEN PRODUCTION CAPACITY TO BE ABLE TO MAKE THAT MUCH AAV. A GROUP IN OHIO HAS DONE A GOOD JOB IN MOVING THE SEAL FORWARD AND OTHERS AT OHIO STATE UNIVERSITIY AND NATIONWIDE CHILDREN'S HOSPITAL, USED AAV FIRST TO DEVELOP THE LIVER GENE THAT IS DEFECTED IN DYSTROPHY. SO THE GENE FOR ONE OF THOSE PROTEINS IN THE MUSCLE PLASMA MEMBRANE THAT MUSCLE BINDS TO, THEY LOOK AT THREE PATIENTS INJECTED INTO THE FOOT MUSCLE, THEY FOUND IN BIOPSYING THE MUSCLE AFTERWARDS HERE THE UNTREATED SIDE AND HERE IS THE TREATED SIDE. IT SEEMS VERY LITTLE EXPRESSION WITHOUT TREATMENT AND THEN WITH TREATMENT AGAIN THOSE RINGS AROUND EACH FIBER, VERY NICE. THEY DID SEE SOME ANTIBODIES THAT DEVELOPED IN THESE PATIENTS. THERE ARE 4-5 FOLD INCREASE IN EXPRESSION OF THE PROTEIN BUT IN THE PRESENCE OF ANTIBODIES. THE GROUP IN OHIO WENT ON, THIS STUDY WAS REPORTED LAST YEAR IN THE NEW ENGLAND JOURNAL TO CHOOSE TO DELIVER THIS TRUNCATED BICEP MUSCLE. SIX PATIENTS WORK WIDTH DYSTROPHY AND AGAIN THEY SAW VERY FEW POSITIVE FIBERS. AND MAYBE A LITTLE BIT CONCERNING, WE SAW CIRCULATING T-CELLS THAT WERE SPECIFIC TO DYSTROPHIN. SO AN INDICATION OF IMMUNE RESPONSE AND LOW-LEVEL OF CORRECTION. NOW WHAT HAS BEEN PARTICULARLY EXCITING HERE IN THE LAST COUPLE OF YEARS, LAST FEW YEARS, IS ANOTHER APPROACH TO TREATMENT, ANOTHER APPROACH TO CORRECTING THE GENETIC DEFECT IN THIS DISEASE. SO THIS APPROACH WHICH IS CALLED EXON SKIPPING IS BASED ON THE FINDING THAT DUE SHEN MUSCULAR DYSTROPHY CAUSED BY GENE DELETIONS IS CAUSED BY -- SO ALL THE NUCLEOTIDES CAN BE DESIGNED TO PROMOTE SKIPPING OF THE EXON THAT CONTAINS MUTATION OR EXONS DOWNSTREAM IN SUCH A WAY TO RESTORE. AND THEN AGAIN, LEAD TO A PROTEIN PRODUCT THAT IS SHORTER THAN NORMAL BUT CAN BE QUITE FUNCTIONAL. SO I HAVE A DIAGRAM HERE. YOU HAVE EXON, EXON, EXON. YOU HAVE A MUTATION THAT LEADS TO A STOP SIGNAL OR A SHIFT IN THE READING FRAME THAT LEADS TO ABEARANT AMINO ACIDS AND THEN A STOP SIGNAL. IF YOU HAVE A NUCLEOTIDE, THE TARGET SPLICED AT THIS EXON, YOU CAN INDUCE THE SPLICING MACHINERY TO SKIP OVER THAT EXON IN SUCH A WAY AS TO RESTORE THE READING FRAME DOWNSTREAM. NOW IT'S BEEN AN IDEA FOR A LONG TIME T HAS ALLOWED US TO GET READY FOR PRIME-TIME, I GUESS, IS TO CHEMICAL MODIFICATIONS OF SYSTEMS DEVELOPED TO ENHANCE THE STABILITY. SO ALL THE NUCLEOTIDES INJECTED NOW CAN LAST FOR WEEKS AND MONTHS AND HAVE LONG LASTING EFFECT. NOW THIS HAS BEEN SHOWN VERY NICELY NOW. SO NICE CORRECTION GOES UNTREATED MOUSE MUSCLE AND MOUSE MUSCLE HAS BEEN TREATED WITH THE NUCLEOTIDES I'LL SKIP OVER THE MUTATION IN THE MDX MOUSE AND IT HAS BEEN SHOWN IN PATIENTS. SO, FIRST IN CELL CULTURE EXPERIMENTS, THIS IS A GROUP THAT SHOWED THAT A OLIGONUCLEOTIDE TARGETING EXON 51 FIRST LEADS TO SKIPPING. THIS IS THE MESS GER RNA AMPLIFIED TO SHOW THAT THE THE TRANSCRIPT YOU GET IN UNTREATED CELLS AND THE TRANSCRIPT YOU GET IN TREATED CELLS AND YOU SEE THE SKIPPING OF THE EXON LEADS TO A SHORTER MESSENGER RNA AND HERE IS THE MUSCLE CELL IN CELL CULTURE TREATED WITH THIS OLIGONUCLEOTIDE AND YOU SEE NICE LEVELS OF EXPRESSION. HERE LONGITUDINAL VIEW OF THIS MUSCLE FIBER. AND SEVERAL YEARS AGO NOW, THIS GROUP REPORTED IN THE NEW ENGLAND JOURNAL, A TREATMENT OF FOUR PATIENTS WITH DYSTROPHY WITH INJECTION INTO THE MUSCLE AND VERY NICE EXPRESSION OF DYSTROPHIN IN THE MUSCLE AFTER DIRECT IN STRA MUSCULAR INJECTION. HERE LEVELS OF EXPRESSION IS BETWEEN 17-35% OF NORMAL LEVELS. HERE IS NORMAL DUE SHEN MUSCLE. HERE IS MUSCLE WITH DUE SHEN MUSCLE TREATED WITH THIS APPROACH WITH INJECTION INTO THE MUSCLE. ANOTHER GROUP IN ENGLAND IN THE U.K. USING A DIFFERENT KIND OF OL GIVE NUCLEOTIDE SHOWED A SIMILAR EFFECT, RESULTS THEY PUBLISHED A COUPLE YEARS LATER. SO TWO DIFFERENT GROUPS, TWO DIFFERENT COMPANIES INVOLVED IN DEVELOPING THESE AND BRINGING IT INTO LARGER SCALE CLINICAL TRIALS. THE GROUP TOGETHER WITH BIOTECH COMPANY CALLED PRO SENSA, AND ŽA, COMPANY, GSK, HAS NOW DONE A MULTICENTER TRIAL WITH SUBCUTANEOUS DELIVERY. REMARKABLY INJECTION OF THESE OLIGONUCLEOTIDES INTO THE SKIN LEADS TO SYSTEMIC CORRECTION OF DYSTROPHIN DEFICIENCY. HERE BY BIOPSY OF THE PATIENTS WEEKS AFTER THE SUBCUTANEOUS INJECTION, YOU CAN SEE EXPRESSION LEVELS OF APPROXIMATELY OR UP TO ABOUT 10% OF NORMAL. SO IT'S NOT FULLY CORRECTING BY ANY MEANS BUT THE IDEA IS THAT MAYBE GIVEN ENOUGH TIME, THE EXPRESSION LEVELS WILL BE MUCH HIGHER. NOW REMARKABLY IN THIS STUDY, IT'S REALLY JUST TWO SITES IN EUROPE, 10 PATIENTS PARTICIPATED IN THE STUDY. IT'S BEEN FOLLOWED NOW FOR -- REPORTED THIS SPRING FOR ONE YEAR NOW UP TO TWO YEARS, AND 7 OF THE 10 HAVE HAD AN IMPROVEMENT IN 6 MIN TIMED WALK. THIS IS NOT A SIGNIFICANT AFFECT. UNTREATED PATIENTS NOT A RANDOMIZED CONTROL GROUP BUT TEMPANEOUS CONTROLS, PATIENTS WITHOUT TREATMENT TEND TO HAVE A DECREASE. THEY'LL HAVE SOME IMPROVEMENT UP UNTIL AGE 8 OR 10 AND THEN THEY'LL CRASH. THEY'LL BECOME VERY MUCH UNABLE TO WALK. NO MATTER HOW MUCH TIME IT TAKES. BUT THE PATIENTS WHO WERE TREATED WITH THE OLIGONUCLEOTIDE, WHILE 7 OF THE 10 HAD IMPROVEMENT, WE COULD LOOK AND SEE THIS LOOKS LIKE NOT A SIGNIFICANT DIFFERENCE BUT IT'S REMARKABLE AFFECT IN SOME OF THESE PATIENTS WHO HAD THIS KIND OF TREATMENT. NOW BASED ON THIS STUDY FROM PRO SENSA, GSK HAS ENTERED INTO A MAJOR DEVELOPMENT EFFORT THAT INCLUDED FIRST THE PHASE I DOSE ESCALATION STUDY IN CLUM BUT US -- COLUMBUS, OHIO AND THEN A PHASE II STUDY TO LOOK AT DIFFERENT DOSES IN EUROPE AND AUSTRALIA AND THEN A LARGE-SCALE RELATIVELY RARE DISEASE SUCH AS THIS, A VERY LARGE SCALE PHASE THREE STUDY, A PIVOTAL STUD THEY IS BEING DONE WORLDWIDE, 30 SITES IN 20 DIFFERENT COUNTRIES STUDYING 180 PATIENTS RANDOMIZED PLACEBO OR OLIGONUCLEOTIDE THERAPY TO SEE WHETHER THIS EFFECT HOLDS UP IN A LARGE SCALE PLACEBO-CONTROLLED STUDY. NOW, THERE ARE ISSUES WITH THIS. IT'S EXCITING TO THOSE OF US IN THE FIELD THAT IT'S BEING STUDIED ON SUCH A LARGE SCALE. PROBABLY THE LARGEST YET RANDOMIZED PLACEBO-CONTROLLED STUDY FOR DUE SHEN DYSTROPHY AND AT LEAST FOR A TREATMENT THAT TARGETS THE GENETIC DEFECT. THERE IS THE ISSUE OF SAFETY. SO THE PATIENTS IN THIS STUDY DO DEVELOP INJECTION SITE REACTIONS. MOST OF THEM GET PROTEINURIA AS A RESULT OF THE ALLERGY NUCLEOTIDE TREATMENT. THIS IS STILL THE ISSUE OF EFFICIENCY AND STABILITY OF THE TREATMENT. IT APPEARS TO BE VERY LONG LASTING. THE NUCLEOTIDE LASTS AT LEAST A MONTH AFTER EACH INJECTION BUT THE UNANSWERED QUESTION, IS HOW MUCH DYSTROPHIN IS NEEDED IN THE MUSTOLL CORRECT THE CLINICAL MANIFESTATION OF THIS DISEASE? TO MITIGATE THE CLINICAL MANIFESTATIONS IN THERE IS AN INTERESTING SITUATION EVOLVING HERE IN THE REALM OF PERSONALIZED MEDICINE. IN THAT, THERE ARE MANY DIFFERENT EXON THAT IS NEED TO BE TARGETED AND MULTIPLE THERAPEUTIC AGENTS THAT NEED TO BE DEVELOPED. EVERY PATIENT HAS A DIFFERENT MUTATION AND THIS TREATMENT, THE OLIGONUCLEOTIDE THERAPY HAS TO TARGET THE SPECIFIC EXON THAT WILL BE PREDICTED TO HAVE A BENEFICIAL EFFECT AND IT NEEDS TO BE SKIPPED IN EACH PATIENT. SO THERE IS A LONG LIST OF DIFFERENT OLIGONUCLEOTIDES THAT NEED TO BE DEVELOPED. EACH NEEDING SEPARATE PROOF OF SAFETY AND EFFICICX FOR REGULATORY APPROVAL. NOW WE HEARD ABOUT THE DISCUSSIONS WITH THE FDA AND HOW TO RELAX THE STANDARDS IF THE FIRST TWO OR 3 EXONS SKIPPED TURNED OUT TO WORK OUT OKAY BECAUSE OF EFFICACY AND SAFETY MANAGEABLE SAFETY ISSUES, BUT STILL IT'S A CHALLENGE HERE. SO THE FIRST EXON BEING TARGETED BY BOTH COMPANIES, THE PRO SENSA CASE STUDY AND THE OTHER COMPANY, AVI, THEY DID EXON 51. THAT WOULD BE CORRECT. PREDICTED TO CORRECT 18% OF THE DELETIONS DELETIONS AND 12% OF THE DELETIONS BUT THEN EACH SUCCESSFUL EXON AND TWO OR 3 OF THESE IN EARLY PHASES OF DEVELOPMENT WOULD HELP, PRO ADDICTED TO HELP A SMALLER PROPORTION OF PATIENTS. 4511% AND 448% AND SO ON. IF YOU HAVE 12 DIFFERENT THERAPEUTIC AGENTS AND CAN TARGET THEM APPROPRIATELY TO THE RIGHT PATIENTS, THAT WOULD BE PREDICTIVE TO HELP 3/4 OF DUE SHEN PATIENTS. THE BEGINNING OF A PATH HERE AND THIS BREAKING TAKING US INTO NEW AREAS, INDIVIDUALIZED MEDICINE, MEDICINE THAT DOESN'T JUST TARGET A DISEASE OR TARGET IN SOME CASES A SMALL SUBPOPULATION OF THE DISEASE. BUT THERE IS CLEARLY HELP HERE. AND SOMETHING THAT HAS BEEN SHOWN MODELS HERE IN IMMUNOLOGY BRANCH DEVELOPED MRI AS A BIOMARKER FOR MULTIPLE SCLEROSIS. EARLY LEAD AS TO WHETHER TO APPROACH TO TREATMENT IS BEING SUCCESSFUL. THERE ARE LIMITATIONS TO HOW THAT IS GOING TO RUN BUT THAT IS SUCCESSFUL IN OPENING UP MS FOR TREATMENT. OUR IDEA HERE IS TO DEVELOP A BIOMARKER THAT WOULD DO THE SAME THING FOR MUSCLE DISEASE AND WHAT THAT MEANS IS A NONINVASIVE BIOMARKER TO GET AN EARLY EDUCATION OF EXON SKIPPING SO WE DON'T HAVE TO WAIT FOR A YEAR OR TWO TO SEE IF THERE IS SAY CLINICAL BENEFIT. WE DON'T HAVE TO DO INVASIVE TESTS TO SEE IF THERE IS A BIOCHEMICAL BENEFIT. WHAT WE ARE ENTERING INTO NOW IS AN NIH IMAGING STUDY SOMETHING TO BE DONE HERE AT THE CLINICAL CENTER AS PART OF THE NEW PHASE II MULTI-CENTER AMERICAN TRIAL OF THIS GSK OLIGONUCLEOTIDE TARGETING EXON 51. WE ARE WORKING WITH OTHERS AT NHBLI TO TEST OUTCOME MEASURES, CARDIAC AND SKELETAL MUSCLE ULTRASOUND. HERE IS FROM THE UNIVERSITY OF FLORIDA, AN ITCHAGE EVER MUSCLE MRI FROM A DUE SHEN PATIENT AND CONTROL AND YOU CAN SEE THERE ARE MARKED DIFFERENCES. THE QUESTION WE ARE ADDRESSING IS WHETHER THEY START TO CHANGE, START TO SHOW STRUCTURAL RESPONSE IN THE MUSCLE IN THE CARDIAC SKELETAL MUSCLE BEFORE WE SEE CLINICAL MANIFESTATIONS BENEFIT. THAT'S THE PROTOCOL JUST APPROVED IN THE FIRST PATIENT TO BECOMING IN THE NEXT FEWe WEEKS. WELL, I COULD GO ON AND TALK ABOUT ANOTHER DISEASE WITH THE REST OF THE TIME WE HAVE AVAILABLE. ANOTHER SEVERE CHILDHOOD ONSET NEUROMUSCULAR DISEASE, THIS IS SPINAL MUSCULAR ATROPHY. AUTOSOMAL RECESSIVE DISEASE. DUE SHEN MUSCULAR DYSTROPHY AFFECTS 1-3000 BOYS. THIS DISEASE AFFECTS MAYBE ONE IN 8000 TO 10,000 BABIES. IT IS AN AUTOSOMAL RECEPTIVE DISEASE AND IS PROBABLY THE MOST SEVERE OR MOST COMMON SEVERE HEREDITARY DISEASE IN IN FANCY AND THE CARRIER FREQUENCY IS REMARKABLY HIGH. SO IN EUROPEAN, ASIAN, NORTH AMERICAN POPULATIONS, THE CARRIER FREQUENCY ISyM ONE-40. SO IN THIS ROOM HERE, THERE ARE PROBABLY I DON'T KNOW, AT LEAST 6 OR 8 PEOPLE WHO ARE CARRYING THIS MUTATION AT RISK OF HAVING CHILDREN AND GRANDCHILDREN AFFECTED IF YOU HAD A BABY WITH SOMEBODY ELSE WHO CARRIES THE MUTATION. IT IS A DISEASE THAT CAUSES ONSET PROGRESSIVE SYMMETRICAL MUSCLE WEAKNESS. AND IT'S MOST COMMON SEVERE FORM, THIS DISEASE PRESENTS EARLY INFANCY AND THE BABIES ARE FLOPPY LIKE RAG DOLLS. SO THAT'S SHOWN HERE IN A PICTURE FROM VICTOR'S TEXTBOOK SOME YEARS AGO. AND THE WEAKNESSES PROGRESSIVE ASSOCIATE THE WITH MUSSEL ATROPHY. SO THIS IS THE PROBLEM NOT PROBABLY NOT PRIMARILY WITH THE MUSCLE SO MUCH AS WITH THE MOTOR NEURON THAT IS INTERGATE THE MUSCLE. THERE IS MOTOR NEURON LOSS AND SUBSEQUENT DEGENERATION OF THE MUSTHEY'LL CAUSES WEAKNESS. THE GENE IDENTIFIED, SO THIS IS THE AFFECT IN THE 90s WAS GIVEN THE NAME, A FRENCH GROUP IDENTIFIED GIVEN THE NAME SURVIVAL MOTOR NEURON OR SNM GENE ENCODES THE SNM PROTEIN. SO YES I LIKE THIS PICTURE. THIS IS A PICTURE FROM THE DOMINICAN REPUBLIC. WE SAW A PATIENT THERE WITH THIS DISEASE. IT IS PRETTY WIDELY DISTRIBUTED TO THE AMERICAS AND EUROPE AND ASIA, INTERESTINGLY, NOT SO COMMON IN AFRICA AND PEOPLE WITH AFRICANOR GIN. BUT, THIS IS ALSO TO ILLUSTRATE NOT ONLY WOULD I AS AN ADULT NEUROLOGIST EXAMINE A BABY, BUT ALSO I WAS SWEATING A LITTLE BIT HERE. BUT THE -- I THINK IT HELPS TO ILLUSTRATE THE DISEASE NOT ALWAYS IS SEVERE AS IT WAS. SOME PATIENTS HAVE LATER ONSET, LES SERIOUSLY EFFECTED. AND SOME CAN HAVE ONSET EVEN LONG TERM SURVIVAL INTO ADULTHOOD. SO, IT'S A DISEASE MOST COMMONLY PRETTY SEVERE BUT THERE ARE MILDER VARIATIONS. AND THE GENETICS IS INTERESTING. SO, THIS SNM GENE IS PRESENT IN MORE THAN ONE COPY. WE HAVE VARIABLE NUMBERS OF THE COPIES OF THE GENE AND IT COMES IN TWO DIFFERENT FLAVORS, THERE IS THE SMN1 GENE WHICH IS MUTATED IN THE DISEASE AND ANOTHER VERSION OF THE GENE CALLED SMN2 WHICH IS NEARLY IDENTICAL TO 1 BUT DIFFERS AT A SINGLE NUCLEOTIDE THAT LEADS TO DIFFERENT SPLICING OF THE TRANSCRIPT. SO THIS NUCLEOTIDE DIFFERENCE IS IN EXON 7 AND IT AFFECTS THE SPLICING OF 7 SUCH THAT THE TRANSCRIPT, THE MESS GER RNA THAT COMES FROM SNM1 IS FULL-LENGTH. 2, THE MAJORITY OF THE TRANSCRIPT IS MISSING EXON 7. THIS LEADS TO A–r PROTEIN WHICH IS UNSTABLE AND DEGRADED. SNM2 DOES ENCODE SOME FORM OF THE TRANSCRIPT AND THIS IS ENOUGH FOR PATIENTS TO GET BY. A COMPLETE LOSS OF SNM IN ANIMALS, THE PATIENTS WITH THE DISEASE WHO HAVE MUTATION OF SMN1 STILL HAVE SMN2 AND THEY HAVE REDUCED BUT NOT ABSENT SMN. THE SMN2 GENE ITSELF IS PRESENT IN MULTIPLE VARIABLE NUMBER OF COPIES. THE MORE COPIES OF 2 THAT A PATIENT HAS, THE MILDER THE DISEASE MANIFESTATION. SO THE SEVERELY AFFECTED PATIENTS HAVE NO SMN1 AND 2 COPIES OF 2 AND MORE MILDLY AFFECTED PATIENTS, AND OTHERS WITH LATER ONSET, AT 3 OR 4 OR MORE COPIES OF SMN2, THIS LEADS TO MORE MILDER DISEASE MANIFESTATION AND LIKELIHOOD THAT INCREASING, IF WE HAD A WAY TO INCREASE SMN LEVELS THAT COULD BE AN EFFECTIVE TREATMENT FOR THIS DISEASE. NOW WHAT IS SMN? WE TALKED ABOUT WHAT DYSTROPHIN IS. SMN'S NORMAL FUNCTION, FIRST IT WASN'T KNOWN. IT WAS KNOWN THAT IT IS UBIQUITOUSLY EXPRESSED, EXPRESSED AT EVERY CELL AND EVERY NUCLEO CELL, EVERY ORGANISM FROM HUMANS DOWN TO YEAST AND IT'S KNOWN NOW TO PLAY AN IMPORTANT ROLE IN SPLICES ON THE -- IT PUTS TOGETHER THE RIBONUCLEOPROTEINS TO FORM A COMPLEX THAT IS RESPONSIBLE FOR SPLICING ALL GENES. AND THAT IS A CLEAR FUNCTION AND PROBABLY HAS OTHER FUNCTIONS AS WELL IN PARTICULAR, THERE IS EVIDENCE TO SUPPORT A ROLL IN THE EXONAL TRANSPORT OF MESSENGER RNA. SO IT BINDS TO MESSENGER RNA AND THAT TRANSPORT THE MESSENGER RNA FROM THE NUCLEUS DOWN TO THE TERMINIS, -- NERVE TERMINIS. NEURONS MAY BE PARTICULARLY DEPENDENT, PARTICULARLY MOTOR NEURONS MAY BE DEPENDENT ON HAVING PROTEIN TRANSLATION OCCURRING AT A DISTANCE FROM THE CELL BODY AND THIS IS A GREAT DISTANCE FROM THE CELL BODY IN CELLULAR ASSURANCE. SO WHY ARE MOTOR NEURONS VULNERABLE TO DECREASED SMN? THEY HAVE VERY LONG EXONS, MULTIPLE TARGETS AND MUSTALES BECOME WEAK EARLY IN MOTOR NEURONS AND A RATIO OF 1-1,000 OR AT LEAST UP TO SEVERAL HUNDRED. ONE MOTOR NEURON INTERIVATES MANY MUSCLE FIBERS. THOSE NERVE TERMINALS ARE 1000 TIMES THE SIZE OF THE TERMINALS IN GREEN. SO THE MOTOR NEURONS HAVE ANATOMY AND PHYSIOLOGY THEY MAKE THEM VULNERABLE. THEY MAY BE VULNERABLE TO SPLICING DEFECTS THAT COME FROM ABNORMALITIES OR DEFECTS ON SPLICES OR MAY BE PARTICULARLY DEPENDENT ON THE EXONAL TRANSPORT OF MESSENGER RNA. BUT THE POINT IS THAT CORRECTING THE SMN DEFICIENCY IS AN APPROACH TO TREATING THIS DISEASE. NOW SINCE THE GENE IS DISCOVERED, A NUMBER OF DIFFERENT MODEL SYSTEM THAT IS HAVE BEEN DEVELOPED. FIRST CELL FREE BIOCHEMICAL ASSAYS JUST SPLICING ASSAYS OR RIBONUCLEOPROTEIN ASSEMBLY ASSAYS AND CELL CULTURE ASSAYS AND THEN A SERIES OF ANIMAL MODELS HAVE BEEN DEVELOPED. SMN DEFICIENT WORMS AND FLIES AND FISH AND MICE AND IN EACH CASE, THERE IS A MOTOR NEURON DEGENERATION THAT OCCURS AND EACH OFFERED DIFFERENT KINDS OF INSIGHTS FOR THE DISEASE. SAY THE FLY WHEN THEY OUTGROW THEIR ATTORNEY SUPPLY, THE LARVAE START TO CRAWL ALONG SLOWER. THEY DON'T MAKE IT TO ADULTHOOD. THE FISH LIKE OUR GOLD FISH AT HOME KIND OF GOES BELLY UP AND THE MICE, THEY HAVE A PHENOTYPE WHICH REALLY LOOKS A LOT LIKE THE HUMAN DISEASE. SO, MICE HAS BEEN KNOWN FOR ABOUT 10 YEARS THAT A COUPLE OF GROUPS DEVELOP MOUSE MODELS 10 YEARS AGO, A GROUP IN TAIWAN AND ANOTHER AT OHIO STATE UNIVERSITY, DEVELOPED MICE WITH SMN DEFICIENCY, NOT A COMPLETE RAT BUT A RELATIVE DEFICIENCY. AND THESE MICE ARE SMALL, VERY WEAK, STARTING WITHIN THE FIRST FEW DAYS OF LIFE. AND THEY DIE. THE PATIENTS WITH TYPE 1 OR MOST SEVERE SMN MAY DIE WITHIN A YEAR OR TWO. THESE MICE DIE WITHIN ABOUT TWO WEEKS. NOW, THE GROUP IN TAIWAN THAT DEVELOPED THESE MICE ALSO TESTED TREATMENTS. THAT'S INTERESTING IN THIS FIRST CAME OUT, IT WAS SECRET FOR A WHILE. SECRET IN THE FIELD AS TO WHAT TREATMENT, WHAT TREATMENT WAS HAVING AN֜ EFFECT. THE WORLD LEAKED OUT FROM TIE ONE, ONE OF THE FIRST 20 AGENTS THEY TESTED IN THESE MICE. MY BROTHER WAS AT BIOMILITARY RESEARCH AND SAID IT PROBABLY BEGAN WITH A OR B. AND SURE ENOUGH, IT WAS THE BUTE RATE. IF THEY HAD TO GO FURTHER THAN THAT, BUT THE BUTE RATE, WHEN GIVEN TO THE PREGNANT MICE, THE MOTHERS OF THE MICE WHO WERE INFECTED, WOULD INCREASE THE SURVIVAL OF THE OFFSPRING. NOW IT'S NOT A DRUG THAT IS USED IN PEOPLE, BUT IT IS REPRESENTATIVE PERHAPS, NOT A VERY POTENT DRUG OF THIS CLASS BUT WHAT IT IS LIKELY TO WORK AS A HISTONE DEACETYLATE INHIBITOR. SO THIS OPENED UP THE POSSIBILITY OF TREATMENT OF SNA WITH OTHER MORE POTENT HISTONE DEACETYLATES OR HDAC INHIBITORS. SO, GENE EXPRESSION IS LARGELY REGULATED. AND THE IMPORTANT WAY TO REGULATE GENE EXPRESSION IS THE ACETYLATION OF HISTONES AND OTHER PROTEINS IN THE CELL. IN GENERAL, WHEN THE HISTONES ARE ACETYLATED, IT OPENS UP THE CHROMATIN STRUCTURE AND IT ALLOWS TRANSCRIPTION FACTORS TO GET INTO THE GENE AND ALLOWS GENE EXPRESSION. SO THERE ARE IN THE CELL A NUMBER OF DIFFERENT ACETYLASES OR TRANSFERASES IN THE GROUPS. AND CORRESPONDINGLY, A NUMBER OF DEACETYLASE THAT IS REMOVE THESE GROUPS AND THE COMBINATION EFFECTS THE LEVELS OF GENE EXPRESSION IN THE CELL. DEACETYLATION INHIBITORS DEVELOPED FOR CANCER TREATMENT AS A WAY PERHAPS TO WORK ON TUMOR SUPPRESSORS, THESE BLOCK THE DEACETYLATION OF HISTONES AND INCREASE GENE EXPRESSION AND THEY INCREASE THE EXPRESSION OF DIFFERENT GENES AT DIFFERENT LEVELS BUT THEY IN PARTICULAR INCREASE THE EXPRESSION OF SNM, THE PROTEIN THAT IS DEFICIENT IN SNM. THAT'S THE ATROPHY. SO A GROUP IN OUR LAB, THE FIRST ONE DONE BY A MEDICAL STUDENT, A CRTD STUDENT IN OUR LAB, GOT THIS TO WORK LIKE TWO OUT OF 19 TIMES. AND IT'S OUR FIRST EXPERIENCE IN THE LAB. BUT, AN EXCELLENT CLINICAL FELLOW, CHARLOTTE SUMNER NOW AT JOHN'S HOPKINS ON THE FACULTY GOT THIS EXPERIMENT TO WORK REPRODUCE BELIEVEY, BEEN REPRODUCED IN A NUMBER OF OTHER LABS -- RUE PRODUCED -- THAT ANOTHER HDAC INHIBITOR IN COMMON CLINICAL USE OF PRO LICK ACID USED FOR PSYCHIATRIC DISORDERS AND FOR SEIZURE DISORDERS THAT VALPROIC ACID WORKS AS AN HDAC INHIBITOR AND INCREASES SNN LEVELS IN PATIENTS AND IN MOTOR NEURON DERIVED CELLS, MOUSE MOTOR NEURON-DERIVED CELLS AND THIS REPORTER CONSTRUCT DOES THIS BY ACTIVATING THE SMN PROMOTOR. IT TAKES PRETTY HIGH LEVELS OF VALPROIC ACID TO HAVE THIS EFFECT, BUT THESE ARE THE LEVELS OF VALPROIC ACID THAT ARE RELEASED THERAPEUTICALLY. SO, I SHOULD SAY MORE POTENT AND SELECTIVE HDAC INHIBITOR SUBSEQUENTLY TESTED IN OUR LAB, AND SHOWN TO HAVE A BENEFIT IN THESE MICE DONE BY OTHER IN OUR LAB. IT'S A MODEST EFFECT INCREASING SURVIVAL FROM 15 UP TO AVERAGE OF 18-20 DAYS. HERE YOU SEE UNTREATED MOUSE AND TREATED MOUSE. THIS SHOWS IN THIS CASE, THE TREATMENT STARTED NOT IN TREATING PREGNANT MOTHER BUT TREATING THE MICE AFTER THEY STARTED TO BECOME WEAK. SO, TREATMENT AFTER THE ONSET OF DISEASE MANIFESTATIONS CAN BE DONE. AND MORE RECENTLY, A GROUP IN OUR LAB, DEBORAH QUAN AND OTHERS HAVE LOOKED AT USING A CLINICAL USE AGENT, AN INHIBITOR OF PROTOSTOME PATHWAY THAT DECREASES THE DEGRADATION OF SMN, SO THE COMBINATION OF INCREASING EXPRESSION AND BLOCKING DEGRADATION OF SMN HAS A GREATER EFFECT, GREATER BENEFICIAL AFFECT OF INCREASE SURVIVAL. IN BOTH CASES SIGNIFICANT EFFECT MORE IN COMBINATION THAN THE STATEN ALONE. BUT ANOTHER INTERESTING STUDY WAS DONE BY HEATHER AND PEOPLE IN OUR LAB, HEATHER IS A VETERINARIAN WHO WORKS OVER IN BUILDING 45. THEY GAVE THEM EXTRA NUTRITION. SO, THE CAREFULLY SEASONED FORMULA TOGETHER WITH THE TSA NOW NUTRITION ALONE DID NOT I HAVE HAVE A BENEFIT BUT NUTRITION PLUS TSA MARKS A INCREDIBLE LIFESPAN, UP TO 1% INCREASE IN SURVIVAL. I THINK THAT'S A MESSAGE TO KEEP IN MIND THAT NUTRITION TOGETHER WITH TREATMENT OF INCREASE SNM CAN ENHANCE THAT. NOW, BASED ON THESE FINDINGS AND OTHERS, SEVERAL GROUPS HAVE ENTERED INTO CLINICAL TRIALS NOW OF DRUGS DESIGNED TO INCREASE SNM, A GROUP IN ITALY USED OTHER HDAC INHIBITORS AND THE GROUP BASED ON MULTI-CENTERED TRIAL ORGANIZED AT THE UNIVERSITY OF UTAH, USED THE CANTEEN TO COUNTER ACT THE EFFECTS OF VALPROIC ACID AND LIVER FUNCTION. NEATH OF THESE STUDIES SHOWED A BENEFIT. MAYBE MIXED RESULTS WITH THIS ONE. BUT THE SENSE IS THESE WERE NOT THE KIND OF POTENT AND SPECIFIC HDAC INHIBITORS NEEDED TO INCREASE SNM AND HAVE IMPACT ON THE DISEASE. NOW, WHAT'S BECOME AVAILABLE OVER THE YEARS, SINCE IT WAS DISCOVERED&IS A NUMBER OF DIFFERENT ASSAYS THAT CAN BE USED TO SCREEN FOR NEW DRUGS AND DEVELOP COMPOUNDS TO APPROACH THIS DISEASE CLINICALLY. AS AS BASED ON THEŽtu PROMOTOR ON THE RETENTION OF EXON 7 IN THE SNM2 GENE, AS A THAT IS MEASURE THE PROTEIN LEVELS. SO THEY CAN PICK UP AGENTS LIKE DEGRADATION OF THE PROTEIN AS WELL AS ENHANCEMENT OF EXPRESSION OR AS AS AND THE DOWNSTREAM FUNCTION OF RNA PROTEIN AND RIBONUCLEAR PROTEIN OR INCREASED SURVIVAL CELLS DEFICIENT IN SMN AND THERE ARE NOW A NUMBER OF DRUGS THAT ARE DIFFERENT STAGES OF DEVELOPMENT BASED ON THESE ASSAYS. SO FIRST STUDY IN EUROPE WITH A PERFECTIVE AGENTS, DEVELOPED BY OTHERS, FAMILIES OF SNA, A VOLUNTARY GROUP HELPED TO FUND DRUG SCREENING EFFORTS AND DRUG TESTING EFFORTS PAST THESE COMPOUNDS ON TO A COMPANY AND IT WAS DEVELOPED. THIS COMPOUND IS IN CLINICAL TRIALS IN EUROPE. THESE ARE HEADING TOWARDS CLINICAL TRIALS HERE. AND HERE AT THE NIH, THE NCGC, NIH CHEMICAL GENOMICS CENTER WORKING WITH THE UNIVERSITY OF MASSACHUSETTS, HAS DONE DRUG SCREENING, PUBLISHED LAST MONTH, A DRUG SCREENING AND OPTIMIZATION OF THE COMPOUNDS THAT WERE REPORTER CONSTRUCTS FOR SMN AND THESE ARE AIRLINE PIPPER DEANS AND ANOTHER SET OF COMPOUNDS THAT CARRY POTENTIAL TREATMENT ASΦ ‡ TREATMENTS FOR THIS DISEASE. BUT MEANWHILE, THERE ARE SOME VERY INTERESTING DEVELOPMENT IN THE LAST YEAR OR TWO WITH BIOLOGICAL APPROACHES TO THERAPY FOR SPINAL MUSCULAR ATROPHY. GENE REPLACEMENT, GENE THERAPY AND AGAIN ALL OF THE NUCLEOTIDE-INDUCED NOT EXON SKIPPING BUT EXON RETENTION. ALL THE NUCLEOTIDES PROMOTE THE RETENTION OF EXON 7 IN THE TRANSCRIPTOME. NOW FIRST WITH GENE REPLACEMENT, WE HAVE SOME GOOD RESULTS WITH INJECTION AGAIN WITH AAV HERE, LENGTHY VIRUS IN MICE AND MUSCLE AND INJECTING GENES THAT DELIVER INTO MOTOR NEURONS IN THE SPINAL CORD, MICE LEVELS OF EXPRESSION, PARTICULARLY WHEN THE SYSTEMIC DELIVERY IS GIVEN EARLY THE FIRST FEW DAYS OF LIFE, AND NICE RESULTS HERE IN MONKEYS. NOW, LAST YEAR THERE WERE THREE REPORTS OF REMARKABLE BENEFIT WITH EARLY POSTNATAL DELIVERY OF SNM AND AAV VECTORS. HERE IS ONE FOR BRIAN'S GROUP AT OHIO STATE PUBLISHED IN NATURE BIOTECH. HERE YOU CAN SEE THAT FIRST THE GENE IS DELIVERED INTO THE MOTOR NEURONS AND THE SPINAL CORD. YOU GET A MARKED INCREASE IN SNM LEVELS IN THE SPINAL CORD AND A NICE BEHAVIORAL BENEFIT IN TERMS OF WRITING TIME AND HOW LONG IT TAKES THESE MICE TO ROLL OVER. THE SMN TREATED MOUSE AND HERE THE CONTROL UNTREATED MOUSE AND BASICALLY PLACEBO TREATED MOUSE AND CONTROL MOUSE. AND LOOK WHAT IT DID TO THE SURVIVAL. SO HERE IS THE PLACEBO GROUP THAT DIED IN 15 DAYS AND HERE IS THE SMN TREATED MOUSE WITH MICE THAT SURVIVED UP TO 250 DAYS. BOY, THIS IS REALLY HAVING A DRAMATIC EFFECT BASICALLY CURING THE DISEASE BUT THE SINGLE INJECTION IN THE FIRST FEW DAYS OF LIFE. MICE DIE PRETTY QUICKLY. IF YOU WAIT EVEN UNTIL 10-DAYS, AFTER FIVE DAYS OF TREATMENT, THIS EFFECT ISSULTS. YOU DON'T SEE IT. IF YOU GIVE THE TREATMENT DAY ONE UP TO DAY 5, YOU CAN CURE THE DISEASE BY REPLACING SNM. LOOK AT THE RESULTS OF THIS PLUS THE HDAC EXPERIMENTS INDICATES A LEVEL OF OPPORTUNITY HERE IN THE EARLIEST PHASES OF THE DISEASE, WHEREAS IF YOU CORRECT THE DEFECT, YOU CAN HAVE A PRONOUNCED EFFECT. THIS IS WITH INTRAVENOUS DELIVERY. NOW, NUCLEOTIDES HERE WORK IS DONE PRIMARILY BY ADRIENNE KRAMER'S GROUP AT COASTAL HARBOR WORKING WITH THE COMPANY IN CALIFORNIA AND FIRST SCREENED THE WHOLE SERIES OF ALL THE NUCLEOTIDES AND MATCHED SEQUENCEOS EITHER SIDE OF SM7. THE GOAL IS TO PROMOTE THE INCLUSION OF THIS EON SO YOU GET FULL TRANSCRIPT FROM THE SMN2 GENE. WHAT THEY FIND IS WHEN THEY INJECT THIS NUCLEOTIDE, JUST SINGLE INJECTION INTO THE CEREBRAL VENTRICLES OF THAT MEAS, YOU WILL GET LONG TERM SURVIVAL AND EXPRESSION INCLUSION OF THE EXON THROUGHOUT THE -- FOR UP TO SIX MONTHS. ONE INJECTION AND SIX MONTHS AFFECT. WHAT WAS JUST PUBLISHED IN THE NEXT SLIDE, LAST WEEK IN "NATURE," ANOTHER STUD FRETHIS GROUP SHOWS THAT YOU DON'T HAVE TO INJECT THIS. YOU CAN INJECT THESE NUCLEOTIDES AND YOU GET A REMARKABLE EFFECT. REMARKABLY, IT'S WORKING ON INCREASING SNM BUT NOT NOT MOTOR NEURONS. IT APPEARS TO BE WORKING BY INCREASING LEVELS OF SNM IN THE LIVER BUT LEADS TO INCREASED PRODUCTION OF THE DEFICIENT INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN THAT LEADS TO RGF ONE DEFICIENCY. SO INTERESTINGLY, SYSTEMIC CORRECTION WORKS NOT DIRECTLY ON THE MOTOR NEURON, NOT LIKE THE CENTRAL NERVOUS SYSTEM BUT BY WORKING OUTSIDE THE NERVOUS SYSTEM AND CORRECTING DEFECTS. SO HERE IS THE SURVIVAL BENEFIT TO THINK AT. THE UNTREATED MICE DIEING IN 15 DAYS AND NORMAL MICE SURVIVAL HERE UP TO 500 DAYS. AND WITH INCREASING DOSES SUBCUTANEOUS INJECTION, INJECTIONS IN THE FIRST THREE DAYS OF LIFE, THEY GET SURVIVAL UP TO 500. SO THEY ARE EFFECTIVELY CURING THIS DISEASE WITH 2 INJECTIONS IN THE FIRST THREE DAYS OF LIFE. NOW THIS SHOWS THIS IS ON THE HANDOUTS YOU GOT IN THE POSTER, THE AFFECT OF THE NEUROMUSCULAR JUNCTION AND THE UNTREATED MICE, THE AONS ARE GOING INTO THE MOTOR AND THE UNTREATED MICE HAVE A RETRACTION OF EXONS FROM THE MOTOR END PLATES WHICH IS CORRECTIVE BY THE NUCLEOTIDE THERAPY. HERE IS WHAT HAPPENS TO THE IGF1 LEVELS IN THESE MICE. SO THIS HASN'T BEEN NOTED BEFORE. BUT WITHOUT TREATMENT, THESE MICE HAVE ZERO IGF1 IN THE CIRCULATION. AS I SAID BEFORE, IT'S A TROPEIC FACTOR FOR MUSCLE FOR MOST MUSCLE REGENERATION AND ALSO KNOWN TO HAVE A TROPEIC EFFECT ON MOTOR NEURONS. SO THE LACK OF IGF1 IN THESE MICE IS LIKELY CONTRIBUTED TO THE MOTOR NEW ON DEGENERATION. THE DEPENDENCE, THERE MAY BE A CRITICAL DEPENDENCE ON RGF1, CLINICAL EARLY STAGE AT THE DISEASE IN THE FIRST FEW DAYS OF LIFE. AND THIS IS NOT DUE TO A PROBLEM WITH IGF1 ITSELF, BUT THROUGH DEFICIENCY OF IGF1 BINDING PROTEIN. DEFICIENCY IS CORRECTED BY TREATMENT. NOW REALLY A REMARKABLE STUDY. IN CLOSING, I'D LIKE TO MENTION ANOTHER INTERESTING OBSERVATION FROM PATRICK WHO IS AT COLUMBIA UNIVERSITY RECENTLY RECRUITED TO THE EXTRAMURAL CLINICAL TRIALS GROUP AT NINDS. SHE AND HER COLLEAGUES A FEW YEARS AGO DID AN INTERESTING STUDY OF THE NATURAL HISTORY OF SEVERE TYPE 1 FORM OF SPINAL MUSCULAR ATROPHY. AND THEY FOUND THAT MICE OR PATIENTS WHO DIAGNOSED IN THE 1980s AND THROUGH THE EARLY 90s HAD A VERY LIMITED SURVIVAL. SO MOST OF THESE PATIENTS DIED WITHIN ONE YEAR OF AGE. A FEW HAVE LONG-TERM SURVIVE. WHEN YOU LOOK AT PATIENTS WITH DIAGNOSED LATER IN THE LATE 90s THROUGH THE EARLY PART OF THIS SENT RE, THE SURVIVAL IS MUCH BETTER. NOW IF WE CAME A RESPONSE LIKE THIS WITH GENE THERAPY AND NUCLEOTIDE THERAPY, WE WOULD BE CELEBRATING BUT THIS IS WITHOUT ANY KIND OF TREATMENT, OTHER THAN, OPTIMIZING STANDARD CARE. PARTICULARLY RESPIRATORY EFFICIENCY. SO IT SHOWS THE FIRST NATURAL HISTORY OF THIS DISEASE IS CHANGING. THE SAME THING TRUE FOR DUE SHEN MUSCULAR DYSTROPHY AND OTHER NEUROMUSCULAR DISEASES AND IT'S PROBABLY BECAUSE OF OPTIMIZING EXISTING CARE. SO A REAL ROLE FOR DOING THAT -- THE ANALOGY HERE OR MODEL FOR US SHEAR WHAT HAPPENED WITH CYSTIC FIBROSIS AND NONNEUROLOGGIC DISEASES, THE ONE THAT HAS SHOWN A REMARKABLE IMPROVEMENT OF SURVIVAL FROM THE 1940s AND 50s OF PATIENTS SURVIVED LESS THAN 10 YEARS AND TODAY SURVIVAL IS UP TO AGE 40 OR BETTER. THERE HAS BEEN OTHER TREATMENTS THAT HAVE BECOME AVAILABLE FOR SISSIST FIBROSIS BUT PRIMARILY A MORE AND MORE AGGRESSIVE OPTIMIZATION OF EXISTING CARE AND NUTRITIONAL SUPPORT. A LOT OF WHAT HELPED TO MAKE THISzV HAPPEN IS WHAT THE CLINICAL CENTRES HAVE DONE TO MAKE MORBIDITY AND DATA OPEN LEVI FOR OPTIMIZATION BETWEEN CENTRES. I'D ARGUE THAT THAT KIND OF APPROACH WHICH HAS BEEN APPLIED TO PLASTIC SURGERY, IS SOMETHING THAT COULD HELP PATIENTS WITH NEUROMUSCULAR DISEASES AND OTHER SEVERE DISEASES WE JUST HAVE TO APPLY THIS KIND OF -- IT'S EASY TO DO. SO THE GOAL SHEAR TO BE ABLE TO HAVE A TREATMENT THAT DOESN'T WORK JUST HERE IN BETHESDA OR MAJOR ACADEMIC MEDICAL CENTRES IN THE UNITED STATES. WE COULD GET BACK TO THE DOMINICAN REPUBLIC AND LACES LIKE THIS, TO HELP PATIENTS WITH THIS DISEASE WHENEVER THEY ARE. AND I THINK THAT'S OUR GOAL. I'D LIKE TO CLOSE BY THIS QUOTE, A PHILOSOPHER FOR THE PAST CENTURY WHO WROTE: CLEARLY IN IS SAY GROUP ENDEAVOR AND IT'S SOMETHING THAT TAKES A LOT OF COLLABORATION, OUTSIDE OF OUR GROUP AND WITHIN OUR GROUP. THIS IS OUR GROUP FROM OUR OUTING LAST SPRING. NOT EVERYBODY IN THIS PICTURE WORKS IN THE LAB, YET. BUT THIS IS SOME OF THE PEOPLE WHO WORK ON THE DUE SHEN MUSCULAR DYSTROPHY TRIAL -- AND THE PEOPLE WORKING ON SPINAL MUSCULAR ATROPHY -- BURNETTE IS NOT IN THE PICTURE. SHE PICKING UP HIS CHILD AT DAY CARE BUT HE IS HERE. AS WELL AS MANY, MANY OTHERS SO, THANK YOU. [APPLAUSE] >> WE CAN TAKE A COUPLE OF QUESTIONS BUT THERE IS A RECEPTION RIGHT AFTER THE LECTURE IN THE LIBRARY. IF ANYBODY HAS QUESTIONS PLEASE GO TO ONE OF THE MICROPHONES. >> IT LOOKS LIKE A LOT OF FRUSTRATIONS. BUT MAKE SOMETHING HEADWAY. SO WHAT IS THE LENGTH OF THIS AND WHAT ARE THE SPECIFICITIES AND THE REMISSION RATE AFTER ADMINISTRATION? >> I DON'T KNOW SPECIFICALLY DURING THE RANGE OF 16-20 NUCLEOTIDES AND THEY ARE DEGRADED VERY SLOWLY. ESSENTIALLY FRIGHTENING SLOW. THE HALF-LIFE IS IN THE DUE SHEN TRIALS IS ABOUT A MONTH. AND YOU KNOW, THE PROBLEM WITH THAT, IF YOU GET INTO TOXICITY, IT TAKES A LONG TIME TO CLEAR THE AGENT OUT. THE ADVANTAGE ON THE OTHER HAND IS THAT IT SINGLE INJECTION CAN GIVE YOU MONTHS OF RESPONSE. IT'S A LIFELONG RESPONSE TO INJECTION. >> FOR THE CLINICAL STUDIES, YOU ARE DOING PHARMACODYNAMICS DEGRADATION? AND LOOKING IF FOR THE MRI. GOOD LUCK. THANK YOU. >> THANK YOU. I WOULDN'T GIVE UP ON THE SMALL MOLECULES. THIS IS THE WAY THERAPEUTICS DEVELOPMENT IS. IT TAKES PERSEVERANCE. IT'S A LOT OF BACK AND FORTH AND BACK AND FORTH AND WE -- THE GOAL IS TO LEARN SOMETHING WITH EACH TRIAL THAT HELPS TO BETTER INFORM THE NEXT ONE AND SOME COMBINATION OF THERAPY COULD BE THE ANSWER. >> JUST A GREAT TALK. WONDERFUL. I HAD A QUESTION ABOUT SNA AND YOUR POINTS ABOUT THE NEED FOR EARLY RECOGNITION AND TREATMENT. SO DO YOU HAVE ANY REMARKS ABOUT THE POSSIBILITY OF NEWBORN SCREENING AND THEN THE DEVELOPING WORLD, THAT'S LARGER PROBLEM, POTENTIAL PROBLEM. WE HAD A LOST TALK ABOUT THIS TO HAVE MORE WIDESPREAD CARRIERS TESTING AND NEWBORN SCREENING, IT'S INTERESTING. SOME INTERESTING MEET BEINGS THAT. THE CARRIER -- PEOPLE ARE ARGUING BOTH SIDES. IF WE PUT TOO MUCH INTO CARRIER TOUCHING, WHAT ABOUT DEVELOPING A CURE FOR THE KIDS WHO ARE ALREADY AFFECTED? THE VOLUNTARY GROUPS OF THAT SIDE OF GENETICISTS AND THE OBVIOUS TA TRISH ANS ARE ON DIFFERENT SIDES OF THAT ISSUE. WHERE THE CONUNDRUM IS, YOU KNOW, THERE WOULD BE A GOOD ARGUMENT FOR WIDESPREAD SCREENING ONCE WE HAVE AN TREATMENT THAT IS SHOWN TO ONLY WORK EARLY. RIGHT NOW WE HAVE A LOT OF EVIDENCE THAT A TREATMENT NEEDS EARLY DIAGNOSIS BUT HASN'T BEEN PROVEN YET AND ONCE WE HAVE, WE'LL GO ALONG WITH THE IDEA. BUT THERE IS A LOT OF WORK IN THAT DIRECTION. WE ARE PUTTING A LOT INTO AS A DEVELOPMENT AND MAKING CHEAPER AS AS WIDELY AVAILABLE FOR THIS DISEASE AND OTHERS. AND I THINK THE FUTURE IS GOING TO BE INCORPORATED INTO NEWBORN SCREENING PANELS. IT'S ALREADY BEING WIDELY DONE IN ISRAEL, FOR EXAMPLE. TING WILL HAPPEN IN THE UNITED STATES TOO. BUT IT'S AN INTERESTING STAGE RIGHT NOW WHERE YOU NEED TO SHOW THAT IT'S NECESSARY AND EFFECTIVE TO MAKE EARLY DIAGNOSIS IN A SITUATION WHERE IT'S PRETTY LIKELY TO BE THE CASE YET. >> DO THESE TWO TYPES OF DYSTROPHY AFFECT EXTRA MUSCLES? DO THEY AFFECT EXTRA OCULAR MUSCLES? >> OH, OKAY. YES, SO YOU DON'T REALLY GET MUCH EYE MUSCLE INVOLVEMENT WITH DUE SHEN DYSTROPHY. MY PATIENTS GET AUTOPSYIED AND THE MUSCLES ARE JUST COMPLETELY GONE BUT YOU STILL HAVE YOUR EXTRA OCULAR MUSCLES. SPINAL MUSCULAR ATROPHY, YOU DON'T HAVE MUCH INVOLVEMENT WITH THE EXTRA OCULAR MUSCLES. THERE ARE OTHER KINDS OF MUSCULAR DYSTROPHY THAT DO. ONE WORKED ON OCULAR DYSTROPHY, A REPEAT EXPANSION DISEASE THAT EFFECTS THE EYE MUSCLES IN PARTICULAR AND THEN WE SEE MITOCHONDRIAL DISORDERS THAT AFFECT THE EYE MUSCLES. >> -- [INDISCERNIBLE] CAN GIVER YOU SOME IDEA ON POSSIBLE THERAPY? >> THAT'S AN INTERESTING QUESTION. I THINK --- SO THE MICE ARE LESS SERIOUSLY AFFECTED THAN PATIENTS. DOGS ARE MORE SERIOUSLY AFFECTED WITH DUE SHEN DYSTROPHY. AND I THINK IT MIGHT BE A MATTER OF MUSCLE SIZE. IT'S A STRUCTURAL PROTEIN THAT BIGAMOUSEL FIBERS AND BIGAMOUS ELSE HAVE MORE OF A DEPEND OWNS THIS STRUCTURE LIKE A TALL BUILDING WOULD HAVE MORE DEPENDENCE ON STRUCTURE THAN A SHORT BUILTING. BUT THAT IS KIND OF THE EXPLANATION. IT'S JUST ONE POSSIBILITY. SO MAYBE INNOVATION RATIO AND OTHER ASPECTS MAKE A DIFFERENCE AND MAYBE IT'S SOMETHING TO BE LEARNED BY THAT. JOHN PORTER IS NOW AN EXTRAMURAL NIDS THAT DID WORK ON THAT WHEN HE WAS AT CASE WESTERN RESERVE BEFORE HE CAME HERE. AND STILL VERY MUCH INTERESTED IN THAT QUESTION. THAT'S NOT THE BUILDING THEME. >> THANK YOU FOR FABULOUS LECTURE. [APPLAUSE] PLEASE JOIN US AT THE RECEPTION ACROSS THE HALL.