WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:48.349 --> 00:48.709 Today, 00:48.720 --> 00:50.790 we're going to review the ongoing 00:50.799 --> 00:53.799 research at the Medical Neurology Branch 00:53.810 --> 00:56.389 of the National Institute of Neurological and 00:56.400 --> 00:59.000 communicative Disorders and stroke into 00:59.009 --> 01:00.560 the viral 01:01.549 --> 01:03.900 metabolic and immunologic 01:03.909 --> 01:05.940 studies on the 01:05.949 --> 01:08.309 ideology and pathogenesis 01:08.599 --> 01:10.819 of amyotrophic gland sclerosis and 01:10.830 --> 01:13.599 associated motor neuron disease. 01:15.610 --> 01:18.319 What I would like to do is review 01:18.559 --> 01:20.260 some of the evidence 01:20.269 --> 01:22.910 suggestive evidence at this 01:22.919 --> 01:25.500 point for a viral ideology to 01:25.510 --> 01:27.709 amyotrophic lateral sclerosis and 01:27.720 --> 01:30.220 outline some of the work which we are doing. 01:31.040 --> 01:31.550 In addition, 01:31.559 --> 01:34.349 we will look at some of the evidence for an immuno pathologic 01:35.300 --> 01:37.680 process involved in amyotrophic lateral 01:37.690 --> 01:38.559 sclerosis. 01:38.569 --> 01:39.230 And again, 01:39.239 --> 01:41.260 what work is being done in this field. 01:41.620 --> 01:42.239 And finally, 01:42.250 --> 01:44.650 we are going to look into the metabolic 01:44.660 --> 01:47.069 studies being performed here at 01:47.080 --> 01:49.430 NIH to see if there are any 01:49.440 --> 01:51.550 unique abnormalities, 01:51.980 --> 01:53.510 regardless of ideology, 01:53.519 --> 01:56.510 which might lead to some way to 01:56.519 --> 01:58.489 counteract the disease process. 02:00.839 --> 02:03.809 There is suggestive evidence for a viral 02:03.819 --> 02:06.209 ideology in amyotrophic lateral sclerosis 02:07.730 --> 02:10.679 for the viral ideology 02:10.690 --> 02:13.639 is the unique observation that there is a late 02:13.649 --> 02:16.639 onset progressive muscular atrophy after 02:16.649 --> 02:19.259 early childhood paralytic poliomyelitis. 02:19.779 --> 02:22.339 This has a usual delayed 02:22.350 --> 02:23.320 onset, 02:23.649 --> 02:26.610 approximately 20 to 40 years following the 02:26.619 --> 02:29.149 childhood disease and 02:29.160 --> 02:31.690 rarely involves cases that 02:31.779 --> 02:34.690 may present with the classic Charcot form of a 02:34.699 --> 02:36.270 myotropic sclerosis. 02:37.779 --> 02:40.210 Other workers have tried to see if there's a 02:40.220 --> 02:42.820 relationship between Anteed and polio virus 02:42.830 --> 02:45.550 infection through looking at serum 02:45.649 --> 02:48.550 antibodies to various polio virus types. 02:49.990 --> 02:52.740 No clear cut relationship has been noted. 02:52.910 --> 02:53.500 However, 02:53.509 --> 02:55.869 if we will remind ourselves of multiple 02:55.880 --> 02:56.779 sclerosis, 02:56.990 --> 02:59.850 we will remember that there is a unique and perhaps 02:59.860 --> 03:02.720 more dramatic rise in the antibody in the cerebral 03:02.729 --> 03:05.380 spinal fluid towards specific viruses in 03:05.429 --> 03:07.899 this disease than in the 03:07.910 --> 03:08.460 serum. 03:09.610 --> 03:12.250 We in conjunction with Dr John sever are 03:12.259 --> 03:15.220 looking at the serum and 03:15.229 --> 03:16.419 cerebral spinal fluid 03:17.690 --> 03:20.500 antibody levels which would neutralize 03:20.509 --> 03:23.410 various types of polio virus antibody in a group of 03:23.419 --> 03:25.699 patients with amyotrophic lateral sclerosis 03:26.089 --> 03:29.070 and comparing this to a group of patients 03:29.080 --> 03:31.899 with other neuromuscular disease such as 03:31.910 --> 03:34.339 peripheral nerve disease and 03:34.350 --> 03:35.779 primary myopathies. 03:36.830 --> 03:39.809 This work is ongoing and I will not report the results 03:39.820 --> 03:40.800 today. 03:41.270 --> 03:43.399 But it is important for us to 03:43.410 --> 03:46.009 conceive of a possibility that an early 03:46.020 --> 03:48.300 infection may lead to late disease. 03:48.539 --> 03:50.800 There is an animal model of marine 03:50.809 --> 03:52.789 progressive muscular atrophy. 03:52.800 --> 03:55.770 After neonatal infection with mouse C type 03:55.779 --> 03:56.660 particles, 03:57.210 --> 03:59.559 this produces an infection in 03:59.570 --> 04:02.500 wild mice and can be reproduced in 04:02.509 --> 04:04.589 the experimental situation leading to 04:04.600 --> 04:07.330 paralysis and pathological changes that 04:07.339 --> 04:09.860 are very much like what is seen in the 04:09.869 --> 04:11.639 human disease. 04:11.649 --> 04:13.259 Amyotrophic sclerosis. 04:13.270 --> 04:14.550 Specifically, 04:14.559 --> 04:17.429 there is a marked absence of 04:17.440 --> 04:19.929 inflammatory response in these animals. 04:20.369 --> 04:20.829 Now, 04:20.839 --> 04:23.589 contrary to what we cannot 04:23.600 --> 04:26.429 find in amyotrophic vito sclerosis 04:26.440 --> 04:29.140 virus particles are seen in 04:29.149 --> 04:31.959 the mice as they develop paralysis and 04:31.970 --> 04:34.579 these are localized in the anterior horn cells. 04:34.720 --> 04:35.260 However, 04:35.269 --> 04:37.950 many anterior horn cells show destruction 04:38.230 --> 04:40.739 without evidence for viral replication. 04:40.779 --> 04:43.549 The exact pathogenesis by which paralysis is 04:43.559 --> 04:46.369 produced is currently under study at the Johns Hopkins 04:46.380 --> 04:47.880 University School of Medicine. 04:49.440 --> 04:52.239 Based on the finding in the animal 04:52.250 --> 04:53.079 model. 04:53.119 --> 04:56.100 Some people including Mike Viola and Saul 04:56.109 --> 04:59.079 Spiegelman at Columbia University College of 04:59.089 --> 05:01.500 physicians and surgeons have looked at the 05:01.510 --> 05:04.410 presence of an RNA instructed 05:04.420 --> 05:07.149 DNA polymerase in the brains of patients with a myotropic 05:07.500 --> 05:08.149 sclerosis. 05:08.869 --> 05:11.790 The mouse C type virus particles and 05:11.799 --> 05:14.730 other C type virus particles are associated with an 05:14.739 --> 05:16.839 enzyme called reverse transcriptase 05:17.059 --> 05:19.720 which will make DNA 05:19.730 --> 05:22.109 from an RN A trans 05:22.239 --> 05:23.660 script. 05:25.089 --> 05:27.649 Looking at extracts of brains from patients 05:27.660 --> 05:30.019 with Guamanian Parkinson's 05:30.029 --> 05:30.950 disease. 05:30.959 --> 05:33.940 He myotropic lateral sclerosis complex. 05:34.589 --> 05:37.130 These workers have been able to find evidence 05:37.140 --> 05:39.190 for a unique RNA 05:39.200 --> 05:42.059 instructed DNA plumes in the brains of 05:42.070 --> 05:43.760 patients with this disease. 05:44.570 --> 05:45.459 However, 05:45.660 --> 05:48.339 patients without the clinical 05:48.350 --> 05:51.179 signs or pathological signs for disease 05:51.239 --> 05:53.489 also have evidence for this enzyme. 05:55.239 --> 05:56.559 More recently, 05:56.600 --> 05:59.540 there have been some reports of virus like particles 05:59.549 --> 06:02.170 occasionally seen in the extra neural tissues 06:02.179 --> 06:04.600 of two cases of acute amyotrophy 06:05.290 --> 06:06.250 out of sclerosis. 06:06.500 --> 06:09.200 The exact role of this 06:09.209 --> 06:11.570 observation in the pathology 06:11.779 --> 06:14.709 of the disease is unclear because 06:14.720 --> 06:17.339 many of these patients had intercurrent infections 06:17.529 --> 06:20.170 and it is possible that these viruses may not 06:20.179 --> 06:22.529 represent direct 06:23.760 --> 06:26.049 infection of the 06:26.059 --> 06:28.649 tissues but may be there as 06:28.660 --> 06:29.850 bystanders. 06:30.239 --> 06:33.089 The exact ideology for possible extra 06:33.100 --> 06:35.929 neural viral infection on central nervous 06:35.940 --> 06:38.089 system degeneration is unclear. 06:38.100 --> 06:38.549 However, 06:38.559 --> 06:41.350 we must keep in mind such syndromes as Ray's 06:41.359 --> 06:44.290 syndrome in which infection involving the 06:44.299 --> 06:47.290 liver leading to liver destruction 06:47.299 --> 06:49.970 can cause a severe neurological deficit. 06:50.880 --> 06:51.149 Now, 06:51.160 --> 06:54.160 there is evidence against the virus ideology 06:54.170 --> 06:56.250 in the classic sense for amyotrophic 06:56.529 --> 06:57.309 sclerosis. 06:57.640 --> 06:59.709 Primarily the 06:59.720 --> 07:02.119 patients with 07:02.839 --> 07:04.489 amyotrophic sclerosis 07:05.679 --> 07:08.609 in Guam and sporadic cases 07:08.619 --> 07:11.470 have not produced disease when 07:11.480 --> 07:13.899 inoculated into cerebrally into experimental 07:13.910 --> 07:16.720 animals in experiments 07:16.730 --> 07:19.149 similar to that which has shown a definite 07:19.160 --> 07:21.959 viral ideology for diseases such as 07:21.970 --> 07:24.220 Kuru and Creutzfeld Jakob 07:24.470 --> 07:26.019 disease in man. 07:26.519 --> 07:27.380 In fact, 07:27.390 --> 07:30.359 the absence of passage for any agent 07:30.369 --> 07:32.649 in amyotrophic sclerosis has served as an 07:32.660 --> 07:35.220 excellent control for the other studies. 07:35.230 --> 07:36.829 Highlighting that 07:37.329 --> 07:40.140 the amyotrophic out sclerosis does not 07:40.149 --> 07:42.940 behave like a simple virus 07:42.950 --> 07:45.260 infection and no clear cut virus is 07:45.269 --> 07:47.950 recoverable in animal inoculation 07:47.959 --> 07:48.760 experiments. 07:49.570 --> 07:50.820 But more importantly, 07:50.829 --> 07:53.540 in contrast to the work being done with the 07:53.549 --> 07:56.350 more sensitive methods of looking at RN A 07:56.359 --> 07:57.829 instructed DNA polymerase. 07:58.070 --> 08:00.480 It is important to note 08:00.730 --> 08:03.640 that the brains 08:03.649 --> 08:06.519 of patients with sporadic cases of 08:06.529 --> 08:09.429 amyotrophic lateral sclerosis show no evidence for 08:09.440 --> 08:11.019 the presence of this enzyme. 08:11.559 --> 08:11.929 Thus, 08:11.940 --> 08:12.859 on the balance, 08:12.869 --> 08:15.369 there is no clear cut evidence 08:15.380 --> 08:17.290 for a viral ideology. 08:17.450 --> 08:20.049 But some animal models suggest that it is 08:20.059 --> 08:22.070 possible for a 08:22.079 --> 08:24.970 progressive muscular atrophy type 08:24.980 --> 08:25.869 syndrome, 08:25.880 --> 08:28.450 similar to amyotrophic sclerosis and 08:28.459 --> 08:31.170 associated motor neuron diseases to occur 08:31.179 --> 08:33.609 following a viral infection early in 08:33.619 --> 08:34.349 childhood. 08:35.489 --> 08:38.489 We are searching for other possible 08:38.500 --> 08:39.909 leads in this regard. 08:42.950 --> 08:45.840 The possibility that there may be an immuno pathologic 08:45.880 --> 08:48.840 process involved in amyotrophic lateral sclerosis 08:48.969 --> 08:51.960 is less clearly established 08:51.969 --> 08:54.830 and evidence sort of lines up on the 08:54.840 --> 08:57.320 side against an immune 08:57.450 --> 08:58.400 process. 08:58.409 --> 08:59.640 For this disease. 09:01.270 --> 09:02.570 Serum cytotoxic 09:03.909 --> 09:06.099 against cultured embryo 09:07.099 --> 09:10.010 anterior horns and culture was thought to 09:10.020 --> 09:12.929 be specific for amyotrophic lao sclerosis serum 09:14.159 --> 09:15.659 in the past few years, 09:16.159 --> 09:19.140 groups at the NIH and elsewhere have shown that 09:19.150 --> 09:21.729 the serum cytotoxic against heterologous 09:22.690 --> 09:25.219 mouse embryo neurons in culture 09:25.950 --> 09:28.840 is non specific and most likely related 09:28.849 --> 09:31.200 to heterologous antibodies 09:31.659 --> 09:33.869 directed toward blood group specific 09:33.880 --> 09:36.299 antigens which cross react in the urine 09:36.309 --> 09:39.030 system at the 09:39.039 --> 09:40.039 present time. 09:40.049 --> 09:42.859 There's no definite histocompatibility 09:42.869 --> 09:43.429 linkage. 09:44.280 --> 09:47.099 Some groups have suggested that there is an increase in 09:47.109 --> 09:49.590 H three and seven in 09:49.599 --> 09:52.580 paralytic poliomyelitis patients and 09:52.590 --> 09:54.969 in patients with amyotrophic lateral sclerosis. 09:56.059 --> 09:58.919 Two other groups including Dr Paul Terrasa, 09:59.140 --> 10:02.109 who is probably the father of the histocompatibility 10:02.119 --> 10:04.940 method have shown that there is no 10:04.950 --> 10:07.549 clear cut statistically significant linkage. 10:08.309 --> 10:08.989 However, 10:09.000 --> 10:11.679 some groups have shown an increase in the L 10:11.690 --> 10:14.299 2-21 haplotype 10:14.859 --> 10:16.940 in patients with severe paralytic 10:16.950 --> 10:18.909 poliomyelitis and 10:20.229 --> 10:21.659 amyotrophic lateral sclerosis. 10:23.020 --> 10:25.960 These findings are suggestive that there 10:25.969 --> 10:28.599 might be a unique susceptibility to some 10:28.609 --> 10:31.510 pathological process that it is linked 10:31.520 --> 10:34.510 to the his compatibility antigens or to the haplotype is 10:34.520 --> 10:35.630 not clear yet, 10:35.640 --> 10:38.150 but perhaps further studies with more specific 10:39.049 --> 10:41.570 delineations of histocompatibility 10:41.580 --> 10:44.500 linkages might give us some idea 10:44.510 --> 10:47.510 as to what is going on at the 10:47.520 --> 10:48.380 present time, 10:48.390 --> 10:51.150 there is no specific lymphocyte response as 10:51.159 --> 10:54.109 measured by macrophage inhibition factor or 10:54.119 --> 10:57.020 lymphocyte transformation to brain 10:57.030 --> 10:59.280 antigens or neuromuscular junction 10:59.289 --> 11:02.090 antigens in the lymphocytes 11:02.099 --> 11:05.059 from patients with amyotrophic lateral sclerosis as 11:05.070 --> 11:07.219 compared to controlled patients. 11:09.190 --> 11:11.179 Some recent evidence has 11:11.190 --> 11:14.099 suggested that there may be a role 11:14.109 --> 11:16.919 for complement in the pathogenesis 11:16.929 --> 11:19.919 of atrophy sclerosis in the medical 11:19.929 --> 11:20.929 neurology branch. 11:20.940 --> 11:23.739 Several groups have demonstrated that there might 11:23.750 --> 11:26.679 be borderline increase in C three levels of 11:26.690 --> 11:29.229 patients with amyotrophic sclerosis compared to 11:29.239 --> 11:30.849 other disease groups. 11:31.590 --> 11:32.719 Recently, 11:32.780 --> 11:35.289 one group has 11:35.299 --> 11:37.960 shown an increased C one Q binding 11:38.849 --> 11:41.739 in patients with Amyotrophy out sclerosis compared to 11:41.750 --> 11:42.640 controls, 11:43.659 --> 11:44.669 it is not clear. 11:44.679 --> 11:45.229 However, 11:45.239 --> 11:47.750 if the controls are adequately age or sex 11:47.760 --> 11:48.469 matched, 11:48.729 --> 11:51.469 but there is some suggestive evidence 11:51.479 --> 11:53.849 that there may be an abnormality and complement 11:53.859 --> 11:56.849 binding in patients with aosis, 11:57.510 --> 12:00.289 whether this is due to intercurrent infection or related 12:00.299 --> 12:03.179 directly to the pathogenesis of the disease is 12:03.190 --> 12:03.809 unclear. 12:04.679 --> 12:07.219 These same people found evidence for some 12:07.229 --> 12:09.979 immune complex deposition in the renal glome 12:11.010 --> 12:12.929 in nine of 18 patients with a 12:13.599 --> 12:16.090 sclerosis suggesting that there might 12:16.099 --> 12:18.690 be some intercurrent infection. 12:19.179 --> 12:20.320 Most recently, 12:20.330 --> 12:23.330 a paper from the same group has shown that 12:23.340 --> 12:25.250 there is no evidence for circulating 12:26.349 --> 12:28.679 immune complexes in these patients. 12:29.090 --> 12:32.049 So exactly why there is increased evidence for 12:32.059 --> 12:34.510 deposition without the presence of circulating 12:34.520 --> 12:36.119 complexes is unclear. 12:36.380 --> 12:39.190 And this issue remains to be decided by 12:39.200 --> 12:40.159 future research, 12:44.679 --> 12:47.530 regardless of whether there is a virus or 12:47.539 --> 12:49.330 immunologic ideology. 12:49.340 --> 12:50.400 For the disease. 12:50.440 --> 12:52.849 There might be some metabolic pathway which is 12:52.859 --> 12:53.570 affected, 12:53.659 --> 12:56.609 which can then be understood and 12:56.619 --> 12:58.549 perhaps changed by drug therapy. 12:58.890 --> 13:01.580 The best example of this would be Parkinson's 13:01.590 --> 13:04.030 disease in man where there is 13:04.039 --> 13:06.739 very good evidence that the post encephalitic 13:06.750 --> 13:09.510 Parkinson's is due to a virus infection. 13:10.159 --> 13:10.909 However, 13:10.919 --> 13:13.390 the exact way that we treat 13:13.400 --> 13:16.219 patients is based on metabolic abnormalities 13:16.229 --> 13:18.349 attended in the dopamine colergic 13:18.830 --> 13:19.750 system, 13:21.190 --> 13:23.510 we are searching for a similar 13:23.580 --> 13:25.840 metabolic abnormality in amyotrophic 13:26.099 --> 13:28.969 sclerosis patients because some 13:28.979 --> 13:31.940 patients with hyper parathyroidism may 13:31.950 --> 13:34.940 present with neurological abnormalities 13:35.140 --> 13:37.890 and occasionally be differentially 13:37.900 --> 13:40.619 diagnosed as having amyotrophic sclerosis. 13:41.200 --> 13:43.969 We have conducted a longitudinal study of 13:43.979 --> 13:46.710 calcium metabolism in patients with amyotrophic lateral 13:46.719 --> 13:47.479 sclerosis, 13:48.559 --> 13:51.489 peripheral neuropathy and primary muscle 13:51.500 --> 13:52.289 disease. 13:53.609 --> 13:56.270 We have looked at the seven 13:56.280 --> 13:59.210 day whole body calcium retention 13:59.450 --> 14:01.780 in patients with als compared to other 14:01.789 --> 14:02.640 controls. 14:04.210 --> 14:07.099 This is a measure of the 14:07.210 --> 14:10.059 absorption of calcium by the body. 14:10.390 --> 14:13.210 Its distribution into the metabolically 14:13.219 --> 14:15.710 active pools of bone and 14:15.719 --> 14:18.469 muscle and its excretion from the 14:18.479 --> 14:19.159 body. 14:19.169 --> 14:21.090 In a fixed length of time. 14:22.609 --> 14:23.390 Normally, 14:23.400 --> 14:25.890 patients will maintain after a 14:25.900 --> 14:28.349 given dose on a given diet 14:28.359 --> 14:30.780 of calcium. 14:31.520 --> 14:33.729 A calcium retention ranging 14:33.739 --> 14:36.359 between 30 to 14:36.369 --> 14:39.190 44 patients with 14:39.200 --> 14:41.320 neuromuscular disease are 14:41.330 --> 14:44.020 statistically below 14:44.030 --> 14:44.820 normal. 14:45.190 --> 14:47.570 But patients with amyotrophic lao sclerosis 14:47.849 --> 14:50.559 are lower yet and lower. 14:50.570 --> 14:53.210 Compared to patients with other neuromuscular 14:53.219 --> 14:53.909 disease. 14:55.159 --> 14:58.150 We have been able to show by measuring the vitamin D level 14:58.159 --> 15:00.969 that is not due to an abnormality in the vitamin D 15:00.979 --> 15:01.330 level. 15:01.340 --> 15:04.250 In the blood as measured by 25 hydroxy vitamin D 15:04.979 --> 15:07.469 and serum calcium is 15:07.479 --> 15:09.289 similar in all three groups. 15:09.299 --> 15:11.070 Although in the low normal range, 15:12.630 --> 15:13.489 interestingly, 15:13.500 --> 15:16.479 when we looked at the parathyroid hormone concentrations, 15:16.489 --> 15:19.340 we found that all three groups 15:19.349 --> 15:21.909 showed evidence that the 15:21.919 --> 15:24.270 parathyroid hormone concentration was 15:24.700 --> 15:27.659 borderline elevated with approximately 40 15:27.669 --> 15:30.340 to 50% of the various groups 15:30.349 --> 15:32.369 being above two standard 15:32.380 --> 15:35.250 deviations from the mean 15:35.260 --> 15:36.039 for normal. 15:36.469 --> 15:39.320 Suggesting that there might be some role of 15:39.330 --> 15:42.020 secondary hyper parathyroidism in these 15:42.030 --> 15:44.630 patients in response to 15:44.640 --> 15:47.219 abnormalities in calcium metabolism 15:47.229 --> 15:49.710 or in the regulators of calcium metabolism. 15:53.130 --> 15:56.080 In order to determine whether there was an abnormality in absorption 15:56.090 --> 15:57.979 early of calcium. 15:57.989 --> 16:00.090 In patients with amyotrophic sclerosis, 16:00.419 --> 16:03.289 we looked at the uptake of radioactive 16:03.299 --> 16:06.000 calcium into the plasma pool in 16:06.010 --> 16:08.200 patients with amyotrophic lateral sclerosis. 16:08.369 --> 16:11.119 Compared to those patients with 16:11.130 --> 16:12.900 nerve and muscle disease. 16:14.210 --> 16:17.169 Patients with neuromuscular 16:17.179 --> 16:17.979 disease, 16:17.989 --> 16:20.539 exclusive of als show 16:21.989 --> 16:24.179 quite normal uptake. 16:24.510 --> 16:27.330 Patients with als show an increased uptake into the 16:27.340 --> 16:29.729 plasma pool and a more heterogeneous 16:29.739 --> 16:30.659 distribution. 16:32.219 --> 16:32.789 Thus, 16:32.799 --> 16:35.049 we were able to show that the decreased 16:35.059 --> 16:37.109 retention is not due to 16:37.119 --> 16:39.739 abnormalities in the absorption acutely 16:39.760 --> 16:40.969 of calcium. 16:40.979 --> 16:43.250 In patients with amyotrophic lateral sclerosis. 16:43.940 --> 16:46.090 The reason for the delayed 16:46.799 --> 16:49.729 decreased retention must have some other 16:49.739 --> 16:50.359 basis. 16:51.349 --> 16:52.559 We know that these, 16:54.559 --> 16:56.799 we know that these patients have 16:57.359 --> 16:59.700 normal vitamin D levels, 16:59.710 --> 17:02.599 but we do not know whether they respond adequately 17:02.609 --> 17:03.919 to this level. 17:04.650 --> 17:06.390 In order to determine this, 17:06.430 --> 17:08.989 we gave patients with als dihydrotachysterol 17:10.578 --> 17:13.129 and a control group with similarly 17:13.139 --> 17:14.909 decreased retentions 17:15.800 --> 17:18.680 and followed these patients before and 17:18.689 --> 17:21.569 after treatment with the seven day whole body 17:21.579 --> 17:22.209 retention, 17:22.939 --> 17:25.430 we were able to show that patients with 17:25.439 --> 17:28.430 amyotrophic lao sclerosis showed an increase in 17:28.439 --> 17:30.939 the whole body retention of calcium 17:30.949 --> 17:33.709 47 at seven days, 17:33.719 --> 17:36.400 similar to the controls and into the 17:36.410 --> 17:37.390 normal range. 17:38.060 --> 17:40.489 This was maintained as long as they were on the 17:40.500 --> 17:43.430 dihydrotachysterol therapy and showed that there was 17:43.439 --> 17:46.150 no vitamin D resistance in these patients. 17:47.140 --> 17:50.060 The exact role that calcium 17:50.069 --> 17:52.750 metabolism plays in amyotrophic sclerosis is 17:52.760 --> 17:53.469 unclear. 17:53.479 --> 17:56.030 Is it an epi phenomena or is it 17:56.040 --> 17:58.589 related to the underlying pathogenesis? 17:58.689 --> 18:01.550 Further studies will have to be done to determine 18:01.560 --> 18:04.489 whether patients with A LS respond 18:04.500 --> 18:06.910 adequately to the normal 18:06.920 --> 18:09.430 stimulation of parathyroid 18:09.439 --> 18:10.040 hormone. 18:10.199 --> 18:12.959 Those studies are currently in progress at the medical 18:12.969 --> 18:13.979 neurology branch 18:17.390 --> 18:19.339 because we were unable to show an 18:19.349 --> 18:22.000 abnormality in calcium 18:22.010 --> 18:24.599 levels in the serum or spinal 18:24.609 --> 18:27.130 fluid between patients with als and other 18:27.140 --> 18:28.670 neurological disease. 18:29.130 --> 18:31.910 We looked at other contaminants of calcium 18:31.920 --> 18:33.680 metabolism in these patients 18:34.969 --> 18:36.510 cyclic nucleotide, 18:36.530 --> 18:39.339 cyclic amp and cyclic GMP are 18:39.939 --> 18:42.530 present in the human body in 18:42.540 --> 18:43.739 large amounts, 18:44.069 --> 18:47.010 but more specifically in the central nervous 18:47.020 --> 18:49.530 system in extraordinarily high 18:49.540 --> 18:51.479 amounts compared to other tissues. 18:52.359 --> 18:53.089 In addition, 18:53.099 --> 18:55.829 the enzymes for their synthesis and degradation are also 18:55.839 --> 18:58.510 present in these tissues. 18:59.780 --> 19:02.349 Cyclic amp and cyclic GMP play an important 19:02.359 --> 19:04.750 role in the metabolic 19:04.760 --> 19:07.550 mediation of certain reactions 19:07.800 --> 19:08.719 such as phosphorylase. 19:10.030 --> 19:10.489 In addition, 19:10.500 --> 19:13.229 there is increasing evidence for a role of cyclic amp and 19:13.239 --> 19:15.949 electrochemical mediation of certain 19:15.959 --> 19:17.660 events in the central nervous system. 19:20.270 --> 19:23.189 In human studies of patients with als and 19:23.199 --> 19:24.310 other diseases, 19:24.319 --> 19:26.949 we use the radio immunoassay to measure cyclic 19:26.959 --> 19:29.709 nucleotides and show here the unique 19:29.719 --> 19:31.910 specificity in distinguishing between the two 19:31.920 --> 19:34.329 nucleotides using our 19:34.390 --> 19:36.349 different rabid antibiotics. 19:38.040 --> 19:40.880 When we looked at cerebral spinal fluid cyclic A MP 19:40.890 --> 19:43.869 levels in the same patient at two different 19:43.880 --> 19:46.680 times under identical pharmacological and 19:46.689 --> 19:48.680 physiological situations, 19:48.689 --> 19:51.520 we showed an excellent correlation with 19:51.530 --> 19:53.770 excellent linear regression 19:54.170 --> 19:56.489 for cyclic amp and cyclic GMP. 19:57.270 --> 20:00.239 The black dots indicate those patients who have not 20:00.250 --> 20:02.920 had proven acid treatment and the 20:02.930 --> 20:05.719 white squares show those patients who have had proven acid 20:05.729 --> 20:06.459 treatment. 20:06.859 --> 20:08.880 There is a clear correlation 20:09.290 --> 20:11.339 regardless of pharmacological 20:11.640 --> 20:14.630 manipulations between the 20:14.640 --> 20:17.560 CSF levels of these cyclic nucleotides in the 20:17.569 --> 20:20.069 same patients on two different 20:20.079 --> 20:20.750 occasions. 20:21.959 --> 20:24.849 And we were able to show that there is no 20:24.859 --> 20:27.829 clear cut difference in the plasma cyclic 20:27.920 --> 20:30.869 amp P level between those patients with motor 20:30.880 --> 20:33.329 neuron disease and those without motor neuron 20:33.339 --> 20:33.949 disease. 20:34.520 --> 20:35.040 However, 20:35.050 --> 20:37.689 there is a significant decrease in the CSF 20:37.699 --> 20:40.010 cyclic amp P compared to these patients. 20:40.390 --> 20:43.099 And there's a more grouping of these 20:43.109 --> 20:46.089 patients compared to a more wide range seen in 20:46.099 --> 20:46.969 other groups. 20:48.650 --> 20:51.300 In order to determine whether the cerebral spinal 20:51.310 --> 20:53.819 fluid cyclic nucleotide level 20:54.530 --> 20:57.390 was completely representative of what was going on in the central 20:57.400 --> 21:00.369 nervous system and did not reflect any changes 21:00.380 --> 21:02.060 in the plasma pool. 21:04.489 --> 21:05.439 We 21:07.239 --> 21:09.790 performed the 21:09.800 --> 21:12.020 following experiment in which we gave Glucagon 21:12.030 --> 21:14.709 infusions and raised the plasma 21:14.719 --> 21:16.979 cyclic A MP level 40 fold 21:18.479 --> 21:21.349 without changing the plasma cyclic GMP level. 21:21.359 --> 21:24.250 There was no significant difference between the 21:24.260 --> 21:26.959 elevations in patients with ALS compared to those 21:26.969 --> 21:27.699 without ALS, 21:28.709 --> 21:31.430 the CSF levels did not change at all during the whole 21:31.439 --> 21:32.920 period of observation 21:33.989 --> 21:34.829 significantly. 21:34.839 --> 21:35.540 However, 21:35.550 --> 21:37.979 the CSF glucose levels rose 21:38.239 --> 21:40.869 significantly in both groups to similar 21:40.880 --> 21:43.430 levels indicating that there was 21:43.439 --> 21:46.069 transfer of glucose into the cerebral spinal 21:46.079 --> 21:48.699 fluid at a time when there was no similar 21:48.709 --> 21:50.609 transfer of cyclic A MP. 21:50.979 --> 21:51.290 Thus, 21:51.300 --> 21:54.040 there is a significant barrier to 21:54.050 --> 21:56.589 cyclic A MP entry into the cerebral spinal 21:56.599 --> 21:59.459 fluid under physiological 21:59.469 --> 22:02.069 conditions such as we employed 22:02.079 --> 22:02.609 here, 22:03.229 --> 22:06.050 the main mode of egress for cyclic A MP from the 22:06.060 --> 22:08.959 plasma pool is to be excreted in the kidney. 22:09.969 --> 22:10.180 Now, 22:10.189 --> 22:13.099 this clearly established that the 22:15.810 --> 22:18.550 level of cyclic nucleotides was 22:18.560 --> 22:21.310 unique in our hands. 22:23.459 --> 22:26.130 And if we look at our formal data 22:26.140 --> 22:26.869 here, 22:27.319 --> 22:30.319 correlating the CSF level of cyclic amp and 22:30.329 --> 22:32.729 cyclic GMP in patients with muscle 22:32.739 --> 22:33.550 disease, 22:33.560 --> 22:35.209 peripheral nerve disease. 22:35.219 --> 22:37.670 To those patients with amyotrophic lateral sclerosis, 22:38.160 --> 22:40.900 we show here a significant decrease in 22:40.910 --> 22:43.890 both cyclic amp and cyclic GMP compared 22:43.900 --> 22:46.489 to patients with these other diseases. 22:47.239 --> 22:47.619 Indeed, 22:47.630 --> 22:50.280 patients with other central nervous system diseases such as 22:50.290 --> 22:51.229 multiple sclerosis, 22:51.239 --> 22:54.099 the level might be slightly increased compared to 22:54.109 --> 22:54.689 normal. 22:56.319 --> 22:59.170 This is important because of our recent studies 22:59.180 --> 23:01.290 involving the Wobbler 23:01.300 --> 23:02.209 mutant, 23:02.219 --> 23:05.119 which is a urine progressive spinal muscular 23:05.130 --> 23:05.790 atrophy, 23:06.489 --> 23:08.469 which is genetically based. 23:08.530 --> 23:11.530 We were able to show in conjunction with Dr David loss of the 23:11.540 --> 23:12.890 laboratory of neuro 23:13.420 --> 23:16.199 neuropathology that there 23:16.209 --> 23:19.089 is an 80% decrease in cyclic 23:19.099 --> 23:21.959 GMP in the spinal cord and brain stem 23:21.969 --> 23:24.079 of these patients of these 23:24.670 --> 23:25.439 mice. 23:25.449 --> 23:26.969 Compared to their literate 23:27.150 --> 23:28.469 controls. 23:28.500 --> 23:29.260 At the same time, 23:29.270 --> 23:32.160 there was no decrease in a neurotransmitter such as 23:32.319 --> 23:34.670 Gaba and high energy phosphate 23:34.680 --> 23:37.229 compounds showed no difference between 23:37.239 --> 23:39.599 control animals and those affected by the 23:39.609 --> 23:40.290 disease. 23:40.939 --> 23:41.430 Thus, 23:41.439 --> 23:44.239 motor neuron disease with anterior 23:44.250 --> 23:46.469 horn loss is associated 23:46.479 --> 23:49.369 uniquely with an abnormality in cyclic 23:49.380 --> 23:52.319 GMP concentration 23:52.329 --> 23:55.310 both in the tissue of animals and in the 23:55.319 --> 23:57.089 cerebral spinal fluid of man. 24:00.900 --> 24:02.439 To highlight this further, 24:02.449 --> 24:05.449 we employed a technique where we gave probenecid 24:05.459 --> 24:07.959 infusions to block the escape of cyclic 24:07.979 --> 24:10.150 nucleotide from the cerebral spinal fluid. 24:11.050 --> 24:13.900 Using an intravenous technique as recently described 24:13.910 --> 24:15.650 by doctors Ebert and Cartel. 24:16.589 --> 24:18.660 We were able to show that there is a 24:19.680 --> 24:22.069 increase in cyclic A MP 24:22.780 --> 24:24.849 at four hours after the infusion, 24:25.030 --> 24:27.599 which is maintained at eight hours after the 24:27.609 --> 24:28.339 infusion. 24:28.670 --> 24:31.239 In comparing patients with als to those 24:31.250 --> 24:33.239 with other neuromuscular disease, 24:33.250 --> 24:35.709 we can show that there is a decrease in the cyclic A 24:35.750 --> 24:37.770 MP turnover 24:39.180 --> 24:41.329 and in the cyclic GMP turnover. 24:41.339 --> 24:44.119 Although this is much more marked in the 24:44.130 --> 24:46.189 case of cyclic GMP turnover. 24:50.229 --> 24:52.910 In order to see whether we could change this in any 24:52.920 --> 24:53.530 manner, 24:53.540 --> 24:56.400 we employed a fossil dia inhibitor 24:57.040 --> 24:58.229 called the lasino, 24:58.420 --> 25:00.800 which does not block the adeno receptor. 25:01.290 --> 25:02.239 The Ayin and papaverine, 25:02.739 --> 25:04.939 which are well known drugs do block the adenosine 25:05.219 --> 25:08.150 receptor and do not allow positive feedback for the increase 25:08.160 --> 25:10.729 in cyclic amp and central nervous system tissues. 25:12.660 --> 25:15.079 By giving thol to patients with als, 25:15.180 --> 25:17.150 we were able to show a dose related 25:17.160 --> 25:20.119 increase in CSF cyclic amp 25:20.630 --> 25:23.410 but no significant change in C 25:24.180 --> 25:27.099 GMP plasma levels show no 25:27.109 --> 25:28.030 significant change. 25:28.040 --> 25:30.920 And we believe that it is because we're able to show that there is a 25:30.930 --> 25:33.650 rapid elimination of plasma cyclic 25:33.709 --> 25:36.430 amp from the 25:36.439 --> 25:37.719 plasma pool. 25:37.729 --> 25:39.349 After this drug is being given 25:41.020 --> 25:43.510 to see if there were any other effect of this 25:43.520 --> 25:46.290 drug on the transport of cyclic 25:46.449 --> 25:46.640 amp. 25:47.079 --> 25:49.739 We did probe infusion studies on patients 25:49.750 --> 25:51.810 before and after therapy. 25:52.160 --> 25:53.430 As we can see here, 25:53.439 --> 25:56.319 there is no significant alteration 25:56.420 --> 25:59.329 from the pre treatment level and those 25:59.339 --> 26:01.010 scraps that I showed previously. 26:01.239 --> 26:01.709 However, 26:01.719 --> 26:03.079 after treatment with thain, 26:03.569 --> 26:06.310 there is a significant increase in the CSF 26:06.319 --> 26:07.380 level of cyclic amp, 26:08.920 --> 26:11.810 cyclic GMP increases slightly but not statistically 26:12.319 --> 26:15.239 at this dose of 40 mg per kilogram. 26:15.790 --> 26:16.030 Thus, 26:16.040 --> 26:18.670 we're able to show a significant effect on cyclic A MP 26:18.680 --> 26:21.599 metabolism but not on cyclic GMP metabolism. 26:21.609 --> 26:24.040 And this possibly relates to the fact that the drug 26:24.060 --> 26:26.800 has a 10 fold greater inhibition of 26:26.810 --> 26:29.770 fossil dira for cyclic amp than GP. 26:31.420 --> 26:33.959 The exact locus for the drug action is 26:33.969 --> 26:34.560 unclear. 26:34.569 --> 26:37.510 Although when we take cerebral spinal fluid from patients with 26:37.520 --> 26:40.339 amy sclerosis and 26:40.349 --> 26:43.319 allow hydrolysis to proceed at room temperature at 26:43.329 --> 26:44.300 four degrees, 26:44.369 --> 26:46.959 it proceeds very rapidly for both cyclic GMP and 26:47.060 --> 26:49.630 cyclic cyclic amp and cyclic GMP. 26:49.839 --> 26:52.670 And the presence of thain is a temperature gradient and 26:52.680 --> 26:54.069 decreased hydrolysis. 26:54.329 --> 26:56.810 For cyclic A MP but not for cyclic 26:57.180 --> 26:57.430 GMP. 26:59.589 --> 26:59.989 In summary, 27:00.000 --> 27:02.359 then we are able to show that 27:02.369 --> 27:05.280 diseases affecting the anterior horn cell are 27:05.290 --> 27:07.910 correlated with decreased cyclic amp and cyclic 27:07.920 --> 27:10.560 GMP in the cerebral spinal fluid diseases 27:10.569 --> 27:13.479 affecting the nerve accent or the muscle 27:13.489 --> 27:16.310 are not similarly correlated with changes in 27:16.319 --> 27:17.420 CSF levels. 27:17.709 --> 27:20.569 And diseases affecting upper motor neurons may 27:20.579 --> 27:23.339 actually enhance or increase the level of the 27:23.349 --> 27:24.430 cyclic nucleotide. 27:25.989 --> 27:28.560 If I may spend a moment on hypothesis 27:28.569 --> 27:31.510 and exact locus of action for some 27:31.520 --> 27:32.219 of these things. 27:32.229 --> 27:34.880 I'd like to relate the observations of doctor 27:34.890 --> 27:37.609 Engle who has shown that a 27:37.680 --> 27:40.229 Neil cycles is 27:40.839 --> 27:43.510 correlated best with the vessels 27:43.890 --> 27:46.819 in the spinal cord and is 27:46.829 --> 27:49.670 much less prominent in the actual neurons. 27:49.920 --> 27:52.760 Most of the previous data showing that there 27:52.770 --> 27:55.479 is increased adniel cyclo 27:56.089 --> 27:58.869 and cyclic nucleotides in gray matter compared to 27:58.880 --> 28:01.569 white matter has been based on dissection studies 28:01.810 --> 28:04.630 and homogenates without clear 28:04.640 --> 28:06.530 cut histo chemical localization. 28:07.680 --> 28:08.989 As you can see here, 28:09.000 --> 28:11.719 the distribution of the anterior spinal artery is 28:11.729 --> 28:14.209 such that the anterior horn and the lateral 28:14.219 --> 28:17.079 column are in the distribution of this 28:17.089 --> 28:17.650 artery. 28:18.880 --> 28:21.010 If there is some way 28:21.579 --> 28:24.530 that disease affecting the vessels 28:24.540 --> 28:26.859 may somehow affect nutrition to the anterior 28:26.869 --> 28:27.689 horns, 28:27.699 --> 28:29.449 we may have some 28:30.199 --> 28:33.089 pathological substrate for the 28:33.099 --> 28:33.689 disease, 28:33.699 --> 28:35.510 amyotrophic lateral sclerosis, 28:35.560 --> 28:38.369 the distribution is the same and 28:38.380 --> 28:41.209 the findings would correlate with our biochemical 28:41.219 --> 28:41.849 findings. 28:42.849 --> 28:45.780 It is of interest that most 28:45.790 --> 28:48.760 recently we have been able to show there is increased 28:48.770 --> 28:51.239 Norine in the spinal fluid of patients with 28:51.250 --> 28:52.670 amyotrophic lao sclerosis. 28:52.680 --> 28:55.349 And how this relates to any possible small vessel 28:55.359 --> 28:56.670 abnormality is unclear. 28:57.800 --> 29:00.609 So these metabolic studies may point the way to some 29:01.410 --> 29:03.719 pathogenesis of the disease. 29:03.729 --> 29:05.579 The exact ideology is unclear, 29:05.829 --> 29:08.739 but we must remember that viruses can attack vessels 29:08.750 --> 29:11.689 and perhaps we can tie everything together in a 29:11.699 --> 29:14.020 similar fashion to Parkinson's disease. 29:14.079 --> 29:14.609 Thank you.