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General Admission: $85.00 Balcony Seating: $60.00
CLICK BELOW FOR FEATURE SUNTIMES STORY
https://chicago.suntimes.com/lifestyles/amy-and-pat-tomasulo-proving-laughter-and-love-really-can-be-the-best-medicine/
The Night’s Schedule
6:30 Doors Open, Silent Auction and Raffle *complimentary valet parking provided
7:00 Passed appetizers, Cash bar
8:00 Comedy show! Help us cure trigeminal neuralgia, and enjoy performances from PAT TOMASULO (WGN Morning News, Man of the People), ROCKY LAPORTE(Last Comic Standing, Tonight Show, Comedy Central), DREW FREES (Last Call with Carson Daly), JEANIE DOOGAN (Nick Jr's Moms Night Out), BRIAN "DA WILDCAT" SMITH (Shaq Allstar Comedy Competition), and other comedians to be announced, plus music from Chicago favorite JOHN VINCENT, passed appetizers from Tria Sorelle, and incredible silent auction and raffle prizes.
FACIAL PAIN RESEARCH FOUNDATION
2017 Research Progress
Submitted
April, 2018
By
Douglas K. Anderson, Ph.D.
Eminent Scholar Professor and Chair Emeritus
Department of Neuroscience
University of Florida College of Medicine
and
Director of Research and Trustee
Facial Pain Research Foundation
Trigeminal Neuralgia (TN), is a prime example of neuropathic pain which is pain caused by injury to or malfunctioning of the nervous system. TN is considered to be one of the most painful afflictions known to humans with debilitating effects on the activities of daily living of individuals with this painful condition. The cost neuropathic conditions like TN adds to the U.S. health care system is greater than $100 billion/year yet funding for research from federal agencies, primarily the National Institutes of Health (NIH) and pharmaceutical companies continues to be woefully inadequate. The meagerness of funding from traditional sources has led the growing realization that discovering the root cause of and treatment for TN and other neuropathic pain conditions is going to have to be accomplished with funding from the private sector. To this end, The Facial Pain Research Foundation (FPRF) was created in January, 2011 to provide the critical elements that are necessary and sufficient to study these facial pain conditions. Consequently, the sole mission of the FPRF is “…to establish a well-funded translational (i.e., fundamental discovery to clinical application) research continuum that is dedicated to identifying the mechanisms underlying neuropathic facial pain and to develop novel new therapeutic strategies that will permanently stop the pain of TN and related neuropathic pain syndromes”. Since its inception a little over six years ago, the FPRF has raised over $4 million dollars to support six separate and distinct research projects. The FPRF uses three fundamental criteria in choosing which proposals are to be considered for funding: (1) the projects are novel and unique; (2) the investigator(s) responsible for each project are among the leading researchers in their respective fields; and (3) all of the projects are not “cut from the same cloth”, i.e., there is significant diversification in the research strategies among the projects. It is important to note that these FPRF funds have also served in a multiplier capacity in that some of our investigators have used FPRF support as seed funding to generate the necessary preliminary data which contributed to these investigators acquiring large grants from the NIH and other foundations and, in some cases, the acquisition of venture capital. Total dollars from these other sources that came to our consortium of investigators emanating, all or in part, from FPRF seed funds, is estimated to be somewhere over $30,000,000. The purpose of this yearly update is to briefly summarize these six projects and to highlight the progress that each achieved in 2017.
“Investigating Protein-Lipid Interactions in Peripheral Nerve Myelin”
Lucia Notterpek, Ph.D. (Principal Investigator)
Professor and Chair Department of Neuroscience University of Florida College of Medicine
Progress report (Year 3): May 2017-April 2018
Project 1: Cholesterol homeostasis in peripheral nerve myelin
Study staff: Ye Zhou, MS, graduate student
With Ye Zhou, a graduate student in Dr. Notterpek’s laboratory leading the way this group continued to make excellent progress on this project during the past year. They gave presentations based on the results at several meetings. Also they have submitted a manuscript titled “Peripheral myelin protein 22 is necessary for ABCA1-mediated cholesterol efflux’’ to PNAS Plus. However this article as written was not accepted for publication. Consequently they are in the process of adding an additional data set to this manuscript and shortly will submit the revised paper to an alternative high impact journal.
Recent publications in the literature along with data from Dr. Notterpek’s lab continue to indicate that cholesterol homeostasis is critical for myelin stability in both the central (CNS) and peripheral (PNS) nervous systems. They are focusing on mechanisms that involve cholesterol trafficking within the cells and cholesterol efflux from myelin-forming cells, including the potential exchange of cholesterol between the nerve and Schwann cells. Their studies indicate that the concentration and localization of cholesterol is tightly regulated within myelin forming cells, as in the absence of proteins that are involved in this process, both mice and humans develop neuropathies. They are also working on understanding how the correct amount of cholesterol is maintained in the myelin membrane, which is critical for membrane stability. Peripheral myelin protein 22 (PMP22), whose haploin sufficiency is linked with a compression induced neuropathy (that often is painful), is critical and necessary for assuring cholesterol transport to the membrane. Utilizing neuropathic mice with PMP22 deletion and point mutation, they discovered that PMP22 regulates cholesterol homeostasis and trafficking via the interplay with ABCA1, the major cholesterol efflux transporter. Considering the positive effects of drugs that facilitate cholesterol transport such as 2-hydroxypropyl-β-cyclodextrin (HβCD) in CNS myelination, along with the likely interaction between PMP22 and cholesterol (see below), they treated nerve explants from PMP22-deficient neuropathic mice with HβCD and found improvements in the myelination capacity of the affected cells in response to drug treatment, as compared to untreated samples. These studies will need to be repeated, but are leading us them toward potential therapeutic approaches on how abnormal levels of cholesterol in myelin could be corrected.
In another set of cellular/molecular studies, they have now identified the exact amino acid motif in PMP22 that likely binds cholesterol and are in the process of finalizing this study for publication. Related to this aspect of the project, Dr. Notterpek is in discussion with a membrane biophysicist at Vanderbilt University who has an assay to monitor the incorporation of normal and cholesterol-binding mutated PMP22 into lipid micelles and are working toward coordinating and/or combining their findings with his for publication purposes. Working with another University of Florida scientist, Dr. Habibeh Khosbouei, they discovered that critical properties of the glial membrane, such as membrane resistance and capacitance, change when the levels of cholesterol are abnormal, e.g., as occurs when PMP22 is deficient. To the best of their knowledge, no one else has performed similar single cell electrophysiological recordings of Schwann cells causing great excitement in the lab because understanding how abnormal membrane-associated cholesterol levels alter the ability of myelin to protect the axon and guide membrane depolarization (neuronal activity), are critical and fundamental aspects of neurobiology. Moreover, Dr. Notterpek’s group is continuing their investigation of the impact of dietary cholesterol on peripheral myelin health using mice with different genetic backgrounds, and discovering strong impact of genotype and gender on the response of the animals to a high fat diet. These studies are at various stages of sample and data analysis which when completed will serve as the foundation for future grant applications to the NIH.
Presentations in poster format
Zhou Y, Lee S, Miles J, Tavori H, Fazio S, Notterpek L. “A novel interaction between PMP22 and ABCA1 in regulating cholesterol trafficking”. This was presented at the 2018 Neurochemistry meeting.
Bazick H, Zhou Y, Salihi Mohammed, Fritz R, Tavori H, Fazio S, Notterpek L. “Investigating the impact of high fat diet-induced dyslipidemia on neuropathic mice.” This will be presented at the 2018 peripheral nerve society meeting
Budget expenditures:
We have about $50,000 left of the total budget for this project, which I would like to extend into the 4th year to allow for Ye to finish her studies and graduate. Dr. Notterpek’s focus will have to be on getting this project funded from the NIH.
Project 2: Cholesterol homeostasis in peripheral nerve myelin, with a focus on statins
Year 1: May 2017-April 2018
Mohammed Al Salihi, MD, PhD, postdoctoral fellow is key investigator on this project
Myelin, a lipid-rich multilayered membrane made by oligodendrocytes (in CNS) or Schwann cell (in PNS), insulates axons and facilitates the transduction of neuronal signals (1). In the brain, cholesterol contained in myelin accounts for about 80% of total brain cholesterol with approximately 25% of the unesterified cholesterol of an entire adult mouse brain located in myelin, Cholesterol, therefore, plays an important role in the nervous system and is essential for brain and neuronal function (2). Statins are lipid lowering agents that are used in the treatment of dyslipidemia (abnormally elevated cholesterol or fats lipids in the blood) that contributes to the development of atherosclerosis. Thus, statins are used to reduce the risks of cardiovascular diseases due to atherosclerosis (3). According to the Centers for Disease Control and Prevention (CDC) and National Center for Health Statistics (NCHS), the usage of statins has increased from 16.3% to 23.2% between the years 2003 to 2012 in adults aged 40 and over, with Simvastatin being the most commonly used cholesterol lowering medication. The primary mechanism of action of statins is the inhibition of the HMG-CoA reductase enzyme, which is the rate limiting step in cholesterol biosynthesis (6). Despite the fact that statins have similar mechanism of action and the same effects on cholesterol profiles, they can be divided into 2 categories: Type 1, which are fungal derived statins, like Lovastatin, Pravastatin and Simvastatin; and Type 2, which include synthetically derived statins like Atorvastatin and Fluvastatin (3). There is a controversy regarding the effect of statins on peripheral nerves. Currently it is debated whether statins alleviate or aggravate neuropathic pain, and/or whether they cause the neuropathic pain. With these largely clinical observations as background, Dr. Nottterpek has developed the hypothesis that in certain individuals, statins alter the stability of myelin making it susceptible to a localized compression-induced demyelination with a subsequent painful neuropathy.
In order to test this hypothesis, they chose statins from each group and are testing their effects on cultured Schwann cells. Their results demonstrated that regarding cellular toxicity, the cells were still viable after 24h exposure to 500 uM of statins, however, morphologically they became rounded and started to lift up from the plate. In collaboration with Dr Khoshbouei’s laboratory, they were able to show that inhibiting cholesterol synthesis by statins altered the Schwann cell membrane electrical resistance, this effect being statistically significant even at low doses such as 1 and 2 μM. These studies are very novel and will likely be controversial. Nonetheless, this approach allows them to examine the impact of cholesterol lowering drugs on Schwann cell biology at a cellular detail that was previously not possible.
Dr. Al Salihi is also testing the effect of statins on myelination of neurites in vitro and has found that statins lead to the fragmentation of myelin basic protein-positive myelin segments, an effect that is reproducible. In statin treated cultures, they also detected pronounced changes in the expression of various proteins related to myelination and are now trying to understand the mechanism for these effects. Notably, when HMGCoA is inhibited by statins, some cholesterol transport proteins go down, while the levels of PMP22 robustly increase. Although at present they do not understand the mechanism for this effect, the data supports our overall hypothesis that PMP22 is critical in the maintenance of lipid homeostasis in myelin-forming glial cells.
As an extension to this work, in the animal models they are “walking back” from the peripheral nerves into the CNS and will begin to examine how the neuronal cell bodies and surrounding CNS microenvironment may sense/respond to ongoing chronic peripheral myelin defects. In summary, Dr. Al Salihi is having had a good start to his postdoctoral training, he learned many of the techniques used in the laboratory and he is continuing to read and learn the literature.
Budget expenditures:
We have used about $110,000 of the total $360,000 budget (with $180,000 from FPRF and $180,000 from MBI over 3 years) for this project. The expenditures include salary and supplies.
References:
- Snaidero N, Mobius W, Czopka T, Hekking LH, Mathisen C, Verkleij D, et al. Myelin membrane wrapping of CNS axons by PI(3,4,5)P3-dependent polarized growth at the inner tongue. Cell. 2014;156(1-2):277-90.
- Saher G, Stumpf SK. Cholesterol in myelin biogenesis and hypomyelinating disorders. Biochim Biophys Acta. 2015;1851(8):1083-94
- McFarland AJ, Anoopkumar-Dukie S, Arora DS, Grant GD, McDermott CM, Perkins AV, et al. Molecular mechanisms underlying the effects of statins in the central nervous system. Int J Mol Sci. 2014;15(11):20607-37
- Ovbiagele B, Schwamm LH, Smith EE, Hernandez AF, Olson DM, Pan W, et al. Recent nationwide trends in discharge statin treatment of hospitalized patients with stroke. Stroke. 2010;41(7):1508-13
- Qiuping Gu et al. Prescription Cholesterol-lowering Medication Use in Adults Aged 40 and Over: United States, 2003–2012. NCHC Data Brief. 2014. No. 177
- Schachter M. Chemical, pharmacokinetic and pharmacodynamic properties of statins: an update. Fundam Clin Pharmacol. 2005;19(1):117-25
“Mapping Towards a Cure: Identification of Neurophysiologic Signatures of Trigeminal Neuralgia Pain.”
John K. Neubert, D.D.S., Ph.D., University of Florida (Project coordinator, animal modeling)
Mingzhou Ding, Ph.D., University of Florida (Human imaging)
Marcelo Febo, Ph.D., University of Florida (Animal imaging)
Robert M. Caudle, Ph.D., University of Florida (Therapeutics)
Todd Golde, M.D., Ph.D. (Gene Therapy)
This team of outstanding investigators at the University of Florida (UF) Colleges of Dentistry, Medicine, and Engineering and Evelyn F. and William L. McKnight Brain Institute (MBI) under the guidance of Dr. John Neubert continues to focus on identifying the neurophysiological signature of TN pain and providing promising new therapies. This group represents expertise in facial pain, functional imaging, molecular biology, pharmacology, and viral vectors.
This integrated project is investigating the cause of TN in both animals (rats) and humans. The purpose of this translational study is to determine if trigeminal injury models in rats replicates or is very similar to the neurobiology of TN in humans. Using state of the art magnetic resonance (MR) scanners and behavioral testing equipment, the UF team will identify and compare the individual imaging patterns caused by the activation of different areas in the brain and spinal cord in both TN patients and rats. These specific areas of the brain and spinal cord are called “signature centers of activity” that are activated by TN pain and present as targets for the new therapies their team is developing. In 2017, Dr. Neubert’s team made significant progress towards completing the goals of this project.
Identifying trigeminal nerve signaling within brainstem nerve tracts and brain regions is of utmost importance, as this will lead to novel therapies directed to relevant trigeminal targets designed to block TN pain. Dr. Neubert’s team of investigators already has access to existing therapies that they speculate will be successful in blocking TN pain and they evaluated some of these therapeutics this year (see below in Animal Studies). The human studies have identified brain regions important for both the genesis and processing of pain following a TN episode. Importantly, they have found critical brain regions that interact together in a network describe sites, interaction of networks, and inflammation.
HUMAN STUDIES
|
TN |
Control |
TN with surgery |
TN without surgery |
TNI |
TNII |
TNI/TNII |
|
28 |
3 |
12 |
16 |
17 |
3 |
8 |
- Recruitment (Table 1)
Twenty-nine TN patients (17 females) and three age and sex matched controls have been recruited and analyzed to date. One patient had surgery and no longer felt pain and was not scanned and 6 new subjects have been scanned but not analyzed yet and are not included in this report.
- Brain Activations during Trigeminal Pain
Figure 1. Brain regions activated during trigeminal pain.
Taking pain ratings while doing fMRI scans allow us to uncover brain regions that are activated during trigeminal pain. As shown in Figure 1, there are many regions involved with the processing of pain. The identification of such brain regions serves as the first step toward finding central-nervous system targets for effective therapeutic interventions in TN.
3. Novel MRI Analyses 
We have implemented novel analyses looking at neuroinflammation in the brain and completing machine learning methods for evaluating different structures that may be important for producing pain in TN subjects (Figure 2). The results suggest that structural MRI and diffusion MRI contain different information about the pathology of TN. This is an important as this information may translate into identification of comprehensive therapeutic targets and development of individualized pain therapies based on brain signatures.
ANIMAL STUDIES
- Trigeminal Pain and Neuroimaging
Dr. Febo’s group has completed approximately 50 high-resolution fMRI scans of rats with various orofacial pain conditions and treated with different therapeutic agents. The data generated is both huge and complex and presenting all of the data is beyond the scope of this report; as such, we are presenting some of the more relevant and exciting findings. Figure 3 demonstrates that animals with trigeminal nerve injury show increased neural-connectivity in pain sensitive structures within the brain. This is important because we will start comparing the human and rat imaging results to assess overlap of thesebrain regions following trigeminal pain.
Figure 3. Brain connectivity is altered with trigeminal nerve injury. Nerve injury (CCI) produces increased brain connectivity in the brain.
- New trigeminal nerve injury model and novel therapy
Figure 4. Novel CGRP-BoTox treatment targets trigeminal neurons. The red-stained structures represent the cell bodies of trigeminal neurons that were treated.
To address the issue of relating animal-to-human comparisons, we have improved our methods for inducing trigeminal nerve pain in rats (and mice). We were successfully in producing a trigeminal injury that has some of the same qualities as TN, such as touch sensitivity. This is exciting as it may provide a more robust and stable trigeminal nerve injury model. Dr. Caudle’s group has successfully designed and tested a novel therapy (CGRP-Botox) to specifically target and silence pain neurons. They have completed the in vitro (in cells) work and demonstrated the treatment is specific for sensory (pain) neurons (Figure 4) and we are now testing this treatment in rats. This is significant because if successful for blocking neuropathic pain in the animal studies, then we will continue development as a future therapeutic for TN patients.
Viral-directed therapies
In a pilot study with Dr. Golde’s group, they have also used a fluorescently-labelled vector to demonstrate that they can specifically target the trigeminal system. This is important because they are confident that they have a strategy for treating trigeminal disorders, a finding they hope will allow them to enter the Phase 2 treatment studies sooner than initially thought.
Limitations. Dr. Neubert’s team continues to have issues regarding subject enrollment and staffing difficulties. The FPRF has generously provided addition funding to increase enrollment and we have hired a research assistant to coordinate recruitment and have been working with Dr. Michael Pasternak of the FPRF to help spread the word that additional subjects are needed. The EEG & MRI animal studies were unsuccessful. We were not able to overcome EEG hardware failures and reliability was unproven.
Plans for the no cost extension period. Due to subject recruitment and staffing issues, we were unable to complete the proposed studies within the 3-year period. With permission of the FPRF and UF, we extended the project to a no cost extension period (2018-2019) that will allow us to use the remaining funds to complete the project.
- Recruit and scan 25-30 more TN1 subjects.
- Evaluate compounds from Dr. Golde’s and Dr. Caudle’s laboratories for pain relief.
- Dr. Febo’s group will continue to analyze the animal imaging data set.
“The William H. and Leila A. Cilker Genetics Research Program to Find a Cure for Trigeminal Neuralgia”. (“Finding the Genes that Predispose to Trigeminal Neuralgia”)
Investigators listed alphabetically
Kim J. Burchiel, M.D.
Professor Department of Neurosurgery
Oregon Health and Science University
Marshall Devor, Ph.D Professor and Chair
Department of Cell and Animal Biology
Institute of Life Sciences
Hebrew University of Jerusalem
Scott R. Diehl, Ph.D.*
Professor, Department of Oral Biology, Rutgers School of Dental Medicine
Professor of Health Informatics, Rutgers School of Health Related Professions
Rutgers University
Ze’ev Seltzer, Ph.D.
Professor of Pain Genetics
Faculty of Dentistry
Professor of Physiology
Faculty of Medicine
University of Toronto
*Genetics Project Coordinator
This project asks the question: Are some individuals genetically predisposed to develop trigeminal neuralgia (TN) pain? This question emanates from research which shows that although 17% of mature adults have a TN lesion (usually a vascular compression of the trigeminal nerve close to where it exits the brain) only a very small minority (0.01-0.2%) of these individuals actually experience TN pain. The disconnect between lesion and pain is an important clue pointing toward a genetic weakness for TN. Other research shows that more than one third of patients with TN do not have vascular compression of the nerve, and the rare patients with bilateral TN do not generally have vascular compression of the nerve on both sides! Further, it appears that younger patients (less than 45 years of age) are four times more likely to be women, than men. All of these new findings point to the possibility of a genetic predisposition for TN.
This project was conceived with the assumption that the risk for having classical TN has a genetic basis and the study’s primary objective is identifying genetic mutation(s) (aka, sequence variant(s) or polymorphism(s) associated with the development of TN pain. To date, the genetic material (DNA) of 348 TN1 patients has been searched at over a million places where people are known to differ from one another in their DNA letters (A, T, G or C). On average, any two people have about five million DNA differences between them. Most differences have no effect on health, but some cause or predispose to disease. The challenge is to find the “needles in a haystack” that cause TN1, hidden among the millions of differences with no relation to TN1. This is done by comparing DNA of TN1 patients (cases) with that of people who do not have TN1 (controls).
Initial results have pointed to several regions in the human genome with promising evidence they harbor genes causing TN1. Some regions include only one gene, but there are 17 genes in the genome region with the strongest statistical support, including 3 genes with biological functions involving nerve degeneration, excitability of neurons or responses to nerve injury. These genes are strong suspects, but to determine which genes actually cause TN1 more genetic data are needed, including a new approach using high speed DNA sequencing, before the initial promising findings are ready for testing in animals or translation to the clinic.
These investigators will first check that the DNA differences observed between TN1 patients and controls aren’t simply due to chance, but occur because mutations in the regions actually cause TN1. To do this, they will repeat the experiment a second time and see if they get the same results. They will analyze a new set of TN1 patients and controls, more than doubling the total sample size. If the same genome regions are again different in TN1 patients compared to controls (like lightning striking in the same place twice), this replication will confirm that TN1 disease-causing genes are indeed located there. It’s very unlikely that all of the initially positive regions will be supported by the new data, but even if only one region is strongly confirmed this will be an extremely important advance, not only for TN1 but for neuropathic pain in general.
Moreover, it is not enough to just find regions of the genome that harbor genes that cause TN1 – it’s also necessary to identify the specific genes and mutations that cause the genes to biologically malfunction. This information is essential for translation to new therapies. Some mutations that cause TN1 may be extremely rare, found only in TN1 patients and their close relatives. To discover additional TN1 genes and TN1-causing mutations, including those that are very rare, the investigators will use the latest technologies for “reading” the DNA sequence of the entire human genome in a select subset of 100 TN1 patients. This expanded data set will enable the investigators to ask several very important questions such as: Do different genes cause TN1 in young patients versus those who experience their first symptoms when older? Are there different genetic effects in males versus females? Do different genes cause TN1 in patients without any vascular compression of their trigeminal nerve compared to patients with nerve damage from years of compression?
The findings obtained thus far suggest that the genetics approach may reveal TN1 clinical subtypes that currently are phenotypically indistinguishable. This has been found in numerous other neurological conditions including the epilepsies and ataxias, where mutations in different genes cause different clinical symptoms. Progress towards a cure (or, more likely, “cures”) will surely be more rapid and have greater chance of success if built on a foundation of knowledge about what is really going on biologically in different TN1 patients rather than forced into a “one size fits all” therapeutic approach. This is a one year project with a target of late Spring 2019 for full completion.
“Cell Replacement Therapy as a Treatment for Injury-Induced Neuropathic Pain”
Allan Basbaum, Ph.D., FRS
Professor and Chair
Department of Anatomy
University of California San Francisco
As described in a previous report, Dr. Basbaum’s laboratory has developed a powerful new approach to reversing the abnormal hyperexcitability that underlies many neuropathic pain conditions including trigeminal neuralgia. Although there are many explanations for the hyperexcitability that occurs after nerve injury, Dr. Basbaum’s laboratory has focused on the loss of inhibitory controls interposed between the peripheral nerve fiber input and the central nervous system circuits that transmit that input to the brain where pain is perceived. There is now considerable evidence that the loss of inhibitory control results from a significantly reduced function of a population of nerve cells that synthesize the inhibitory neurotransmitter, GABA. With these findings confirmed, Dr. Basbaum’s group took on the task of developing a strategy for rebuilding those lost or dysfunctional circuits. They chose a transplant paradigm and, to date, have documented the survivability and functionality of precursors of GABA nerve cells that have been transplanted into the spinal cord of a mouse model of neuropathic pain created with a hindlimb peripheral nerve injury. Results reported in a series of publications from Dr. Basbaum’s laboratory established that these nerve cells integrate incredibly well into host spinal cord circuits and restore inhibition, the result of which is a near complete loss of the hyperexcitability of spinal cord neurons and most importantly of the mechanical hypersensitivity that occurs in this neuropathic pain model.
Building upon these studies, Dr. Basbaum and his team have now turned their attention to a chemotherapy-induced neuropathic pain model. it is significant that Dr. Basbaum’s group has shown that these GABA precursor cell transplants can also reduce both the mechanical and thermal hypersensitivity that occurs after chemotherapy treatment.
Dr. Basbaum continues his exciting studies with mouse transplantation of progenitor cells, which have the ability to develop into functioning GABAergic inhibitory nerve cells. Previously, his laboratory demonstrated that transplantation of these cells into the spinal cord can overcome the mechanical hypersensitivity that occurs in a mouse model of peripheral nerve injury-induced neuropathic pain. Their new studies, in a chemotherapy-induced neuropathic pain model, are built on the scientific literature indicating that dysfunction of inhibitory circuits in the anterior cingulate cortex (ACC) is a major contributor to the affective (aversive), but not the sensory-discriminative features (mechanical hypersensitivity), of the pain experience. As after spinal cord transplants, they found that the transplants integrated into the host cortical circuits and profoundly inhibited host neurons. As predicted, mechanical hypersensitivity, which they believe is processed at the level of the spinal cord, was not reduced. However, the cortical transplants did block the animal’s preference for a pain-relieving drug (gabapentin). From these findings they conclude that selective and long lasting inhibition of the ACC can reduce the ongoing pain and aversiveness that contribute to neuropathic pain’s most negative influences on quality of life. In ongoing studies, Dr. Basbaum’s laboratory, in collaboration with scientists at Neurona, are evaluating the utility of transplanting human embryonic stem cells that have been modified to take on properties of GABAergic nerve cells. Those studies are critical first steps in the development of an approach to treatment clinical pain conditions.
Neurona Therapeutics
Cory R. Nicholas, PhD Co-Founder and Chief Scientific Officer; Neurona Therapeutics Assistant Professor, Adjunct; University of California, San Francisco
Neurona was conceived in 2008 to realize the therapeutic potential of neuronal cell-based therapy. The rationale for pursuing this translational effort was based on many years of rigorous scientific discovery. In the late 1990’s, co-founders John Rubenstein, MD, PhD, and Arturo Alvarez-Buylla, PhD, were among the first to demonstrate that interneurons, a type of nerve cell, in the cerebral cortex mostly originate from precursor cells in the medial ganglionic eminence (MGE), a transient structure during fetal brain development. In these early studies, MGE cells were isolated from fetal mouse brain and injected into the brains of post-natal mice. In contrast to other neural stem and progenitor cells from neighboring fetal brain regions that remained as large cellular masses post-injection, the MGE cells rapidly dispersed away from the injection site and appeared to seamlessly integrate into juvenile and adult mouse recipient brain tissue. The injected MGE cells appropriately matured into various sub-lineages of cortical interneurons that secreted GABA, the major inhibitory neurotransmitter in the central nervous system. Electrophysiology confirmed these cells to be functional neurons that both received and formed synapses, validating their integration post-transplant. The interneurons persisted long-term following transplantation. Moreover, the transplanted interneurons augmented functional inhibition in the brain regions where they were placed. Therefore, MGE interneuron precursor cells had unique properties that could be advantageous if developed into a transplantation cell-based therapeutic. These cells could potentially provide targeted inhibition to hyper-excitable neural networks in relevant neurological disorders. Rather than acting as a transient point source of GABA or a drug pump, the injected interneuron precursor cells integrated into neural circuitry, possibly allowing for stable repair of the injured nervous system.
All of the studies above were performed with mouse MGE interneuron precursor cells. However, a human cell source is required to facilitate the translation of an interneuron therapeutic for patients. Since the MGE structure disappears before birth and human interneurons in the adult brain are not accessible, they turned to human pluripotent stem cell (hPSC) lines. These hPSC lines can be expanded to meet clinical demand and can be coaxed into becoming virtually any cell type in the body. They developed methods to direct hPSCs into the MGE-type interneuron lineage in petri dish cell cultures. These human interneurons produced in petri dishes were then isolated and provided to collaborators at UCSF for testing in many of the preclinical animal models described above. Encouragingly, Dr. Basbaum found that version 1.0 of the human interneurons also could reduce pain hypersensitivity in the sciatic nerve injury mouse model. Arnold Kriegstein, MD, PhD, in collaboration with another laboratory, next demonstrated that the human interneurons mitigated neuropathic pain and bladder dysfunction following spinal cord injury in mice. Thus they believe that multiple neurological disorders are associated with interneuron dysfunction and/or imbalances in neuronal activity. Because they do not innately regenerate, stem cell technology is required to generate inhibitory interneurons to re-balance the nervous system. Technology to produce human interneurons was developed at UCSF using research-grade stem cell lines, materials, and methods. The company is now tasked with extending this work and developing clinical-grade product candidates. They have assembled an all-star team of 35 researchers from around the world to advance this technology toward the clinic and have made tremendous progress and continue to passionately pursue regenerative neuronal cell-based therapies with the potential to successfully treat patients who have neurological disorders.
Evaluation of adeno-associated virus (AAV) constructs directed at pain pathway targets – a rapid approach for identification of effective therapies for trigeminal neuralgia
Principal Investigators (PIs):
Todd E. Golde, M.D., Ph.D., University of Florida (Therapeutics)
John K. Neubert, D.D.S., Ph.D., University of Florida (Behavioral pain testing)
Other Significant Contributors:
Yona Levites, Ph.D., University of Florida (Therapeutics)
Robert M. Caudle, Ph.D., University of Florida (Behavioral pain testing)
The FPRF is pleased and excited to add Todd Golde,M.D., Ph.D. to the outstanding international group of investigators that comprises the FPRF scientific consortium. Dr. Golde is a professor in the Department of Neuroscience at the University of Florida Colllege of Medicine and Executive Director, University of Florida McKnight Brain Institute. His is recognized as an international thought leader in the general research areas of neurodegeneration and neuroinflamation. In 2017 Dr. Golde submitted a proposal to the FPRF entitled “Evaluation of adeno-associated virus (AAV) constructs directed at pain pathway targets – a rapid approach for identification of effective therapies for trigeminal neuralgia” The purpose of Dr. Golde’s project is to investigate novel viral-based delivery therapeutics that will be aimed at specific targets within the pain processing network. He hypothesizes that advances in specific gene-targeting vectors will allow for the rapid identification of potential therapies for the treatment of trigeminal neuralgia (TN). Importantly, Dr. Golde’s team already has expertise in designing and testing viral-based delivery systems in established pain animal models. Not only is testing new therapies in animal models absolutely mandatory before considering their use in humans, animal testing of new therapeutic approaches can be used as a way of rapidly screening for therapies with significant efficacy to block and/or cure TN pain.
The primary objective of this project is to design and synthesize a number of viral vectors directed at specific genes related to pain processing and then determine which of these constructs are safe and the most efficacious in doing so…initially in animals. Further, he posits that in addition to determining safety, this approach should decrease the time needed to discover novel new therapies for the treatment of TN. Dr Golde’s team will utilize established expertise in Adeno Associated Virus (AAV) delivery systems to evaluate the effectiveness of these vectors for reducing pain.
Since gene therapy is a central character in this program perhaps a review of the fundamentals of gene therapy would be in order to assure that everyone has some understanding of this technology.
Viruses are simple organisms consisting primarily of viral DNA encased in a protein coat. In order to make a viral construct that can be used to introduce corrective DNA.
In to animals/humans, it is necessary to first remove the wild-type viral DNA leaving only the protein coat. Without its wild-type DNA, this viral protein shell can serve as a modified delivery system or a viral vector. Placing exogenous therapeutic genes into the empty protein shell creates what is termed a viral construct. When these viral constructs are injected into the brain, spinal cord, trigeminal ganglion, etc., the therapeutic genes are released into the interior of cells through existing receptors in the cell membrane because the viral protein shell can alter its structure and lock on to these vacant receptors. The therapeutic DNA can either integrate with the cell’s native DNA or remain as an independent strip of DNA and either way will produce the desired protein product in the injected tissue. In short, gene therapy or delivery is the use of a viral construct to put in a copy of a gene that replaces a missing or defective gene; overproduces a protein that promotes cell growth and/or is “protective”, e.g., can control pain; and bioengineer stem cells and other types of cells to produce missing or protective proteins.
Dr. Golde has designed a solid, well thought out strategy for attempting to identify genes that are involved in TN pain. Based upon the published findings from other laboratories in addition to his own, Dr Golde has chosen six AAV constructs to test that represent a number of different targets within the pain-sensing system. His initial strategy are proposing to attack both excitatory and inhibitory pathways – an inhibition of excitatory signals or an enhancement of inhibitory pathways is expected to produce pain relief. While the goals and the experimental design used to achieve these goals are major strengths of this application, what excites me about this application is the intended consequence of the very real possibility of using Dr. Golde’s gene therapy expertise and technology to determine if gene(s) identified by our genomics team are causally related to the genesis of TN pain or merely an epiphenomena. The genes they identify and then replicate to confirm should be genes directly associated with TN pain. Using gene therapy technology, these candidate genes can either be eliminated (knocked out)or added back (knocked in) depending on whether TN pain is caused by excessive excitation or loss of inhibition. Dr. Golde and his team with their considerable expertise in designing and synthesizing AAV constructs for identifying specific genes related to pain processing and then, using accepted animal pain models, determine which of these constructs are the best at limiting TN pain could play an important and pivotal role in moving from the discovery of candidate genes to determining their functional role in the genesis of TN pain.”
“Novel Ways to Deliver Compounds That Can Eliminate the Pain of Trigeminal Neuralgia”
Wolfgang Liedtke M.D., Ph.D.
Professor
Department of Neurology
Duke University
In 2015, Dr. Wolfgang Liedtke approached the Facial Pain Research Foundation (FPRF) with a proposal to develop novel techniques for direct anatomic targeting of specific components of the trigeminal system. The primary advantage of this approach is with delivery of the drug directly to the lesioned area, only a small fraction of the normal systemic dose of the drug will be needed thereby eliminating the unwanted side effects associated with systemic or whole body delivery of the drug. While, development of techniques that allow for the direct delivery of therapeutic substances to the diseased or injury site is laudable and needed, often the proposed strategy is highly speculative using materials and delivery systems in new and untested ways, Without an indication in the way of solid preliminary data that the proposed system will work as advertised, a speculative proposal not supported by positive preliminary findings submitted to federal funding agencies (NIH, VA), drug companies, and venture capitalists would in all likelihood would be DOA. Thus, in order to get the seed funding needed to acquire important preliminary data demonstrating that either he or his co-investigators have the necessary expertise to perform the proposed experiments and that the approach espoused by Dr. Liedtke stands a good chance of being successful. To this end Dr. Liedtke submitted a proposal for seed funding that after review, was recommended for funding to the FPRF Board of Trustees BoT who subsequently awarded him a one year $50,000 seed grant to initiate his program.
To develop his very unique and innovative delivery system, Dr Liedtke proposes to combine material science with cell engineering. This idea of blending a unique porous material to encase specially engineered cellular pumps will provide focused delivery of molecules or drugs that have previously shown the capacity to block or eliminate pain in other models and/or primitive models of TN pain. Thus, the objective of his approach is to deliver molecules that have displayed the capacity to shut down transmission of the aberrant neuronal signals arising from injured site(s) on the trigeminal system. These little assemblies are designed to be placed around peripheral trigeminal nerve branches and around the trigeminal nerve root at the point where this root exits the brainstem. The experiments described in this proposal are based on previous work by Dr. Liedtke and collaborators using a specifically-created kind of carbon nanomaterial, i.e., a few-walled carbon nanotubes with high electrical conductance that has been highly purified to the point that it is devoid of any neurotoxic contaminating by-products
Dr. Liedtke also proposed to develop another variant of a topical drug delivery vehicle, i.e., one that will be made of immunologically inert biocompatible polymers designed to hold human fibroblast-like cells. Using gene therapy techniques, Dr. Liedtke proposes to replace the native DNA from a wild-type virus with genes harvested from fibroblasts (which are readily obtainable from skin) that code for pain inhibiting substances like GABA or glycine. This switch in genetic material will should effectively reengineer the fibroblasts turning them into anti-pain generating pumps. The biocompatible polymer devices will prevent the cells from dispersing but will be made sufficiently porous to allow the pain inhibiting molecules to escape. Dr. Liedtke’s complete progress reports are on file with the FPRF and are available upon request.
Dr. Liedtke has made good progress in developing his delivery systems given that his starting point was very close to the bottom of the development curve for both device. His future plans include using these two approaches to deliver substances to the . cisternal trigeminal nerve root in an attempt to create a valid pre-clinical model of TN which can then be used to obtain the necessary and sufficient pre-clinical data to move these two technologies towards clinical studies. Finally, Dr. Liedtke has indicated a desire to leverage these preliminary findings (collected with funding from the FPRF) to acquiring a substantial NIH grant or additional funding.
THANK YOU PAT AND AMY TOMASULO
AND CHICAGO
LAUGH YOUR FACE OFF RAISED OVER $700,000!!!
NEXT LAUGH YOUR FACE OFF MAY 5, 2018
BY MICHAEL PASTERNAK
When Pat and Amy started Laugh Your Face Off to raise funds for research to find the cures for trigeminal neuralgia and related neuropathic pain they never knew how successful they would be in both raising funds and bringing hope to thousands of people suffering from the most painful condition known to humankind. All six of the research projects funded by the FPRF have benefitted greatly from their wonderful efforts. On behalf of the Research Foundations Trustees, Volunteers, and those in pain Thank you Pat and Amy Tomasulo.
They have raised over $600,000 in Chicago and they are just beginning. This year the show will double in size, and Amy Tomasulo and their team of Volunteers are planning the best Laugh Your Face Off ever! Because of the huge turn-out in past years to see outstanding nationally known comedians, they are moving to a new Chicago location able to seat twice as large an audience. Last year tickets for LYFO sold out in five days!! On May 5, 2018 the LYFO will be held at the Park West, Located in scenic Lincoln Park, a few blocks from Lake Michigan, and just minutes from downtown Chicago. Park West is surrounded by numerous hotels, exciting night life, retail stores, and a fabulous park with Chicago's Lincoln Park Zoo. Ticket information will be available after the New Year. May is a beautiful month in Chicago! Pat and Amy hope that TN patients, their families, and friends can enjoy LYFO and Chicago! Hoping for a huge TN family and friends gathering!
After three years of hosting Laugh Your Face Off many people in the Chicago area know that WGN-TV Sports Anchor Pat Tomasulo's wife Amy has the rare TN pain disorder. Beyond the comedy events Pat and Amy attend the Foundations Trustee Meetings and Scientific Meetings. Amy has written Newsletters for Foundation and both have assisted others in raising funds for the research.
Those who wish to join the list of LYFO sponsors please contact This email address is being protected from spambots. You need JavaScript enabled to view it.
Research Update
More Than A DNA-Genetics Project
By Michael Pasternak
I have received numerous emails regarding the recent WebNewspaper article and report about the Foundation’s DNA/Genetics Research Project. I have also received a continuous flow of questions about the progress of other Foundation research projects. Each April, Dr. Douglas Anderson prepares a report to share with everyone and will do so in 2018. But, because of the large numbers of requests here is a brief update which will create even more questions from you, our wonderful supporters. And yes, the goal of The Facial Pain Research Foundation has been to find cures by the end of 2020 and it still is! As soon as any of the projects move into human studies we plan on informing everyone.
First, the Genetics/DNA Project: We now have a team of scientists who have worked hard using their unique skills and understandings and have presented a report to our Trustees and asked to go forward to replicate the study during the next year to prove that what they have found are really the genes that will lead us to finding the cures. We have put in print their non-technical report in the WebNewspaper. We will NOT report ALL that we know until the study is replicated and proves what we know. Yes, not everything we know is in the non-technical report. Our scientists have seen far too many research journal articles that prematurely announced findings that could not be replicated. I assure you that the Foundation is not about to spend $325,000 in the next year to prove that we have found the genes responsible for trigeminal neuralgia if our scientific team didn’t believe we are on the edge of reporting great findings.
The money to pay for our Foundation’s research has great character and integrity. It comes from thousands of Volunteers who have been involved in grass-roots efforts to find the cures.
We are only funding research that is novel and unique, the investigators responsible for each project are among the leading researchers in their respective fields, and there is significant diversification among the projects…and we believe that they will succeed.
Second, Researching Stem Cell Replacement Theory: This is one of the primary research approaches targeted and supported by the FPRF since its inception. This unique therapeutic approach involves the transplanting cells that produce pain inhibitory neurotransmitter(s) that can suppress the devastating pain of TN. The chief Investigator of this approach is Allan Basbaum at the University of California San Francisco. These studies have developed to the extent that they contributed to the formation of several new companies that have developed the concept of transplantation of cells that produce inhibitory neurotransmitters in animals and are being developed to be used in humans for the management of different neurological conditions that appear to arise from loss of inhibition with an emphasis on trigeminal neuralgia. Elizabeth Cilker-Smith and I have been invited to visit with the 34 scientists working at Neurona, Inc in San Francisco in a few weeks to discuss their progress and we will also meet with Dr. Basbaum and the scientific team at CODA to get further progress reports. Frankly, I’m expecting excellent progress.
Third, Investigating Peripheral Nerve Myelin: “They are working on making myelin.” They are also trying to develop the necessary processes that would assist people in strengthening and repairing the damaged myelin. An intact myelin sheath is necessary for the proper functioning of the nervous system. Dr. Lucia Notterpek and her team’s overall goal is to define specific protein-lipid interactions, with a focus on PMP22, and cholesterol in the establishment and maintenance of lipid membrane domains in the peripheral myelin. In the absence of PMP22, myelin is prone to compression-induced damage leading to localized myelin injury. For completing the aims of the project they are using cultured cells and nerves from normal and PMP22-deficient mice and engineered molecular constructs. It is exciting to visit Dr. Notterpek’s lab and view the activity in the microscopes. This is hard basic research.
Fourth, Mapping Toward A Cure: Dr. John Neubert, the Lead Investigator at the McKnight Brain Institute and is team has been very active in recruiting volunteers to have their brains scanned to investigate the cause of TN in both animals and humans. Knowing where the pain in the brain is occurring and exploring the compounds and other substances that can block the
pain pathways to the brain signature centers will be a great achievement. We need over 50 volunteers to prove scientifically the imaging aspects and the project is well past the 50 percent mark. More volunteers are scheduled for the next few weeks and we will make another announcement for additional Volunteers in mid-March. While the imaging of humans continues there is also animal imaging and substance testing in the laboratory. The goal is to complete the imaging before the end of 2018.
Fifth, Delivering Compounds That Can Eliminate The Pain: or a Dr. Wolfgang Liedtke calls it
“Not Science Fiction”
In a “nutshell” what we have is a most unusual way to deliver substances (cells) at the base of the brain that stops neuropathic pain from entering the brainstem.!!
Dr. Liedtke has submitted his most recent report to the Foundation and has made a request for continuing the research that would lead to stopping the pain. We are unable to share his findings with the public right now…but it has great merit. Sometimes research is unique and proprietary. State tuned!
Sixth, Gene Therapy to target pain: The Facial Pain Research Foundation’s newest
research project launched in the Fall of 2017 with the goal to be completed in 2-21/2 years.
Dr. Todd Golde and his research team (google Todd Golde!) have added new professionals to the lab and launched to project to find the cures.
Please feel free to call me regarding our research progress.
Thank you for your great support and interest in our research.
Michael Pasternak, Ph.D., Founding Trustee
This email address is being protected from spambots. You need JavaScript enabled to view it.
352-377-1437
Editor’s Note
Todd E. Golde, M.D., Ph.D., is executive director of the Evelyn F. and William L. McKnight Brain Institute of the University of Florida. He oversees neuroscience and neuromedicine research programs across the University of Florida campus. A professor of neuroscience and neurology, Dr. Golde joined the University of Florida faculty in 2009 and became founding director of the university’s Center for Translational Research in Neurodegenerative Disease, which he led until taking charge of the McKnight Brain Institute in December 2016. He is also director of the NIH funded 1Florida Alzheimer’s disease Research Center group of institutions.
An internationally known expert in the scientific understanding of Alzheimer’s disease, Dr. Golde has published more than 240 papers that have been cited more than 30,000 times, (https://scholar.google.com/citations?user=X_9xacsAAAAJ&hl=en), and has expanded his leading-edge research to include other neurodegenerative diseases, cancer and even malaria. He is lead investigator for the Facial Pain Research Foundation’s Gene Therapy Research Project, at the University of Florida, to find the cures for TN.
Dr. Golde spoke with Mervyn Rothstein, who was a writer and editor at The New York Times for nearly 30 years and now writes the Stage Directions column – a series of interviews with theater directors – for Playbill.com. His first symptoms of trigeminal neuralgia occurred in 2005.
Mervyn Rothstein Interviews
Todd Golde
How and why did you become Involved In the “World” Of Scientific Research?
TG: I’ve loved biology from as far back as I can remember. The real catalyst was when I was in my junior year in college. I didn’t know what I was going to do. I was thinking about going back and teaching at a boarding school for a while before I figured out what I was going to do with my life. But I was a biology major at Amherst College and I took a course with a professor named Richard Goldsby, a wonderful teacher, who was basically teaching a graduate level course to undergraduates. We had to write a term paper, a research-hypothesis type paper, the first time I’d had to do that in college, and the response back was that this was one of the best papers he’d read in many years, undergraduate or graduate. Please come talk to me. I think you might like to do research.
Your laboratory conducts disease oriented research with specific, but not exclusive focus on neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease. How did you get involved in developing a research project to find a cure for Trigeminal Neuralgia and related neuropathic pain?How did the development of this research project come about, and what motivated you to take on the leadership role?
TG: I make no claims about being a facial pain or trigeminal neuralgia expert. I’m just thinking opportunistically about how we can make a difference. When I came to the University of Florida, I was the founding director of the Center for Translational Research in Neurodegenerative Disease. The chair of the department of neurology at that time had hired somebody named Dr. Andy Ahn. Andy worked on headache and pain, and the director needed a place for him. I had some space at that time, so Andy was a scientific neighbor, and we would have discussions.
The University of Florida is one of the hotbeds in the world in terms of a gene therapy approach based on adeno-associated viral vectors – we call it AAV for short. A former dean actually discovered this virus. One of our senior faculty members participated in creating the first gene therapy vectors around it. My lab had already been using AAV vectors, but we doubled or tripled down when we came to the University of Florida. AAV has a naturally affinity to get into neurons.
So Andy sort of triggered this, but my bandwidth was stretched at that point – it’s still stretched. I kept on tweaking Andy to go down this road. Andy left academics, and at some point I said I should do this.
We felt it could be something that could be rapidly translatable. Finding a cure for trigeminal neuralgia is a huge unmet medical need, but it’s an orphan disease that doesn’t affect enough people to attract a huge amount of attention.
There’s a chance for harm if we get into humans, but the nice thing about working with trigeminal neuralgia is we can at least start our initial studies in humans in people whose next option is surgical ablation of the trigeminal nerve. That means that there’s an out if we actually happen to make people worse. When we do these kinds of trailblazing experiments or envision them in humans, we need to make sure that if something could go wrong we have a way out.
Now we’ll begin the animal phase of study – testing in animals. And I know how much this research can really affect people’s lives. It may not work, but we have everything in place to test it. So let’s try.
If Gene Therapy isn’t new, why do you believe that it can work to block pain signaling in the nerve?
TG: It really comes down to technical details. People have used the wrong vectors before that had their own liabilities. I honestly just don’t think people have thought that much about this approach.
Last year, gene therapy had its first really radical major success outside of the eye, which was with children who had a disease called spinal muscular atrophy (SMA). They were treated systemically with a AAV vector – a different flavor of the same thing. These kids basically get spinal motor neuron degeneration when they’re young, by the time they’re two years old, typically, they die. Fifteen children were treated with huge amounts of virus, and reports last October showed that every one of these kids was alive at two years of age. And those with high-dose vectors, many of them were almost asymptomatic. At that age the expected survival rate would have been eight percent. So there are some children walking and living normal lives after gene therapy who otherwise would be most likely dead.
So I think that was a turning point in the field, to say this, AAV-based gene therapies, really will have its place in modern medicine. And that study in SMA was much more heroic and much more challenging than what we envision. So I think the time’s right. We know we can deliver the gene to the nerve. So now it’s just finding the right gene that will dampen pain signaling in that set of neurons, hopefully without doing harm.
Supposing your theory and project is proven successful. What implications or lessons wil this work provide for other researchers?
TG: I think it would say that perhaps the gloves come off on gene therapies for many disorders, especially things that are targeting nerve cell dysfunction.
Because of the Hippocratic Oath – physician, do no harm – we need an out, so we wouldn’t want to go and do this on intractable sciatic nerve pain. Because what happens if you make them worse – you can’t cut their sciatic nerve without serious implications.
But I think success could open up the door to many different approaches targeting pain. And given the current opioid epidemic, driven from people at least initially taking these medications to treat chronic pain – (whether that’s right or wrong or medically appropriate is another question) – I think this viral approach enables us to deliver the medicine or treatment precisely to the cells or organ or nerve and hopefully avoid the systemic side effects that would come from taking a pill or an antibody or other approaches.
And ultimately, I think it could also be relatively affordable. We’re jubilant about a medical success when a new treatment comes out for a previously incurable or untreatable disorder, especially when it shows a huge impact – for instance, something that saves somebody from a cancer that was previously untreatable. And then you dig in and find what the price tag of that therapy is and you go oh, my God, can we afford that as a society? So you never know – I wouldn’t be the person to set a price if we potentially have a therapy for this – but at least the development cost associated with this could be dramatically lower than development costs typically for current small-molecule therapies or for current biologic therapies like antibodies.
For getting to a phase one trial for initial proof of concept in man, often just the investment is $30 million or $50 million, just for the goods, to make enough of the drug and have the safety testing of it. We think we could probably do this now for $5 million or $10 million, but I expect that cost, especially for very limited diseases, to come down much lower in the future. And that would be transformative.
The final thing is that pretty much the therapy that we find in the laboratory, we might tweak it a little bit along the way as we move it toward a human study, but it’s pretty much the same as we would use in a human. Often that’s not the case with any other type of therapies – what I do in a mouse model, for example, has to be tweaked so much. I think this would be a huge advantage.
When do you envision (or hope) that gene therapy treatments for neuropathic pain {including Trigeminal Neuralgia) will be ready for use in humans?
TG: I think we have about a year to find out whether we can make a go/no go decision in our animal models. If everything goes well, it’s reasonable to say that will be about a year.
Then there are a whole lot of factors that will go into answering the question “can you take something from a laboratory to get into a human clinical trial?” In the best-case scenario, that would take about a year. That’s if everything aligned. That means you have to have investors, funding, a production method. Two years would be very, very optimistic. Three years would be more realistic.
What are the biggest obstacles you face in translating your preclinical findings to the clinic?
TG: Something untoward that you can’t predict – unexpected toxicities, for example. Also, funding. For less than $200,000 we think we can actually figure out what a lead therapeutic agent might look like – if I and my colleagues have been smart enough to come up with the right thing. Then you take an exponential leap of costs in terms of everything you have to do to get into humans. You’re not going to do that probably in something like this for less than multiple millions of dollars. Many, many agents need tens of millions of dollars to get through what they call the valley of death. And they call it that for a lot of reasons – many things can go wrong. You never know. So it’s just the unknowns. This is pioneering in many ways. There’s not necessarily even F.D.A. guidance for things like this. You’d have to be the trailblazer.
The Facial Pain Research Foundation is moving forward with a sense of urgency to find cures for Trigeminal Neuralgia and related facial pain. Why have you linked your efforts to such a new organization in the field of pain research? And what is the importance of this Trigeminal Research Study and what potential is there for having an impact on the study of other diseases and possible cures?
TG: Well, Michael Pasternak’s a persuasive guy.
We’re doing some really neat science in multiple areas, and I could spend my life doing things that are just neat science. But I’ve always felt that I’d like to see the fruits of my scientific labors actually make a difference for a patient. I think they have in some ways in terms of the mass contribution to our understanding of Alzheimer’s disease and therapies, but I can’t say that that was my therapy that’s actually being used in a patient.
I think maybe it’s a little bit of hubris, but I think we have the right people at the right time sitting around a table with enough resources to address an area of a huge unmet medical need on the individual level. If we can make an impact in a very noninvasive and permanent treatment for trigeminal neuralgia, then perhaps we can expand that in a big way to take on many local pain syndromes using essentially the same methodology.
Every day people in pain are contacting The Facial Pain Research Foundation asking if it is truly possible to find a cure for Trigeminal Neuralgia and related facial pain. How would you respond to their questions? And how can patients in pain help scientists like yourself work toward the cures?
TG: The more people that get engaged, the more people are aware, the better things will be. We have gained a huge amount of knowledge over the years about pain signaling and receptor biology. And one way to help is to philanthropically support us. Benefactors can provide that seed funding that can open up science that’s in the shadows. We’re doing stuff with gene therapy here in terms of a pre-clinical tool or moving it toward therapeutics in cancer or for brain disease, but I hadn’t really thought about applying it for trigeminal neuralgia. Those two have sort of come together, and maybe we’ll take this from science in the shadows to being science right under the streetlight that will now become a common way to move therapies forward for nerve disorders.
Some Trigeminal Neuralgia patients are fearful that we may never find a cure and are fearful to try risky surgeries. What encouraging words do you have for these people?
TG: I think the encouraging words are that what we’re trying here is a very precision-medicine approach. We’re trying to target the molecular pathways of pain signaling very specifically within a nerve so that we can perhaps block that pain signaling, and do so in a minimally invasive way and do so potentially permanently. Will it work on everyone? I can’t guarantee that. But if we can do something where we can reduce pain levels on average 90 percent and we can do so nine times out of ten, I’d take those odds. And I’m pretty confident that we can make an impact. I don’t know how big that impact will be and I don’t know if in the initial versions we can make this as precise as I’d like. But that’s what we’re going to try to address over the next year. Conceptually, this is pretty straightforward. Things can always go wrong. Science can be really humbling. I thought that when we figured out the trigger of Alzheimer’s disease or at least laid the groundwork for what we think is the trigger of Alzheimer’s disease in the early 1990s that we’d be a lot farther along in treating that disease. But that’s not where we’re at.
You are considered an outstanding scientist, Director of UF McKnight Brain Institute. What keeps you awake at night?
TG: I run a big lab. I have multiple collaborators. I have employees dependent on rewards linked to producing successful science. We live hand to mouth every year. We’re dependent on Alzheimer’s funding from the state of Florida. We are dependent on grants to keep the science moving forward and my staff employed. I am tenured, it’s hard to get rid of me, but if we don’t have funding, the team around me might have to find employment elsewhere. That’s what I worry about. We’re always fighting for enough funds to make this happen, and advance our science that might benefit patients in some way.
Neurona Therapeutics Joins
The Facial Pain Research Foundation
Consortium
Cory R. Nicholas, PhD
Co-Founder and Chief Scientific Officer; Neurona Therapeutics
Assistant Professor, Adjunct; University of California, San Francisco
Dr. Cory Nicholas is Chief Scientific Officer at Neurona Therapeutics. Prior to co-founding Neurona, Dr. Nicholas was a faculty member in the Department of Neurology at the University of California, San Francisco where his research program was focused on investigating the ontogeny of human cortical interneurons. Dr. Nicholas pioneered methods to derive interneuron precursors from human pluripotent stem cells for transplantation into multiple animal models of neurological disease. He maintains an adjunct faculty appointment at the University. Dr. Nicholas’s post-doctoral studies were conducted at UCSF. His pre-doctoral work at both UCSF and Stanford University investigated germ cell development from primordial germline and pluripotent stem cells. He received his Bachelor’s degree from the University of California, Berkeley. Prior to his interest in stem cell and developmental biology, Dr. Nicholas was a member of the research team at Sugen.
Neurona Therapeutics
Neurona was conceived in 2008 to realize the therapeutic potential of neuronal cell-based therapy. The rationale for pursuing this translational effort was based on many years of rigorous scientific discovery. In the late 1990’s, co-founders John Rubenstein, MD, PhD, and Arturo Alvarez-Buylla, PhD, were among the first to demonstrate that interneurons, a type of nerve cell, in the cerebral cortex mostly originate from precursor cells in the medial ganglionic eminence (MGE), a transient structure during fetal brain development. In these early studies, MGE cells were isolated from fetal mouse brain and injected into the brains of post-natal mice. In contrast to other neural stem and progenitor cells from neighboring fetal brain regions that remained as large cellular masses post-injection, the MGE cells rapidly dispersed away from the injection site and appeared to seamlessly integrate into juvenile and adult mouse recipient brain tissue. The injected MGE cells appropriately matured into various sub-lineages of cortical interneurons that secreted GABA, the major inhibitory neurotransmitter in the central nervous system. Electrophysiology confirmed these cells to be functional neurons that both received and formed synapses, validating their integration post-transplant. The interneurons persisted long-term following transplantation. Moreover, the transplanted interneurons augmented functional inhibition in the brain regions where they were placed. Therefore, MGE interneuron precursor cells had unique properties that could be advantageous if developed into a transplantation cell-based therapeutic. These cells could potentially provide targeted inhibition to hyper-excitable neural networks in relevant neurological disorders. Rather than acting as a transient point source of GABA or a drug pump, the injected interneuron precursor cells integrated into neural circuitry, possibly allowing for stable repair of the injured nervous system.
To investigate the therapeutic potential of interneuron cell transplantation therapy, we first injected mouse MGE precursor cells into multiple rodent models of epilepsy, Parkinson’s, and Alzheimer’s disease. Although their etiologies are largely unknown and progression is divergent, these disorders can be associated with neural hyper-excitability and have overlapping co-morbidities. We collaborated with preclinical animal model experts in these disease areas, and, indeed, we found that the injected cells were effective. The injected MGE cells matured into inhibitory interneurons and virtually eliminated seizures, improved motor function, and reduced cognitive impairments, respectively.
In each of these animal models, the MGE cells were injected into forebrain regions where MGE-type interneurons would normally reside during endogenous brain development. To our surprise, the MGE cells also integrated into ectopic regions of the central nervous system, regions they do not normally populate during development. In collaboration with Allan Basbaum, PhD, mouse MGE cells were injected into the mouse spinal cord where they matured into inhibitory cortical-type interneurons and synapsed with resident spinal cord neurons. The mouse MGE cells were next injected into the mouse spinal cord after a sciatic nerve injury. Sciatic nerve injury produces chronic neuropathic pain that is associated with a loss of GABAergic inhibitory tone in key sensory pathways. This loss of inhibition leads to hyper-excitability of sensory neurons that send pain signals to the brain. The delivery of GABAergic inhibitory interneurons into the spinal cord was able to provide missing inhibition, rebalance sensory circuits, and suppress pain hypersensitivity. The transplanted interneurons achieved a complete rescue, reducing pain sensitivity to pre-injury levels without any observable side effects. Rather than a transient treatment of symptoms, the interneuron cell therapy was truly disease modifying by addressing the underlying pathophysiology of neuropathic pain following the administration of a single dose of cells. In addition, the disease modifying activity persisted long-term for six months post-transplantation, as long as was studied in a mouse. Dr. Basbaum’s laboratory has subsequently shown that interneuron cell therapy can be similarly effective at rescuing experimental pain hypersensitivity in mice following trigeminal nerve-injury or chemotherapy.
All of the studies above were performed with mouse MGE interneuron precursor cells. However, a human cell source is required to facilitate the translation of an interneuron therapeutic for patients. Since the MGE structure disappears before birth and human interneurons in the adult brain are not accessible, we turned to human pluripotent stem cell (hPSC) lines. These hPSC lines can be expanded to meet clinical demand and can be coaxed into becoming virtually any cell type in the body. We developed methods to direct hPSCs into the MGE-type interneuron lineage in petri dish cell cultures. These human interneurons produced in petri dishes were then isolated and provided to collaborators at UCSF for testing in many of the preclinical animal models described above. Encouragingly, Dr. Basbaum found that version 1.0 of the human interneurons also could reduce pain hypersensitivity in the sciatic nerve injury mouse model. Arnold Kriegstein, MD, PhD, in collaboration with another laboratory, next demonstrated that the human interneurons mitigated neuropathic pain and bladder dysfunction following spinal cord injury in mice.
Based on this body of work, Drs. Rubenstein, Alvarez-Buylla, Kriegstein, and I officially launched Neurona Therapeutics in early 2015 to develop neuronal cell-based therapeutics, starting with interneurons. We have assembled an all-star team of 35 researchers from around the world to advance this technology toward the clinic. We believe that multiple neurological disorders are associated with interneuron dysfunction and/or imbalances in neuronal activity. Because they do not innately regenerate, stem cell technology is required to generate inhibitory interneurons to re-balance the nervous system. Technology to produce human interneurons was developed at UCSF using research-grade stem cell lines, materials, and methods. The company is now tasked with extending this work and developing clinical-grade product candidates. We have made tremendous progress and continue to passionately pursue regenerative neuronal cell-based therapies with the potential to successfully treat patients who have neurological disorders.
The Facial Pain Research Foundation
Dr. Michael Pasternak and Elizabeth Cilker Smith introduced me to the Foundation. They were familiar with Neurona’s efforts from our collaboration with Dr. Basbaum. I was immediately impressed with the progress being made by the Foundation, its ability to raise important research dollars, and the selective investment of those funds into breakthrough facial pain research efforts that are making critical advances. I was equally struck by Michael and Beth’s passion, dedication, and determination to find a cure - attributes undoubtedly shared by all who contribute and volunteer at the Foundation and responsible for its success thus far.
Neurona and the FPRF share a bold vision to achieve pain-free disease modification. Neurona’s mission is, in part, an extension of Dr. Basbaum’s work funded by the FPRF. We continue to develop a human inhibitory interneuron therapeutic for the treatment of neuropathic pain syndromes. We are pleased to be formally acquainted with the Facial Pain Research Foundation and look forward to an ongoing relationship.
Genetics Study
Finds Genes That Cause
Trigeminal Neuralgia
Introduction by Michael Pasternak
In 2012 The Facial Pain Research Foundation approved a research study to find the genes responsible for trigeminal neuralgia.
While each of our Foundation’s scientific projects are valuable, the one that has been the most awesome and challenging for me has been the Genetics/DNA project. Dr. Doug Anderson (FPRF Director of Research) and I have had to communicate with scientists from four different countries (including Joanna Zakrzewska in London) and Collection Centers in 9 different cities in three countries! Doug has spent months on this project “everyday”! He has also had to communicate with additional scientists interested in our efforts and has done this while still overseeing the creation and development and evaluation of all of our Foundation’s other projects! How did we and he get so lucky?
While Doug has overseen and worked through the science some of our other Volunteers have been involved in working with the DNA Collection Centers, working through intellectual property problems, legal questions, raising the funds to pay for all of this, communicating to patients to give their DNA, creating PR pieces for the public to participate, keeping track of collection numbers, certifying completion of collections and data sent to OHSU and Rutgers, and making payments to the Collection Centers for their efforts. This project has been an enormous accomplishment. No Volunteer Foundation or organization has ever done this before! All completed while we grew our outstanding scientific project numbers to six and linked with two venture capital funded research projects.
The FPRF has spent over $650,000 of funds raised by our Volunteers and donors on this project. The FPRF Trustees have committed another $325,000 to complete the project in the next year.
So, now we have a team of scientists who have worked hard using their unique skills and understandings and have presented a report to our Trustees and asked to go forward to replicate the study during the next year to prove that what they have found are really the genes that will lead us to finding the cures. The Cilker Genetics/DNA Research Report has arrived. It is remarkable. We are extremely thankful to Drs. Devor, Burchiel, Seltzer, Diehl and Anderson for all of their voluntary efforts to create these findings. We are also truly thankful for Our Trustees and all of our Volunteers who helped raise the necessary funds to complete the tasks. This is an exciting time for all of us committed to ending the pain for all TN and related neuropathic sufferers.
The Following is a Non-Technical Summary Report…The detailed full Scientific Report has been presented to the Foundation Trustees and contains confidential information. It will be confidential until the replication of findings has been completed. Following the report is an article by Dr. Scott Diehl for general distribution.
Genome-Wide Association Study
Of Trigeminal Neuralgia Type 1 (TN1)
The William A. Cilker and Leila A. Cilker
Research Project
A Report Prepared for the Board of Trustees of the Facial Pain Research Foundation by Kim J Burchiel, MD (Oregon Health and Science University), Marshall Devor, PhD (Hebrew University of Jerusalem), Scott R Diehl, PhD (Rutgers Biomedical Health Sciences), and Ze’ev Seltzer, DMD (University of Toronto)
Findings and Future Plans – Non-Technical Summary
The main goal of our study is to find genes that cause “Classical” Trigeminal Neuralgia Type 1 (TN1). This information will help clinician-scientists find cures that relieve patients’ severe chronic pain or prevent it from developing. Thus far, we’ve searched the genetic material (DNA) of TN1 patients at over a million places where people are known to differ from one another in their DNA letters (A, T, G or C). On average, any two people have about five million DNA differences between them. Most differences have no effect on health, but some cause or predispose to disease. Our challenge is to find the “needles in a haystack” that cause TN1, hidden among the millions of differences with no relation to TN1. We do this by comparing DNA of TN1 patients (cases) with that of people who do not have TN1 (controls).
Our initial search focused on 348 Caucasian TN1 patients, a modest sample size for human genetic studies today. Nevertheless, we are delighted to report discovery of several regions in the human genome with promising evidence they may harbor genes causing TN1. Some regions include only one gene, but there are 17 genes in the genome location with the strongest statistical support, including 3 with biological functions involving nerve degeneration, excitability of neurons or responses to nerve injury. These genes are strong suspects, but to determine which genes actually cause TN1we need a combination of: a) more genetic data of the kind we have already been gathering, and b) information from a complementary approach that uses high speed DNA sequencing. This further research is absolutely necessary before our initial discoveries are ready for testing in animals or translation to the clinic.
First, we must be absolutely certain our TN1 patients and controls do not happen to be very different by chance alone, but that the DNA differences occur because mutations hidden in the regions actually cause TN1. To do this, we will repeat our experiment a second time and see if we get the same results. We will analyze variation across the human genome for a new set of TN1 patients and controls using the most advanced genomic assays now available, more than doubling our sample size. If the same genome regions are again different in TN1 patients compared to controls (like lightning striking in the same place twice), this replication will confirm that TN1 disease-causing genes are indeed located there. Some regions have initial statistical support stronger than others, so these are more likely to be confirmed, but only by doing the assays and carefully evaluating what the data tell us will we know for sure which regions are confirmed. We do not expect all of our initially positive regions to be confirmed, but even if only one region is strongly confirmed this will be an extremely important advance, not only for TN1 but for the entire biomedical field of neuropathic pain in general. 2 Submitted January 3, 2018
Moreover, it is not enough to just find regions of the genome that harbor genes that cause TN1 – we also have to identify the specific genes and mutations in these genes that cause them to biologically malfunction, as this information is essential for translation to new therapies. It is possible that some of the mutations that cause TN1 are extremely rare, found only in TN1 patients and their close relatives. To discover additional TN1 genes and TN1-causing mutations, including those that are very rare, we will use the latest technologies for “reading” the DNA sequence of the entire human genome in a select subset of our TN1 patients. This method is called Next Generation Sequencing (NGS), and we propose to perform this assay for 100 TN1 patients.
Combining our previously-studied as well as our new TN1 cases gives us a sample of approximately 900 TN1 cases, of mostly Caucasian racial origin but with some non-Caucasians included too. Combining these with a similar number of controls will provide us with substantially increased statistical power to ask several very important questions such as the following: Do different genes cause TN1in young patients versus those who experience their first symptoms when older? (We already started to ask this first question in a limited way in the first phase of our research and with a larger sample can address this more rigorously.) Are there different genetic effects in males versus females, as found in many other genetic diseases? Are there different genes causing TN1 in the (typically younger) patients without vascular compression of their trigeminal nerve compared to patients whose trigeminal nerve has been damaged by years of vascular compression?
Our research may lead to a more complex picture of TN1 as being caused by not just mutations of just one gene, but in fact mutations found in several different genes may be associated with various subtypes of TN1. Genetics may reveal TN1 clinical subtypes that we currently do not even recognize exist, as has been found in numerous other neurological conditions including the epilepsies and the many forms of ataxia caused by different genes. While our primary goal remains identifying gene mutations that cause TN1, the research described here for the next phase of our study may also identify genetically distinct subgroups of TN1 patients as a very important secondary benefit of our genetic approach. Progress towards a cure (or, more likely, “cures”) will be more rapid and have greater chance of success if it is built on a foundation of knowledge about what is really going on biologically in different TN1 patients rather than if forced into a “one size fits all” therapeutic approach.
Project Timeframe: With adequate funding all research can be completed within one year. 3 Submitted January 3, 2018
Genetics Study Brings Precision Medicine
To Trigeminal Neuralgia
By Scott Diehl
The Genetics Study team supported by the Foundation has completed a search of over one million locations in the DNA of 348 Trigeminal Neuralgia (TN) patients. This “Big Data” effort has pointed to genes affecting excitability of neurons, nerve degeneration and responses to nerve injury. These genes are very strong suspects, and the team will now gather additional information from more patients and from a complementary approach that uses high speed DNA sequencing.
In the team's next effort, these genes will be tested in a new set of TN patients.
If the same results are found again, this replication will be like lightning striking in the same place twice and confirm that mutations in these genes cause TN in some patients. These next steps are essential to confirm the initial findings and they may also reveal additional genes not detected with a strong enough signal in the initial search. Once confirmed, these discoveries will then be ready for testing in animals and translation to patients in the clinic.
The genetics data gathered thus far are painting a complex picture of TN as being caused by not just mutations in any one gene. It appears more likely that several different genes are involved in different patients, a phenomenon known as “genetic heterogeneity.” For example, one of the most strongly supported genes is important only for TN patients whose symptoms first appeared after age 55. A different gene with different biological functions is implicated in patients who developed TN at a younger age. Genetic heterogeneity has been found in other neurological conditions including the epilepsies and the many forms of ataxia caused by different genes. This strategy, known as Precision Medicine, is a major US and International effort getting underway focusing on nearly all human health problems today (https://allofus.nih.gov/).
While the primary goal of the genetics study is to identify gene mutations that cause TN, this research may also identify genetically distinct subgroups of TN patients as a very important secondary benefit. Progress towards a cure (or, more likely, “cures”) will be more rapid and have greater chance of success if built on a foundation of knowledge about what is really going on biologically in different TN patients rather than if forced into a “one size fits all” therapeutic approach.
The Genetics Study Team supported by the Foundation is an international collaboration of leaders in the fields of neurosurgery, pain biology and human genetics at Oregon Health and Science University (Dr Kim Burchiel), The Hebrew University of Jerusalem (Dr Marshall Devor), the University of Toronto (Dr Ze’ev Seltzer) and Rutgers School of Dental Medicine (Dr Scott Diehl). Numerous additional locations have provided valuable assistance with recruiting patients.