Category Archives: Neurology & Psychiatry

Kuru continues to inform

Neurologists of my generation were fascinated with Kuru, a disease of the (formerly) obscure Fore tribe of New Guinea. Who would have thought they would tell us a good deal about protein structure and dynamics?

It is a fascinating story including a Nobelist pedophile (Carleton Gajdusek) https://en.wikipedia.org/wiki/Daniel_Carleton_Gajdusek and another (future) Nobelist who I probably ate lunch with when we were both medical students in the same Medical Fraternity but don’t remember –https://en.wikipedia.org/wiki/Stanley_B._Prusiner

Kuru is a horrible neurodegeneration starting with incoordination, followed by dementia and death in a vegetative state in 4 months to 2 years. For the cognoscenti — the pathology is neuronal loss, astrocytosis, microglial proliferation, loss of myelinated fibers and the kuru plaque.

It is estimated that it killed 3,000 members of the 30,000 member tribe. The mode of transmission turned out to be ritual cannibalism (flesh of the dead was eaten by the living before burial). Once that stopped the disease disappeared.

It is a prion disease, e.g. a disease due to a protein (called PrP) we all have but in an abnormal conformation (called PrpSc). Like Vonnegut’s Ice-9 (https://en.wikipedia.org/wiki/Ice-nine) PrPSc causes normal PrP to assume its conformation, causing it to aggregate and form an insoluble mess. We still don’t know the structure of PrPSc (because it’s an insoluble mess). Even now, “the detailed structure of PrPSc remains unresolved” but ‘it seems to be’ very similar to amyloid [ Nature vol. 512 pp. 32 – 34 ’14]. Not only that, but we don’t know what PrP actually does, and mice with no PrP at all are normal [ Nature vol. 365 p. 386 ’93 ]. For much more on prions please see https://luysii.wordpress.com/2014/03/30/a-primer-on-prions/

Prusiner’s idea that prion diseases were due to a protein, with no DNA or RNA involved met with incredible resistance for several reasons. This was the era of DNA makes RNA makes protein, and Prisoner was asking us to believe that a protein could essentially reproduce without any DNA or RNA. This was also the era in which X-ray crystallography was showing us ‘the’ structure of proteins, and it was hard to accept that there could be more than one.

There are several other prion diseases of humans (all horrible) — mad cow disease, Jakob Creutzfeldt disease, Familial fatal insomnia, etc. etc. and others in animals. All involve the same protein PrP.

One can take brain homogenates for an infected animal, inoculate it into a normal animal and watch progressive formation of PrPSc insoluble aggregates and neurodegeneration. A huge research effort has gone into purifying these homogenates so the possibility of any DNA or RNA causing the problem is very low. There still is one hold out — Laura Manuelidis who would have been a classmate had I gone to Yale Med instead of Penn. n

Enter [ Nature vol. 522 pp. 423 – 424, 478 – 481 ’15 ] which continued to study the genetic makeup of the Fore tribe. In an excellent example of natural selection in action, a new variant of PrP appeared in the tribe. At amino acid #127, valine is substituted for glycine (G127V is how this sort of thing is notated). Don’t be confused if you’re somewhat conversant with the literature — we all have a polymorphism at amino acid #129 of the protein, which can be either methionine or valine. It is thought that people with one methionine and one valine on each gene at 129 were somewhat protected against prion disease (presumably it affects the binding between identical prion proteins required for conformational change to PrPSc.

What’s the big deal? Well, this work shows that mice with one copy of V127 are protected against kuru prions. The really impressive point is that the mice are also protected against variant Creutzfedlt disease prions. Mice with two copies of V127 are completely protected against all forms of human prion disease . So something about V/V at #127 prevents the conformation change to PrPSc. We don’t know what it is as the normal structure of the variant hasn’t been determined as yet.

This is quite exciting, and work is certain to go on to find short peptide sequences mimicking the conformation around #127 to see if they’ll also work against prion diseases.

This won’t be a huge advance for the population at large, as prion diseases, as classically known, are quite rare. Creutzfeldt disease hits 1 person out of a million each year.

There are far bigger fish to fry however. There is some evidence that the neurofibrillary tangles (tau protein) of Alzheimer’s disease and the Lewy bodies (alpha-Synuclein) of Parkinsonism, spread cell to cell by a ‘prionlike’ mechanism [ Nature vol.485 pp. 651 – 655 ’12, Neuron vol. 73 pp. 1204 – 1215 ’12 ]. Could this sort of thing be blocked by a small amino acid change in one of them (or better a small drug like peptide?).

Stay tuned.

The twists and turns of topoisomerase (pun intended)

It is very sad that my late friend Nick Cozzarelli isn’t around to enjoy the latest exploits of the enzyme class he did so much great work on — the topoisomerases. For a social note about him see the end of the post.

We tend to be quite glib about just what goes on inside a nucleus when DNA is opened up and transcribed into mRNA by RNA polymerase II (Pol II). We think of DNA has a linear sequence of 4 different elements (which it is) and stop there. But DNA is a double helix, and the two strands of the helix wind around each other every 10 elements (nucleotides), meaning that within the confines of our nuclei this happens 320,000,000 times.

I’ve written a series of six posts on what we would see if our nuclei were enlarged  by a factor of 100,000 (which is the amount of compaction our DNA must undergo to fit inside the 10 micron (10 millionths of a meter) in diameter nucleus (since if fully extended our DNA would be 1 meter long. So if you compacted the distance from New York to Seattle (2840 miles or 14,995,200 feet) down by this factor you’d get a sphere 150 feet in diameter or half the length of a football (US) field. Now imagine blowing up the diameter and length of the DNA helix by 100,000 and you’d get something looking like a 2,840 mil long strand of linguini which twists on itself  320,000,000 times. The two strands are 3/8th of an inch thick. They twist around each other every 9/16ths of an inch.

For the gory details start at https://luysii.wordpress.com/2010/03/22/the-cell-nucleus-and-its-dna-on-a-human-scale-i/ and follow the links.

Well, we know that for DNA to be copied into mRNA it must be untwisted, the strands separated so RNA polymerase II (Pol II) can get to it.  Pol II is enormous — a mass of 500 kiloDaltons and 7 times thicker at 140 Angstroms than the DNA helix of 20 Angstrom thickness.

Consider the fos gene (which we’ll be talking about later). It contains 380 amino acids (meaning that the gene contains at least 1140 nucleotides ). The actual gene is longer because of introns (3,461 nucleotides), which means that the gene contains 346 complete turns of the double helix, all of which must be unwound to transcribe it into mRNA.

So it’s time for an experiment. Get about 3 feet of cord roughly 3/8 of an inch thick. Tie the ends together, loop one end around a hook in your closet, put a pencil in the other end and rotate it about 100 times (or until you get tired). Keeping everything the same, have a friend put another pencil between the two strands in the middle, separating them. Now pull on the strands to make the separation wider and move the middle pencil toward one end. In the direction of motion the stands will coil even tighter (supercoiling) and behind they’ll unwind.

This should make it harder for Pol II to do its work (or for enzymes which copy DNA to more DNA). This is where the various topoisomerase come in. They cut DNA allowing supercoils to unwind. They remain attached to the DNA they cut so that the DNA can be put back together. There are basically two classes of topoisomerase — Type I topoisomerase cuts one strand, leaving the other intact, type II cuts both.

Who would have thought that type II topoisomerase would be involved in the day to day function of our brain.

Neurons are extended things, with information flowing from dendrites on one side of the cell body to much longer axons on the other. The flow involves depolarization of the cell body as impulses travel toward the axon. We know that certain genes are turned on by this activity (e.g. the DNA coding for the protein is transcribed into mRNA which is translated into protein by the ribosome). They are called activity dependent genes.

This is where [ Cell vol. 1496 – 1498, 1592 – 1605 ’15 ] comes in. Prior to neuronal activity, when activity dependent genes are expressed at low levels, the genes still show the hallmarks of highly expressed genes (e.g. binding by transcription factors and RNA polymerase II, Histone H3 trimethylation of lysine #4 {H3K4Me3 } at promoters).

This work shows that such genes are highly negatively supercoiled (see above) preventing RNA polymerase II (Pol II) from extending into the gene body. On depolarization of the cell body in some way Topoisomerase IIB is activated, leading to double strand breaks (dsbs) within promoters allowing the DNA to unwind and Pol II to productively elongate through gene bodies.

There is evidence that neuronal stimulation leads to dsbs ( Nature NeuroScience vol. 16 pp. 613 – 621 ’13 ) throughout the transcription of immediate early genes (e.g. genes turned on by neural activity). The evidence is that there is phosphorylation of serine #139 on histone variant H2AX (gammaH2AX) which is a chromatin mark deposited on adjacent histones by the DNA damage response pathway immediately after DSBs are found.

Etoposide (a topoisomerase inhibitor) traps the enzyme in a state where it remains bound to the DNA of the dsb. On etoposide Rx, there is an increase in activity dependent genes (Fos, FosB, Npas4). Inhibition of topiosomerase IIB (the most prevalent topoisomerase in neurons) by RNA interference (RNAi) leads to blunted activity dependent induction of these genes. This implies that DNA cutting by topoisomerase IIB is required for gene activation in response to neuronal activity.  Other evidence is that knocking down topoisomerase  using RNA interference (RNAi) stops activity dependent gene transcription.

Further supporting this idea, the authors induced dsbs at promoters of activity dependent genes (Fos, fosB, Npas4) using the CRISPR system. A significant increase in transcription was found when the Fos promoter was targeted.

I frankly find this incredible. Double strand breaks are considered bad things for good reason and the cell mounts huge redundant machines to repair them, yet apparently neurons, the longest lived cells in our bodies are doing this day in and day out. The work is so fantastic that it needs to be replicated.

Social Note: Nick Cozzarelli is one of the reasons Princeton was such a great institution back in the 50s (and hopefully still is). Nick’s father was an immigrant shoemaker living in Jersey City, N. J. Princeton recognized his talent, took him in, allowing him to work his way through on scholarship, waiting tables in commons, etc. etc. He obtained a PhD in biochemistry from Harvard and later became a prof at Berkeley, where he edited the Proceedings of the National Academy of Sciences USA for 10 years. He passed away far too soon of Burkitt’s lymphoma in his late 60s. We were friends as undergraduates and in grad school.

I can only wonder what Nick would say about the latest twists of the topoisomerase story

The uses of disorder

There was a lot of shock and awe about a report showing how seemingly minor changes in an aliphatic group on benzene led to markedly different conformations in its protein target (lysozyme from bacteriophage T4) http://pipeline.corante.com/archives/2015/06/18/tiny_and_not_so_tiny_changes.php.

Our noses are being rubbed in just how floppy proteins are, in contrast to the first glimpses of protein structure obtained by Xray crystallography. Back then we knew so little about proteins, that seeing all the atoms laid out in alpha helices and beta sheets was incredibly compelling. We talked about the structure of a protein rather than a structure. Even back then, with hemoglobin (one of the first solved proteins) it was obvious that proteins had to have more than one structure. The porphyrin ring in heme that oxygen binds to is buried deep in hemoglobin, and the initial structure had to move in some way to allow oxygen to find its way in (because the initial structure showed no obvious channel for oxygen). So hemoglobin had to breathe.

We now know that many proteins have intrinsically disordered segments. Amazingly, the most recent estimate I could find in my notes (or in Wikipedia) is this — It is estimated that over 30% of eukaryotic proteins have stretches of over 30 amino acids that are intrinsically disordered [ J. Mol. Biol. vol. 337 pp. 635 – 645 ’04 ]. Does anyone out there know of more recent data?

We’re a lot smarter now — here’s a comment on Derek’s post — “I have always thought crystal structures of proteins/enzymes are more a guide than actually useful. You are crystallizing a protein first-proteins don’t pack like that in vivo. Then you are settling on the conformation that freezes out- is this the lowest energy form? Then you are ignoring hte fact that these are highly dynamic structures that are constantly moving, sliding, shaking, adjusting. Then if you put a ligand in there you get the lowest energy form-which is what it would look like after reaction and before ligand dissociation- this is quite different from what it can look like at other stages of the reaction.”

Here is an interesting example of the uses of protein disorder going on right now in just about every neuron in your body. Most neurons have long processes, far too long for diffusion to move a needed protein to their ends. For that purpose we have microtubules (aka neurotubules in neurons) stretching the length of the processes, onto which two types of motors attach (dyneins which moves things to negative end of the microtubule and kinesins which move things to the positive end).

The microtubule is built from a heterodimer of two proteins (alpha and beta tubulin). Each contains about 450 amino acids and forms a globule 40 Angstroms (4 nanoMeters) in diameter. The heterodimers pack end to end to form a protofilament. 13 protofilaments line up side by side to form the microtubule, a hollow structure about 250 Angstroms in diameter. In cells microtubules are 1 to 10 microns long, but in nerve process they can be ‘up to’ 100 microns in length. Even at 1 micron (1,000 nanoMeters) that’s 13 * 250 heterodimers in a microtubule.

Any protein structure this important has a lot of modifications imposed on it to alter structure and function. Examples include phosphorylation and the addition of glutamic acid chains (polyglutamylation). The carboxy terminal tails of alpha and beta tubulin are flexible and stick out from the tubulin rod (which is why they aren’t seen on Xray crystallography). The carboxy terminal tail is the site of post-translational glutamylation. The enzyme polyglutamylating the carboxy terminal tail of beta tubular is TTLL7 (you don’t want to know what the acronym stands for). It binds to the alpha/beta tubular heterodimer by an intrinsically disordered region of its own (becoming structured in the process), then it binds to the intrinsically disordered carboxyl terminal tails, structuring them and modifying them. It’s basically a mating dance. There is a precedent for this — see https://luysii.wordpress.com/2013/12/29/the-mating-dance-of-a-promiscuous-protein/

So disordered regions of proteins although structureless are far from functionless

At the 55th

This is a mostly nonscientific post concerning the 55th reunion of the Princeton Class of 1960 last weekend. First the Science. Nick Cozzarelli was one of the most distinguished members of our class — great work on Topoisomerase, editor of PNAS for 10 years which established a prize named for him for the best paper each year. No one I’ve ever talked to in the class knew of him or his work. Shirley Tilghman, president of Princeton certainly did, and was shocked to hear of his untimely passing from Burkitt’s lymphoma when I told her of it at our 50th, saying he was a great scientist. However, he’s one of the reasons Princeton back then was a great institution (and hopefully still is). The son of an immigrant shoemaker in Newark NJ, he was taken in, given a scholarship, and worked his way through, serving meals in commons etc. etc. I made sure the undergraduates picking up a little cash by pouring drinks and serving meals at reunions heard about him. He was a good friend.  R. I. P. Nick.

Another friend, an emeritus prof of chemical engineering, referees a lot of papers. He estimates that 80% of the papers in his field, quantum chemistry, coming from China are absolute trash. According to him China gives bonuses to people getting published in high impact journals. What he finds particularly appalling is that he writes up a detailed list of corrections and improvements for the paper, and then finds it published totally unchanged in another journal.

He and I reminisced about our great undergraduate advisor Paul Schleyer with the department chair (who of course knew of him since he is one of the most cited and prolific (1,400 papers) chemists of the 20th century). He’s another reason Princeton was such a great institution back then (and hopefully still is). For details please see https://luysii.wordpress.com/2014/12/15/paul-schleyer-1930-2014-a-remembrance/ and https://luysii.wordpress.com/2014/12/14/paul-schleyer-1930-2014-r-i-p/

I finally saw the new Chemistry building (under construction at the 50th) and it is gorgeous. The NMR set up is particularly impressive, with the megaHertz of the machinery a factor of 15 greater than those we first started using in the 60s. Alas Varian is no more. It was bought a few years ago by another company which terminated the business. For where the money came from see https://luysii.wordpress.com/2011/05/16/princeton-chemistry-department-the-new-oberlin/.

In a remarkable coincidence, my wife an I were able to chat with the son of a neurologist in my call group, just finishing up his PhD in Chemistry there. How improbable is that?

Now for the nonScientific part.

For those undergraduates reading this at similar institutions, some advice — get to know as many of your classmates as you can. Premeds at Princeton back then had to take a lot of the same courses — biology, basic chemistry, organic chemistry, calculus, physics etc. etc. So we got to know each other. The rest of the class, not so much unless we were in other organizations (in my case, the marching band, Triangle club, and the eating club). At reunions I always meet classmates that I wish I knew back then and form new friendships.

Sometimes that isn’t always easy, with everyone working out the various important issues present from 18 to 22. A classmate’s wife described the men of the class at their 25th reunion as ‘roosters’, crowing and impressing each other. Not the case 30 years later. Everyone glad just to be there and catch up.

Princeton was all male back then. The current wives (some being #2, #3, #5) are an impressive bunch. They were uniformly intelligent and interesting. Not a bimbo in the lot of them, although most were very attractive physically. So the class may have slept with bimbos, but they were no longer in evidence.

Various seminars were held. I went to one about America’s relation to food. The panelists were 6 trim females with a fair amount of pseudoscience and touchy feely crap emitted, but at least the cautionary tale of the trash in the popular press about diet was mentioned (e.g. the paper about eat chocolate lose weight). What was fascinating was that the incidence of obesity (BMI over 29) in the group of several hundred listeners was at most 5%, proving, once again, that obesity in the USA is largely a class phenomenon. Also noted, is that I only saw one or two undergraduates and graduates smoking, again a class phenomenon, something Americans don’t like to talk about, but there nonetheless.

A memorial service for classmates was held in the chapel (built in 1929 but designed to appear that it was built in 1299). The organ is magnificent as were the acoustics, the sound surrounding you rather than coming at you. Bach and Vidor were performed by the organist. Apparently there was quite a battle about which to do first — refurbish the organ or the chapel acoustics. The stone had roughened distorting the sound so it didn’t echo properly. Clear plastic was applied to smooth the stone and then the organ was fixed. If you can hear a concert there please do so. Great composers write for the space their music will be performed in as well as the instruments it will be performed on, certainly true of Gabrielli, Bach and Vidor.

On a sadder note. I know of 4 suicides of class members (we started with around 725). Probably there are more. Also a good friend and classmate’s wife and daughter appeared to accept an award in his name. Although still alive he is incontinent, unable to walk and demented from Alzheimer’s. Despite degrees from Princeton, Harvard and Penn, Board examiner in Neurology blah blah blah, I was totally unable to help him. All I could do was offer emotional chicken soup to his wife, something my immigrant grandmother did with her 4th grade education in the dry goods store she ran. That’s why it’s good to be retired from neurology and not see this day after day.

Finally the P-rade. It is a great emotional lift for the psyche to march a mile or so to the reviewing stand being cheered by probably 1,000 – 2,000 younger graduates the whole time. The younger they got the louder the cheers and the drunker they were. It’s pretty hard not to feel good after that. I have heard that the only weekend event where more beer is consumed than Princeton reunions is the Indianapolis 500.  Along those lines, I only saw one truly drunk individuals among the 250 or so classmates and significant others although just about everyone had alcohol.  The alcoholics are no longer around for the 55th.

What is schizophrenia really like ?

The recent tragic death of John Nash and his wife warrants reposting the following written 11 October 2009

“I feel that writing to you there I am writing to the source of a ray of light from within a pit of semi-darkness. It is a strange place where you live, where administration is heaped upon administration, and all tremble with fear or abhorrence (in spite of pious phrases) at symptoms of actual non-local thinking. Up the river, slightly better, but still very strange in a certain area with which we are both familiar. And yet, to see this strangeness, the viewer must be strange.”

“I observed the local Romans show a considerable interest in getting into telephone booths and talking on the telephone and one of their favorite words was pronto. So it’s like ping-pong, pinging back again the bell pinged to me.”

Could you paraphrase this? Neither can I, and when, as a neurologist I had occasion to see schizophrenics, the only way to capture their speech was to transcribe it verbatim. It can’t be paraphrased, because it makes no sense, even though it’s reasonably gramatical.

What is a neurologist doing seeing schizophrenics? That’s for shrinks isn’t it? Sometimes in the early stages, the symptoms suggest something neurological. Epilepsy for example. One lady with funny spells was sent to me with her husband. Family history is important in just about all neurological disorders, particularly epilepsy. I asked if anyone in her family had epilepsy. She thought her nephew might have it. Her husband looked puzzled and asked her why. She said she thought so because they had the same birthday.

It’s time for a little history. The board which certifies neurologists, is called the American Board of Psychiatry and Neurology. This is not an accident as the two fields are joined at the hip. Freud himself started out as a neurologist, wrote papers on cerebral palsy, and studied with a great neurologist of the time, Charcot at la Salpetriere in Paris. 6 months of my 3 year residency were spent in Psychiatry, just as psychiatrists spend time learning neurology (and are tested on it when they take their Boards).

Once a month, a psychiatrist friend and I would go to lunch, discussing cases that were neither psychiatric nor neurologic but a mixture of both. We never lacked for new material.

Mental illness is scary as hell. Society deals with it the same way that kids deal with their fears, by romanticizing it, making it somehow more human and less horrible in the process. My kids were always talking about good monsters and bad monsters when they were little. Look at Sesame street. There are some fairly horrible looking characters on it which turn out actually to be pretty nice. Adults have books like “One flew over the Cuckoo’s nest” etc. etc.

The first quote above is from a letter John Nash wrote to Norbert Weiner in 1959. All this, and much much more, can be found in “A Beatiful Mind” by Sylvia Nasar. It is absolutely the best description of schizophrenia I’ve ever come across. No, I haven’t seen the movie, but there’s no way it can be more accurate than the book.

Unfortunately, the book is about a mathematician, which immediately turns off 95% of the populace. But that is exactly its strength. Nash became ill much later than most schizophrenics — around 30 when he had already done great work. So people saved what he wrote, and could describe what went on decades later. Even better, the mathematicians had no theoretical axe to grind (Freudian or otherwise). So there’s no ego, id, superego or penis envy in the book, just page after page of description from well over 100 people interviewed for the book, who just talked about what they saw. The description of Nash at his sickest covers 120 pages or so in the middle of the book. It’s extremely depressing reading, but you’ll never find a better description of what schizophrenia is actually like — e.g. (p. 242) She recalled that “he kept shifting from station to station. We thought he was just being pesky. But he thought that they were broadcasting messages to him. The things he did were mad, but we didn’t really know it.”

Because of his previous mathematical achievments, people saved what he wrote — the second quote above being from a letter written in 1971 and kept by the recipient for decades, the first quote from a letter written in 12 years before that.

There are a few heartening aspects of the book. His wife Alicia is a true saint, and stood by him and tried to help as best she could. The mathematicians also come off very well, in their attempts to shelter him and to get him treatment (they even took up a collection for this at one point).

I was also very pleased to see rather sympathetic portraits of the docs who took care of him. No 20/20 hindsight is to be found. They are described as doing the best for him that they could given the limited knowledge (and therapies) of the time. This is the way medicine has been and always will be practiced — we never really know enough about the diseases we’re treating, and the therapies are almost never optimal. We just try to do our best with what we know and what we have.

I actually ran into Nash shortly after the book came out. The Princeton University Store had a fabulous collection of math books back then — several hundred at least, most of them over $50, so it was a great place to browse, which I did whenever I was in the area. Afterwards, I stopped in a coffee shop in Nassau Square and there he was, carrying a large disheveled bunch of papers with what appeared to be scribbling on them. I couldn’t bring myself to speak to him. He had the eyes of a hunted animal.

Why making money in the stock market is as stressful than a missile attack (for me)

I made a ton of money in stock market in the past 7 weeks. I hated every minute of it. I found the stress very hard to take, particularly the anxiety and the inability to think of little else. As wives often do, my wife told me I’m nuts. “Don’t you remember how hard you worked for those neurosurgeons? This is the easiest money you’ve ever made”. I made probably more than half a year’s salary from them in absolute amount, and I was well paid.

But that was 25 years ago. For details see https://luysii.wordpress.com/2015/04/19/hilarys-stroke/. Yes, I was on every other night and probably was out between midnight and 8 AM every third night on call with a full day’s work to follow before sleep. It was physically demanding, but not particularly stressful mentally. “All you could lose was money, but in practice you could lose a life”. True, but I knew that I’d never make a mistake of omission, or commission or due to lack of knowledge (fairly arrogant but true, I really kept up with the literature in practice). Decisions didn’t always work out, initial diagnoses weren’t always correct, untoward reactions ensued (particularly to drugs), but I always knew that I given it my best shot. The stress came from doing everything right but still being unable to help, watching helplessly as patients deteriorated.

Thinking this over, after what my wife said, I realized that I was very much like a patient who really educated me.

Neurologists see headaches, lots of headaches. This young man came to see me about them, complete with his own (correct) diagnosis of their cause — a divorce in progress. Taking the history always starts things off, and a standard question is “When did the headaches start?” Oh, just after I got back from Riyadh. (This was during the Gulf War). Riyadh? Wasn’t there a missile attack that killed people while you were over there? Yes. Didn’t you have headaches then? No, but this divorce is killing me, doc. He was right.

So just like the shrinks say, it isn’t the situation itself, but how you perceive it.

Don’t get your hopes up — but

Amyotrophic lateral sclerosis (ALS) is a God-awful disease, where patients progressively weaken and die because they aren’t strong enough to breathe, remaining mentally intact the entire time. A recent paper [ Science vol. 348 pp. 239 – 242 ‘ 15 ] showed that a drug already released by the FDA for treating hypertension — Wytensin (Guanabenz) was of benefit in a mouse model of the disease. So the drug is out there. If I were still in practice, I’d certainly give it a shot in my patients — off-label use be damned. Even better, enterprising organic chemists synthesized an analogue of Wytensin (Sephin1) which doesn’t lower blood pressure, but which still works in the mouse model.

Here’s why you shouldn’t get your hopes up too high. [ Nature vol. 4564 pp. 682 – 685 ’08 ] The work using SOD1 mutant mice (the mouse model of ALS mentioned above) is quite sloppy and nearly 12 drugs with benefit in mouse models have had no benefit in clinical trials. Minocycline which was effective in 4 studies in mice actually made things worse in a clinical trial of over 400 patients .

Now for a bit of background. Most cases of ALS aren’t familial, but a few are. One protein Superoxide Dismutase 1 (SOD1) was found to mutated in about 20% of familial ALS. It’s been studied out the gazoo, and some 140 different mutations have been found in its 153 amino acids in familial cases.

It’s hard to conceive of them all acting the same way, and literally thousands of papers have been written on the subject. It does seem clear that aggregated proteins occur in the dying neurons of ALS patients, but whether they are made mostly of SOD1 remains controversial (although it is present in the inclusions to some extent). Mature SOD1 is a 32 kiloDalton homodimeric metalloenzyme, in which each monomer contains Cu and Zn and one intrasubunit disulfide bond. It is one of the most abundant cellular proteins. It has a tendency to aggregate when overexposed.

The mouse results are impressive, as it improved established disease. In vivo, Sephin1 prevented the motor morphological and molecular defects of two unrelated protein misfolding diseases in mice (Charcot Marie Tooth 1B and ALS ! ! !). The mice had a mutant SOD1 (G93A). SOD1 mutants bind to Derlin1 on the the cytosolic side of the endoplasmic reticulum (ER) membrane blocking degradation of ER proteins causing ER stress. Very impressive ! ! ! !

The neuron as motherboard

Back in the day when transistors were fairly large and the techniques for putting them together on silicon were primitive by today’s standards, each functionality was put on a separate component which was then placed on a substrate called the motherboard. Memory was one component, the central processing unit (CPU) another, each about the size of a small cellphone today. Later on as more and more transistors could be packed on a chip, functionality such as memory could be embedded in the CPU chip. We still have motherboards today as functionality undreamed of back then (graphic processors, disc drives) can be placed on them.

It’s time to look at individual neurons as motherboards rather than as CPUs which sum outputs and then fire. The old model was to have a neuron look like an oak tree, with each leaf functioning as an input device (dendritic spine). If enough of them were stimulated at once, a nerve impulse would occur at the trunk (the axon). To pursue the analogy a bit further, the axon has zillions of side branches (e.g,. the underground roots) which than contact other neurons. Probably the best example of this are the mangrove trees I saw in China, where the roots are above ground.

How would a contraption like this learn anything? If an impulse arrives at an axonal branch touching a leaf (dendritic spine) — e.g. a synapse, the spine doesn’t always respond. The more times impulses hit the leaf when it is responding to something else, the more likely the spine is to respond (this is called long term potentiation aka LTP).

We’ve always thought that different parts of the dendritic tree (leaves and branches) receive different sorts of information, and can remember (by LTP). Only recently have we been able to study different leaves and branches of the same neuron and record from them in a living intact animal. Well we can, and what the following rather technical description says, its that different areas of a single neuron are ‘trained’ for different tasks. So a single neuron is far more than a transistor or even a collection of switches. It’s an entire motherboard (full fledged computer to you).

Presently Intel can put billions of transistors on a chip. But we have billions of neurons, each of which has tends of thousands of leaves (synapses) impinging on it, along with memory of what happened at each leaf.

That’s a metaphorical way of describing the results of the following paper (given in full jargon mode).

[ Nature vol. 520 pp. 180 – 185 ’15 ] Different motor learning tasks induce dendritic calcium spikes on different apical tuft branches of individual layer V pyramidal neurons in mouse motor cortex. These branch specific calcium spikes cause long lasting potentiation of postsynaptic dendritic spines active at the time of spike generation.

Disentangling Heredity and Environmental effects on IQ

No sensible person thinks intelligence is completely determined by heredity or by environment. Recent Swedish work [ Proc. Natl. Acad. Sci. vol. 112 pp.4612 – 4617 ’15 ] tries to control for heredity while measuring environmental effects on IQ, assuming that IQ measures intelligence, a position some find contentious. Every Swedish 18 year old man is conscripted into the military apparently. IQ tests are given to all. Amazingly the authors found 436 sibships where the brothers had been raised apart.

The intelligence of the biological and adoptive parents wasn’t measured. Rather the surrogate of educational level was used instead. It was divided into 5 classes.

What did they find? Adopted sibs had an IQ 4.41 points higher than the nonAdopted sib (recall that average IQ is stated to be 100 points although it’s been rising, and that IQ levels of the population fall on the Bell (Gaussian) curve, with a standard deviation of 15 points). These results are not surprising, as few willingly give children up for adoption, so the adopted environment was quite likely better. The educational level of the adoptive parents was an average of 2.6 points higher.

Next, the authors measured the effect of the surrogate marker for intelligence (educational level) on IQ. For each point in the 5 point scale that the adoptive parent was at a higher educational level than the biologic ones there was an increase in IQ of the adopted sib relative to the unadopted one. This is as unequivocal evidence as we have for the effect of environment and educational level on IQ.

We’ll never have perfect data, and many caveats about this work are possible, but it is an impressive effort. 436 sibs is a huge number compared to the twins who’ve been reared apart and studied this way.

Just how large an effect do you think it was? I’ve already told you everything you need to know.

Each additional unit of rearing parental education was associated with 2 IQ units. Are you surprised? I was, because I thought the effect would be much larger. So environment is important in determining intelligence, just not so much.

Hillary’s stroke

Hillary Clinton had a stroke toward the end of 2012. It was not due to the faint she had presumably because of the flu in mid December. The information given out at the time was extremely sketchy and confusing (see the copy of the post of 31 Dec ’12 at the end).

She fainted while giving a speech in Buffalo according to one account and at her home in Washington according to another and was not hospitalized. She is said to have suffered a concussion when she fell. Then on the 30th of December she was hospitalized because a blood clot was found (more later) and placed on blood thinners. She suffered double vision and had to wear corrective glasses (Fresnel lenses) for congressional testimony 23 January 2013.

So she had a blood clot in her head and a neurologic deficit persisting for a few weeks. That’s what a stroke is.

Could it have been due to the head trauma? This is extremely doubtful based on an intense 42 month experience managing acute head injuries.

To get my kids through college, I took a job working for two busy neurosurgeons. When I got there, I was informed that I’d be on call every other night and weekend, taking first call with one of the neurosurgeons backing me up. Neurologists rarely deal with acute head trauma although when the smoke clears we see plenty of its long term side effects (post-traumatic epilepsy, cognitive and coordination problems etc. etc.). I saw plenty of it in soldiers when I was in the service ’68 – ’70, but this was after they’d been stabilized and shipped stateside. Fortunately, my neurosurgical backup was excellent, and I learned and now know far more about acute head trauma than any neurologist should.

We admitted some of the head trauma cases to our service, but most cases had trauma to other parts of the body, so a general surgeon would run the show with our group as consultants. The initial consultant in half the cases was me. If I saw them initially, I followed the patients until discharge. On weekends I covered all our patients and all our consults, usually well over 20 people.

We are told that Hillary had a clot in one of the large draining veins in the back of her head (venous sinuses actually). In all the head trauma I saw (well over 300 I’d guess), I never saw a clot develop there. I’ve spoken to two neuroradiologists still in practice, and they can’t recall seeing such a clot without a skull fracture near the vein. Nothing like this was mentioned at any time about Hillary.

Hillary’s neurologic deficit involved a nerve going to the muscles of her left eye. These start in the brainstem, a part of the brain quite near the site where she is said to have the clot in her vein. The brainstem is crucial in maintaining consciousness, and it is far more likely that the faint in early December was a warning sign of the stroke she had subsequently.

I can’t believe that she would not have been hospitalized had she complained of double vision when she fainted in early December, so it must have come on later.

So the issue is why did she have the stroke, and how likely is it to recur. I seriously doubt that it had anything to do with the head injury she sustained when she fainted. We’ve have two presidents neurologically impaired by stroke in the past century (Woodrow Wilson after World War I and Franklin Delano Roosevelt at Yalta). The results were not happy for the USA or the World.

Certainly all this would be cleared up if her medical records were released. Only Hillary can do this, but at least she cannot destroy them, as although she ‘owns’ them, they are not in her sole possession.

The following is a post written 31 December ’12 when the news of Hillary’s illness first broke showing how fragmentary the information about it was back then (it isn’t a good deal better now).

Medical tribulations of politicians — degrees of transparency

Remarkably on the last day of the year, 3 political figures and their medical problems are in the news. Here they are in order of medical transparency (highest first).

l. George Bush Sr. — the most transparent. We are told what he has (pneumonia), when he was admitted to hospital when he was in the ICU, when he came out. Docs call pneumonia ‘the old man’s friend’ not out of cynicism, but because its a mode of death with (relatively) little suffering. The patient lapses into unconsciousness and usually dies quickly and quietly. It took my cellist’s father only a day or two to pass away this month. Clearly it isn’t invariably fatal, and Bush Sr. was now out of the ICU at last count (he’s 88).

2. Hillary Clinton — admitted to the hospital yesterday with a ‘blood clot’ somewhere, said to be a complication of the concussion she suffered a few weeks ago. Also said to be under treatment with anticoagulants. Most clots due to head trauma are inside the head and treating them with anticoagulants is a disaster. The most likely type of clot given the time from the concussion is a subdural hematoma. It is possible that she’s been so inactive since the concussion that she developed thrombophlebitis in her legs, in which case anticoagulation would be indicated.

More disturbingly, is that her passing out a few weeks ago is a sign of something more serious going on. Hopefully not.

The powers that be should have told us where the clot actually is.

Update 5:50 PM EST — Well the powers that be did open up and it is a most unusual complication of head injury (and one I’d never seen in nearly 4 decades of practice) — a venous thrombosis in the head. I’m not even sure it’s due to her head injury. It might have even caused her syncope, but presumably she had some sort of radiologic study of her head when she fainted, which should have picked it up. The venous sinuses draining the brain in the back of the head are notoriously asymmetric, so a narrowing attributable to a clot could just be a variant anatomy. One very bad complication of cerebral venous thrombosis back there (which I saw as a complication of chronic mastoid bone infection — not head trauma) is pseudotumor cerebri. I really wonder if these guys have the right diagnosis.

3. Hugo Chavez — Yesterday it was announced that he’s had a third complication since his surgery for cancer 3 weeks ago. Naturally, we’re not told just what this complication actually is. This is consistent with the information that has been released about his case. We know almost nothing about his actual tumor (except that he has one). He most assuredly is not free of cancer as he stated last fall. He is said to have have a bleeding problem and a lung infection as the first two complications.

My guess for this third complication is that it is a dehiscence of his abdominal incision, which must have been fairly large for a 6 hour operation. Dehiscence just means that the wound has spontaneously opened up exposing abdominal contents (which means that peritonitis is not far behind). Why should this happen? Two reasons — he’s had radiation to the area which inhibits wound healing, and he’s been on high dose steroids in the past (and perhaps presently) which also inhibits wound healing.

I don’t think he’s going to be able to take office 10 days hence, and doubt that he’ll come back to Venezuela alive. Transparency has been zilch. Hopefully the people of Venezuela are beginning to realize just how misleading the information they’ve been fed about his health has been.

This is the sort of thing physicians taking care of really sick people deal with daily, which may explain why your doc friends aren’t as jolly as you are at the New Year’s Eve parties you’re about to attend.

Nonetheless, Happy New Year to all ! ! ! !

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