Amyotrophic lateral sclerosis and Parkinsonism-dementia complex of Guam: Descriptive epidemiology, secular trends, and birth cohort effects on incidence, 1950--1989

This study describes the patterns of occurrence of amyotrophic lateral sclerosis (ALS) and parkinsonism-dementia complex (PDC) of Guam during 1950-1989. Both ALS and PDC occur with high frequency among the indigenous Chamorro population, first recognized in the early 1950's. Reports in the early 1980's indicated that both ALS and PDC were disappearing, due to a purported reduction in exposure to harmful environmental factors as a result of the dramatic changes in lifestyle that took place after World War II. However, this study provides compelling evidence that ALS and PDC have not disappeared on Guam and that rates for both are higher during 1980-1989 than previously reported.^ The patterns of occurrence for both ALS and PDC overlap in most respects: (1) incidence and mortality are decreasing; (2) median age at onset is increasing; (3) males are at increased risk for developing disease; (4) risk is higher for those residing in the south compared to the non-south; and (5) age-specific incidence is decreasing over time except in the oldest age groups.^ Age-specific incidence of ALS and PDC, separately and together, is generally higher for cohorts born before 1920 than for those born after 1920. A significant birth cohort effect on the incidence of PDC for the 1906-1915 birth cohort was found, but not for ALS and for ALS and PDC together. Whether or not a cohort effect, period effect, or both are associated with incidence of ALS and PDC cannot be determined from the data currently available and will require additional follow-up of individuals born after 1920.^ The epidemiological data amassed over this 40-year period provide evidence that supports an environmental exposure model for disease occurrence as opposed to a simple genetic or infectious disease model. Whether neurodegenerative disease in this population occurs as a consequence of a single exposure or is explained by a multifactorial model such as a genetic predisposition with some environmental interaction is yet to be determined. However, descriptive studies such as this can provide clues concerning timing and location of potential adverse exposures but cannot determine etiology, underscoring the urgent need for analytic studies of ALS and PDC to further investigate existing etiologic hypotheses and to test new hypotheses. ^

Hemodynamic changes associated with manual and automated lateral rotation in mechanically ventilated intensive care patients

Objective: To investigate hemodynamic responses to lateral rotation. ^ Design: Time-series within a randomized controlled trial pilot study. ^ Setting: A medical intensive care unit (ICU) and a medical-surgical ICU in two tertiary care hospitals. ^ Patients: Adult patients receiving mechanical ventilation. ^ Interventions: Two-hourly manual or continuous automated lateral rotation. ^ Measurements and Main Results: Heart rate (HR) and arterial pressure were sampled every 6 seconds for > 24 hours, and pulse pressure (PP) was computed. Turn data were obtained from a turning flow sheet (manual turn) or with an angle sensor (automated turn). Within-subject ensemble averages were computed for HR, mean arterial pressure (MAP), and PP across turns. Sixteen patients were randomized to either the manual (n = 8) or automated (n = 8) turn. Three patients did not complete the study due to hemodynamic instability, bed malfunction or extubation, leaving 13 patients (n = 6 manual turn and n = 7 automated turn) for analysis. Seven patients (54%) had an arterial line. Changes in hemodynamic variables were statistically significant increases ( p < .05), but few changes were clinically important, defined as ≥ 10 bpm (HR) or ≥ 10 mmHg (MAP and PP), and were observed only in the manual-turn group. All manual-turn patients had prolonged recovery to baseline in HR, MAP and PP of up to 45 minutes (p ≤ .05). No significant turning-related periodicities were found for HR, MAP, or PP. Cross-correlations between variables showed variable lead-lag relations in both groups. A statistically, but not clinically, significant increase in HR of 3 bpm was found for the manual-turn group in the back compared with the right lateral position ( F = 14.37, df = 1, 11, p = .003). ^ Conclusions: Mechanically ventilated critically ill patients experience modest hemodynamic changes with manual lateral rotation. A clinically inconsequential increase in HR, MAP, and PP may persist for up to 45 minutes. Automated lateral rotation has negligible hemodynamic effects. ^

Prognosis of amyotrophic lateral sclerosis

Two cohorts of amyotrophic lateral sclerosis (ALS) patients were identified. One incidence-based cohort from Harris County, Texas with 97 cases, and the other a clinic referral series from an ALS clinic in Houston, Texas with 439 cases were followed-up to evaluate the prognosis of ALS. The overall Kaplan-Meier 3-year survival after diagnosis was similar, 0.287 for the incidence cohort and 0.313 for the referral cohort. However, the 5-year survival was much lower for the incidence cohort than the referral cohort (0.037 vs. 0.206). The large difference in 5-year survival was thought to be the results of a stronger unfavorable effect of the prognostic factors in the incidence cohort than in the referral cohort.^ Cohort-specific Weibull regression models were derived to evaluate the cohort-specific prognostic factors and survival probability with adjustment of certain prognostic factors.^ The major prognostic factors were: age at diagnosis, bulbar onset, black ethnicity, and positive family history of ALS in both cohorts. Female gender, simultaneous upper and lower extremities onset were specifically unfavorable factors in the incidence cohort. In the incidence cohort the prognosis was relatively favorable for cases with duration from onset to diagnosis longer than 4 months, however in the referral cohort the relatively favorable prognosis only occurred in cases with duration from onset to diagnosis 1 year or longer and was strongest in cases with duration 5 years and longer. Age at diagnosis modified the effect of bulbar onset in the incidence cohort but not in the referral cohort. The estimated survival with presence of an unfavorable prognostic factor identified in the incidence cohort was higher for the referral cohort than for the incidence cohort. Future studies are indicated to investigate the disease heterogeneity issue of ALS based on survival distribution of ALS. ^

STUDYING AGGREGATE FORMATION BY AMYOTROPHIC LATERAL SCLEROSIS-ASSOCIATED MUTANT SOD1 PROTEIN IN DROSOPHILA MODEL

A common pathological hallmark of most neurodegenerative disorders is the presence of protein aggregates in the brain. Understanding the regulation of aggregate formation is thus important for elucidating disease pathogenic mechanisms and finding effective preventive avenues and cures. Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, is a selective neurodegenerative disorder predominantly affecting motor neurons. The majority of ALS cases are sporadic, however, mutations in superoxide dismutase 1 (SOD1) are responsible for about 20% of familial ALS (fALS). Mutated SOD1 proteins are prone to misfold and form protein aggregates, thus representing a good candidate for studying aggregate formation. The long-term goal of this project is to identify regulators of aggregate formation by mutant SOD1 and other ALS-associated disease proteins. The specific aim of this thesis project is to assess the possibility of using the well-established Drosophila model system to study aggregation by human SOD1 (hSOD1) mutants. To this end, using wild type and the three mutant hSOD1 (A4V, G85R and G93A) most commonly found among fALS, I have generated 16 different SOD1 constructs containing either eGFP or mCherry in-frame fluorescent reporters, established and tested both cell- and animal-based Drosophila hSOD1 models. The experimental strategy allows for clear visualization of ectopic hSOD1 expression as well as versatile co-expression schemes to fully investigate protein aggregation specifically by mutant hSOD1. I have performed pilot cell-transfection experiments and verified induced expression of hSOD1 proteins. Using several tissue- or cell type-specific Gal4 lines, I have confirmed the proper expression of hSOD1 from established transgenic fly lines. Interestingly, in both Drosophila S2 cells and different fly tissues including the eye and motor neurons, robust aggregate formation by either wild type or mutant hSOD1 proteins was not observed. These preliminary observations suggest that Drosophila might not be a good experimental organism to study aggregation and toxicity of mutant hSOD1 protein. Nevertheless this preliminary conclusion implies the potential existence of a potent protective mechanism against mutant hSOD1 aggregation and toxicity in Drosophila. Thus, results from my SOD1-ALS project in Drosophila will help future studies on how to best employ this classic model organism to study ALS and other human brain degenerative diseases.