In the developing world, health care providers often don’t have access to diagnostic technologies like the automated lab tests taken for granted in the resource-rich United States. Specimens often have to be sent to a distant central lab, and it can be weeks before an answer wends its way back.

That’s a tough situation when you’re, say, trying to assess whether a patient is having liver toxicity from a drug, such as drugs used to treat tuberculosis (TB) and HIV. By the time the results come back and indicate you need to stop or switch medications, the patient may be long gone, unable to travel back to the clinic.

For the past four years, Nira Pollock, MD, PhD, associate medical director of the Infectious Diseases Diagnostics Lab at Boston Children’s Hospital, has been working with Diagnostics For All (DFA), a nonprofit organization based in Cambridge, Mass., to develop and test a low-cost diagnostic device that works on the spot, involving just a finger-stick and a square of paper. The technology is all in the paper square—using wax printing and microfluidics techniques initially developed by DFA’s founder, George Whitesides, PhD, of Harvard University.

The result is a multilayered paper device that splits a small blood sample into streams, allowing multiple tests to be done at once without the need for multiple finger-sticks—at a cost of pennies per test.

“The wax creates channels that steer the fluid to certain places as it wicks through the paper,” explains Pollock, also a member of the Division of Infectious Diseases at Beth Israel Deaconess Medical Center (BIDMC). “You put a drop of blood on the center of the device, and a filter separates blood cells from the plasma, which continues down to the layers of paper underneath and wicks to different detection zones. You can spot different reagents in different zones on the paper to perform multiplexed assays.”

Readouts take approximately 15 minutes: the paper in the detection zones changes color to indicate results, which can be matched by eye with a range of expected colors on a chart. Or, through telemedicine, photos of the device (i.e., the paper) can potentially be sent to an expert reader.

DFA and Pollock’s test, evaluating liver function, may emerge as the first clinical diagnostic of this kind. With eradication of TB and HIV as a global priority from the World Health Organization, liver toxicity from regimens used to treat these diseases is important to detect and address. The paper test measures levels of enzymes like AST and ALT, which are good indicators of liver damage.

In a study published in Science Translational Medicine last fall, funded in part by the Boston-based Center for Integration of Medicine and Innovative Technology (CIMIT), Pollock and her DFA colleagues tested the device using 223 blood samples obtained by venipuncture and 10 finger-stick samples from healthy volunteers. The test allowed visual measurements of AST and ALT, in both whole blood and serum, that could be placed into three standard readout categories (AST or ALT less than three times the upper limit of normal (ULN), three to five times the ULN and more than five times the ULN)—with more than 90 percent accuracy.

In a pilot finger-stick study last summer in Vietnam, funded by PATH (Seattle, Wash.), Pollock and collaborators trained nurses to perform the test and interpret the color changes on the devices. In this collaboration between PATH, BIDMC, DFA, the Hospital for Tropical Diseases in Vietnam and the Harvard Medical School AIDS Initiative in Vietnam, the team looked at factors like ease of interpretation, consistency of results and lot-to-lot variability.

With those findings, they’re tweaking and optimizing the paper test and planning a follow-up finger-stick study to take place this summer in collaboration with colleagues from the BIDMC Liver Center and Infectious Diseases clinics, supported in part by another CIMIT grant. The team will also test transmitting pictures of the devices (taken by cellphone cameras) to a remote reader.

“In the future, we could potentially even develop tests like this for home use, like people do glucose monitoring now,” says Pollock.

A big question in point-of-care (POC) diagnostics, she notes, is “how accurate does the test have to be in order to be useful?” Even if the paper test doesn’t perform as well as the gold standard, it could still have a big impact on global health; in equivocal cases, venipuncture samples could still be sent for automated testing.

“People are starting to argue that all the benefits of point-of-care use might ultimately make low-cost POC tests a better choice,” Pollock says.

Joshua Frase, who died from X-linked myotubular myopathy (MTM), with his father, Paul Frase, in 2006.

Back in the 1990s, rheumatologist Richard Weisbart, MD, of University of California, Los Angeles (UCLA), was studying lupus in a mouse model and found that the mice were making an antibody that had the intriguing ability to get inside tissues and cells.

Weisbart shifted his work away from studying lupus to studying and refining the antibody, called 3E10, and he and others showed that proteins could be delivered into different tissues of the body simply by attaching them to a fragment of 3E10.

Dustin Armstrong, PhD, a postdoc at Novartis at the time, was trying to find molecules that could activate growth in weakened muscles—without activating possibly cancerous growth in other tissues. He saw Weisbart’s work and contacted UCLA. In 2008, he obtained seed money and founded a company around 3E10-based therapeutics for muscular diseases, now known as Valerion Therapeutics (formerly 4s3 Bioscience).

“There’s a huge need for therapies for genetic muscle diseases, and muscle was a tissue we could target well with our technology,” says Armstrong. “The 3E10 antibody requires a membrane transporter to enter cells—and skeletal muscle has 20-fold higher expression of this transporter.”

Armstrong

“There’s a clear indication from the gene therapy work that if you could replace myotubularin, you could have an immediate effect on muscle,” Armstrong says. “Alan brings a large depth of experience in the genetic aspects of congenital muscle myopathies, and his lab has animal models and experience doing physiologic testing. That creates opportunities to do drug development.”

Homing to muscles

Beggs

He and Armstrong received a venture philanthropy grant from the Muscular Dystrophy Association (MDA). In the April 15 issue of Human Molecular Genetics, they showed that injection of myotubularin—attached to the 3E10 fragment—into the leg muscles of mice reversed muscle weakness and improved muscle structure.

“We gave a dose that we thought would be sufficient for just one limb, but it circulated in the blood and treated the entire animal,” says Beggs. “Since it’s an enzyme, we don’t have to replace a lot of it—a little bit goes a long way.”

Enzyme replacement could have a relatively fast path to clinic. There’s regulatory precedent for enzyme-based drugs, notably Genzyme’s Myozyme, approved by the FDA in 2008 for Pompe disease, another rare genetic disorder.

Under a pending $1.2 million grant from the MDA, Armstrong and Beggs plan to further the animal studies and figure out questions of dosage, timing of treatment, how often treatment would need to be repeated and whether the body will tolerate enzyme replacement long-term. But Beggs wants to continue developing gene therapy too.

“The best therapy might be a combination therapy,” he says. “You could give a child gene therapy first, and wait for it to wear off, or for the immune system to reject the virus. You could try this for two to three years and follow it with the protein therapy. An alternative scenario is to do both at the same time to more fully deliver the treatment to the entire body. It’s important to have more than one way to skin the cat.”

With either approach, a big question is whether the treatment will work once muscle weakness is established. Unlike dogs and mice, which develop weakness after birth, children with MTM are born weak, often nearly motionless.

“I definitely think, having followed Alan’s work over the years, that things are getting close,” says Erin Ward, whose son Will has MTM, and who, with her husband Mark, helps direct the MTM-CNM Family Conference, which next meets in July. “We’re educating the community about how to hold onto that hope and what a clinical trial process would look like. We’re kind of on that threshold, I feel.”

“Once they get the delivery process down, it is likely this science will translate to other similar neuromuscular diseases,” says Alison Frase, whose son Joshua passed away from MTM two years ago, at the age of 15. Joshua’s favorite biblical scripture, posted on the Frase Foundation’s website, perhaps best captures that feeling of hope.

“But they that wait upon the Lord shall renew their strength. They shall mount up with wings as eagles. They shall run and not be weary, and they shall walk and not faint.” —Isaiah 40:31.

End of series.

[Ed. note: For more information about this research and to discuss partnership opportunities, please contact the Technology & Innovation Development Office, 617-919-3019 or TIDO@childrens.harvard.edu. To learn about supporting the research, please contact morgan.herman@chtrust.org.]

Will Ward at the NSTAR Walk for Boston Children’s Hospital in 2012—his family’s fifth year leading a team to raise funds for the Beggs Laboratory.

This two-part series examines two potential treatment approaches for myotubular myopathy, a genetic disorder that causes muscle weakness from birth.

Sixth-grader William Ward cruises the hallways at school with a thumb-driven power chair and participates in class with the help of a DynaVox speech device. Although born with a rare, muscle-weakening disease called X-linked myotubular myopathy, or MTM, leaving him virtually immobile, he hasn’t given up.

Neither has Alan Beggs, PhD, who directs the Manton Center for Orphan Disease Research at Boston Children’s Hospital, and who has known Will since he was a newborn in intensive care.

“From the very beginning, Alan connected with our family in a very human way,” says Will’s mother, Erin Ward. “In the scientific community, he’s been the bridge and the connector of researchers around the world. That makes him unique.”

Since the 1990s, Beggs has enrolled more than 500 patients with congenital myopathies from all over the world in genetic studies, seeking causes and potential treatments for congenital myopathies—rare, often fatal diseases that weaken children’s skeletal muscles from birth, often requiring them to breathe on a ventilator and to receive food through a gastrostomy tube.

Beggs’s lab has helped identify many of the dozen or more known causative genes, and has studied the MTM1 gene that’s mutated in Will for many years, modeling the mutations’ effects in animals and examining their impact on children’s muscles. Now, after 20 years, he’s at the brink of seeing his work finally translated into a treatment that could help patients get stronger. If either of two approaches being tested succeeds, it would be the first directed therapy for any congenital myopathy.

“There are hurdles to clear during this last push,” says Alison Frase, whose son Joshua passed away from MTM two years ago, and who, with her husband, founded the Joshua Frase Foundation, which has supported Beggs’s lab for almost 16 years. “But the trans-Atlantic team of scientists whom Alan has brought together has accomplished some miraculous milestones.”

Moving a muscle

Normally, when a muscle needs to move, calcium rushes into the muscle cells and sets off a contraction. Stores of calcium are held at the ready in sausage-shaped structures called T-tubules, maintained by an enzyme called myotubularin that is encoded by the MTM1 gene. But in children with MTM1 mutations, like Will and Joshua, myotubularin is absent or dysfunctional. As a result, Beggs and his collaborators have shown that the T-tubules are disorganized and leaky.

“The calcium is not going where it should be,” says Beggs. “It is not available to surge into the cell. The last step in triggering a muscle to contract is disrupted.”

When T-tubule structure is compromised, as at right, the triad structure to which it belongs falls apart and calcium stores are lost. (Credit: Michael Lawlor)

In 2008, Beggs and collaborators in France reported a successful fix in mice: gene therapy, using an injected virus to carry a healthy MTM1 gene into the muscles. Muscle structure, volume and contractile force all improved, and in follow-up research, the animals’ lifespans—normally shortened to two months by MTM—were prolonged to more than six months.

Beggs needed to test gene therapy in a larger animal before it could be attempted in humans. At a scientific meeting, he heard about some Labrador retrievers that had a disease very much like MTM. He mentioned this to Frase, who had become a professional collaborator, helping raise awareness and money for MTM research while lending support to families.

“Alan told me that a researcher thought she saw Joshua’s muscle disease in a dog,” says Frase. “We had a pretty good hunch that this dog had an MTM1 mutation.”

Nibs

Hoping to do genetic studies in the Labrador retrievers, Beggs contacted the researcher, G. Diane Shelton, DVM, PhD, a veterinary pathologist at the University of California, San Diego. Shelton then introduced Frase to the vet in Canada who was treating these dogs.

“The vet located a family with two affected puppies,” says Frase. “I called the owner and explained to him about Joshua, where we were in the research, and how we needed a large animal model. Before I could even finish my story, he said, ‘I want to give you my dog Nibs.’”

Frase with Nibs

Will with Simba, one of Nibs’s descendents

Nine days later, Frase flew from Florida to Saskatoon to meet Nibs, the puppies’ healthy mother, at the airport. They instantly bonded. “She was a genetic carrier, just like me,” Frase said.

That was the start of the world’s first MTM dog colony, established at the Wake Forest Institute of Regenerative Medicine in Winston-Salem, N.C., with funding from the Joshua Frase Foundation and in collaboration with Casey (Martin) Childers, DO, PhD. Childers, now at the University of Washington, had previously studied golden retrievers with a form of muscular dystrophy.

Within weeks, Beggs, Shelton and colleagues in France confirmed that Nibs carried an MTM1 mutation, as did seven male Labs with the same syndrome. Nibs produced a litter of 12 puppies, including five carrier females and one affected male pup. Today, the colony has more than a dozen carriers, many of which have been bred. (Will Ward’s family adopted two healthy, non-carrier dogs from the colony.)

The diseased dogs are clearly benefiting from gene therapy. At a conference late last year, Beggs, Childers and colleagues in France reported improved leg strength and diaphragm function during breathing—to near-normal levels. The muscles bulked up, had larger fibers and showed fewer pathological features. “To date, the dogs that have received gene therapy have survived to four times the age of their untreated littermates with MTM,” says Frase.

As for Nibs, she eventually was returned to her Canadian owner. “I felt I needed to bring her home,” Frase says. “She did what she needed to do for me. When she took off and ran for her original owner at the airport, I knew I had done the right thing.”

Part 2 will look at the promise of enzyme replacement for congenital muscle disorders.

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Lin28, a known player in cancer, is hard to suppress with drugs. But two related enzymes present highly druggable targets. (Emw/Wikimedia Commons)

In 2008, Gregory and his colleagues showed how a factor called Lin28, which is associated with numerous cancers, makes a cell more prone to revert to a less specialized, stem-like state.

Lin28 acts by preventing maturation of Let-7—an ancient family of microRNAs found in creatures from humans to worms. Let-7 is the yin to Lin28’s yang: it causes stem cells to differentiate (embryonic stem cells, which are completely unspecialized, have very low levels of it). If a cell’s Let-7 can’t mature, it can’t differentiate; instead, it remains stem-like and can potentially become cancerous.

Suppressing Lin28 with RNA interference (RNAi) has been shown to suppress tumor growth. But Lin28 is difficult to target with drugs. Gregory’s lab, part of the Stem Cell Program at Boston Children’s Hospital, has now identified two other key players that work in tandem with Lin28. Both are associated with loss of Let-7 and with tumors, but what’s exciting is that they are enzymes, presenting far more “druggable” targets.

Gregory

Dis312 hasn’t been looked at systematically in cancer, but there’s one rare, highly lethal disease, known as Perlman syndrome, in which Dis312 is known to be mutated. Perhaps not coincidentally, Perlman is associated with fetal overgrowth and a predisposition to Wilm’s tumor, the most common form of renal cancer. Few people born with Perlman syndrome survive infancy.

Meanwhile, the team has shown in the journal Cell that when you use RNAi to suppress production of the TUTase, you can inhibit tumor growth. “That was a nice proof of principle,” says Gregory.

With funding from the National Cancer Institute, Gregory and colleagues will soon start screening some 5,000 small-molecule compounds to find ones that might block TUTase. Dis312 could eventually be tested in drug screens too, and if either search pans out, we could have a new weapon against cancer.

To learn more about Lin28/let-7 pathway collaboration opportunities at Boston Children’s, please contact Abbie Meyer, PhD, in the Technology & Innovation Development Office, abbie.meyer@childrens.harvard.edu. To learn about supporting the research, please contact kathleen.corcoran@chtrust.org.

Ed Smith explains the moyamoya operation during a live webcast.

Lindsay Hoshaw contributed to this post.

It’s 7 a.m. and neurosurgeon
Ed Smith, MD, is downing a Diet Coke as he reviews the MRIs of today’s patients. He sprints up a stairwell to greet his first patient in the pre-operating wing.

Thirteen-year-old Maribel Ramos, about to have brain surgery at Boston Children’s Hospital, sits in her bed fidgeting. Smith reassures her about the operation, promises they’ll shave off as little hair as possible, and gets Maribel to crack a smile by telling her he moonlights as a hairdresser.

Maribel’s operation is meant to correct a rare brain disorder called moyamoya—a narrowing of blood vessels that constrains blood flow in the brain. Smith becomes animated when he talks about it.

“Imagine the pipes in your bathtub don’t work and you’re only getting a trickle of water,” he explains. “But instead of fixing the pipes, you run a hose in through the window so you have a new source of water.”

Without surgery, moyamoya poses a five-year stroke risk of 60 to 90 percent. The operation, developed by Smith’s mentor, Michael Scott, MD, takes a healthy artery and attaches it to the part of the brain that isn’t getting enough blood. The artery naturally takes root, providing a permanent new source of blood.

Scott’s name got stuck in Smith’s head when he was just a teenager. “One of my best friends in high school, Seth, had a brain tumor,” Smith says as he walks out of pre-op. “He was treated at Boston Children’s, and although Seth ultimately passed away in college, the experience inspired me to become a neurosurgeon and work with Dr. Scott. It’s a joy to treat kids, because they can get better.”

Though he’s director of pediatric cerebrovascular surgery at Boston Children’s, Smith is the first to say that surgery isn’t always in a child’s best interest. He decides, for example, not to operate on a boy with a Chiari malformation, a condition where brain tissue protrudes into the spinal canal.

“I don’t have anything in my [surgical] toolbox that can make you better,” he tells the boy and his mom in the exam room.

Instead, Smith orders medication and schedules a follow-up MRI. “So tell me if you’ve heard this one,” Smith says to the boy. “A kid goes to his doctor with a carrot in his ears and a banana in his butt and peanut butter in his hair. And his doctor says, ‘Hmmm…you’re not eating right.’”

Peeing in a cup

In his laboratory across the street, Smith is looking for better ways to monitor his patients postoperatively—and determine whether he should even operate at all. Under the tutelage of another mentor, Marsha Moses, PhD, his sights are now on biomarkers—proteins whose presence may signal new or recurring brain disease.

Moses, director of the Vascular Biology Program, has pioneered the use of urine biomarkers to detect breast and ovarian cancer. Smith approached her after a lecture about a decade ago and soon found himself working in her lab. In 2008, he and Moses reported that a family of biomarkers Moses had identified—matrix metalloproteinases—are a good test for brain tumors.

“In my professional career, I’ve been fortunate to have Mike Scott as a sort of clinical ‘dad’ and Marsha Moses as a scientific ‘mom,’” Smith says.

Smith is now running a 12-hospital trial of a panel of urine biomarkers for monitoring pontine glioma or DIPG (diffuse infiltrative pontine glioma), a highly lethal brainstem tumor. He was able to incorporate the study into a larger treatment trial, hoping that the use of biomarkers will spare children from extra imaging tests and surgery.

“We can have people pee in a cup, drop it in a mailing box, and—hopefully—find out if their tumor has come back without us having to operate on them,” Smith says.

“Right now, if I take a tumor out of a child’s head, his parents are going to sweat bullets wanting to know if the tumor has grown back,” he adds. “They have to drive him to Boston every three months, pay for parking, walk over here, then see us knock the kid out with general anesthesia and do an MRI. Then we wake the kid up, send the family home and make them wait two or three days for a call after the radiologist reads the MRI. And often, I have to tell them, ‘Well, we’re not sure. Let’s check again in three months.’ And the parents are biting their nails for three months.”

Tumor recurrence may, in fact, show up in urine well before it’s visible on MRI. Smith also has data showing that urine markers can help to tell whether a child has moyamoya disease and, potentially, how well he’ll respond to surgery. He’s identified urine markers of arteriovenous malformations, and, in the future, hopes to find urine markers distinguishing between genetic subtypes of medulloblastoma. Right now, these subtypes—recently described by Neurologist-in-Chief Scott Pomeroy, MD, PhD, and collaborators at Dana-Farber/Children’s Hospital Cancer Center—can only be distinguished through tissue analysis.

Smith thrives on finding connections between his surgical practice and the findings of the lab scientists across the street, feeling they have a lot to teach each other.

“People in the lab may say, ‘We have this magic piece of RNA that we can kill tumor cells with,’ but they do it in a Petri dish or in a mouse,” he says. “And I may say, ‘You know what, to surgically put those agents in the brain is not feasible. You have to give an incredibly high dose; you have to reach parts of the brain that aren’t easily reachable. Let’s work on something else. Can we put this in some form of delivery that can be done with liquid? Is this something we can aim in a different direction?’”

Fixing the pipes

Two hours into Maribel’s operation, Smith locates an artery underneath her scalp that he can graft to her brain. “It’s amazing,” he marvels. “We’re in the part of her brain now that affects language and speech, and the part that makes Maribel, Maribel.”

After sewing the artery onto the surface of Maribel’s brain—the artery that should provide a new steady source of blood—Smith and his team carefully replace the small piece of her skull that they’d removed and stitch her skin back together. For Smith, it was a fairly “boring” operation—exactly what he’d hoped for—that should reduce Maribel’s stroke risk to just 4 percent in the next five years.

By 4 p.m., after a nine-hour day, Smith shows no signs of fatigue. He waxes passionate about his larger visions—to establish a multidisciplinary center for cerebrovascular neurosurgery, bringing together teams from Neurosurgery, Interventional Radiology and the Vascular Anomalies Center, and a fellowship that would give neurosurgeons protected time to do research.

“I’m a big fan of trying to make things happen—by taking advantage of all the great resources and smart folks at this hospital,” he says. Then he heads out the door for the gym.

Smith illustrates the moyamoya operation in this video:

Lindsey Hoshaw contributed to this post.

A technology from a small research institute, originally developed as a safer way to make embryonic-like stem cells, just hooked a very large fish. As The New York Times reported yesterday, pharma giant AstraZeneca is betting at least $240 million that this technology could be the source of a variety of new drugs—drugs that spur the body itself to make what it needs.

In 2010, the lab of Derrick Rossi at the Immune Disease Institute, which is now the Program in Cellular and Molecular Medicine at Boston Children’s Hospital, reported that they could reprogram ordinary cells into pluripotent stem cells by simply injecting them with messenger RNAs. The mRNAs reprogrammed the cells up to 100 percent more efficiently than other techniques, and did so without becoming part of the cell’s genome, greatly reducing concerns about cancer associated with other methods.

Key to the discovery were the chemical modifications made to the mRNAs so that cells wouldn’t “see” them as viruses and attack them. This video and this article describe the modified mRNA technique, also described in Cell Stem Cell:

As AstraZeneca recognized, these synthetic, modified mRNAs have therapeutic implications that go far beyond making stem cells. The technology is the flip side of RNA interference (RNAi), the gene-silencing technology that earned the Nobel prize in 2006. Whereas RNAi silences genes by blocking the production of abnormal or unwanted proteins, mRNAs spur cells to make proteins we want to have—adding back proteins our bodies don’t make enough of, or that don’t work as they should.

Messenger RNAs (shown in pink), modified to prevent the cell from attacking them, take instructions to the ribosomes where the desired proteins are made. The cell's DNA is unchanged. (Graham Peterson illustration)

Soon after the paper came out, Boston Children’s Hospital licensed the technology to Moderna Therapeutics in Cambridge. Moderna was cofounded by Rossi, Robert Langer, ScD, of the Massachusetts Institute of Technology, Kenneth Chien, MD, PhD, of Massachusetts General Hospital, and Flagship Ventures Labs, with investment from Flagship and angel investors. Its strategic alliance with AstraZeneca is aimed at developing mRNA therapeutics for the treatment of cancer and cardiovascular, metabolic and renal diseases—with the option for AstraZeneca to select up to 40 drug products for clinical development.

“I am very hopeful and optimistic that modified-mRNA therapeutics will positively impact the lives of patients suffering from a wide spectrum of protein-deficiencies,” Rossi says.

(leesean-Flickr)

There’s a widespread view that attention-deficit hyperactivity disorder (ADHD) is grossly over-treated in kids, especially boys, and will eventually be outgrown. But the results of the first large, long-term population-based study, published recently in Pediatrics, suggest that couldn’t be further from the truth.

While other studies have indicated dire outcomes when children with ADHD grow up, most of these have been small and have focused on the severe end of the spectrum—for instance, boys referred to psychiatric treatment facilities. This new study, started at the Mayo Clinic and led by William Barbaresi, MD, looked at the general population of kids with ADHD and found a greater likelihood of their having other psychiatric disorders as adults, doing jail time or committing suicide.

“Only 37.5 percent of the children we contacted as adults were free of these really worrisome outcomes,” says Barbaresi, now at Boston Children’s Hospital. “That’s a sobering statistic that speaks to the need to greatly improve the long-term treatment of children with ADHD and provide a mechanism for treating them as adults.”

Barbaresi, lead Mayo Clinic investigator, Slavica Katusic, MD, and colleagues followed all children born in Rochester, Minn., from 1976 through 1982, who were still in Rochester at age 5, and whose families allowed access to their medical records. That amounted to 5,718 children.

Of these children, 367 were diagnosed with ADHD, and 232 of them took part in the follow-up study. About three-quarters had received treatment as children. Yet at follow-up:

• 29 percent still had ADHD as adults, diagnosed through structured neuropsychiatric interviews.
• 57 percent had at least one other psychiatric disorder as compared with 35 percent of controls. Most common were substance abuse/dependence, antisocial personality disorder, hypomanic episodes, generalized anxiety and major depression. That number was even higher—81 percent—in the children who still had ADHD as adults, versus 47 percent of those who no longer had ADHD.
• Seven children (1.9 percent) had died by the time of study recruitment, three of them from suicide. Of the 4,946 controls whose outcomes could be ascertained, only 37 children (0.01 percent) had died, five by suicide.
• 10 children with ADHD (2.7 percent) were incarcerated at the time of study recruitment.

Barbaresi thinks the study findings may actually underestimate the bad outcomes of childhood ADHD. The study population in Rochester, Minn., was relatively heterogeneous and largely middle class, and the children tended to have good educations and good access to health care. “One can argue that this is potentially a best-case scenario,” Barbaresi says. “Outcomes could be worse in socioeconomically challenged populations.”

But he feels that bad outcomes can be avoided. Parents of children with ADHD should seek high-quality treatment and have their kids stay in treatment as they enter adolescence—a time when many drift away.

“Data indicate that the stimulant medications used to treat ADHD in children are also effective in adults, although adults tend not to be treated and may not be aware they have ADHD,” Barbaresi says.

Pilot work for a portion of the study was funded by McNeil Pharmaceuticals, a fact cynics may use to discredit the findings. Over-diagnosis is a problem, but when it really is ADHD, treatment can help, and that doesn’t—and shouldn’t—exclusively mean drug treatment. Children should also be closely monitored for other conditions associated with ADHD, including substance use, depression and anxiety; and they should be assessed for learning disabilities, which commonly accompany ADHD, Barbaresi says. Unfortunately, insurance often doesn’t cover these neuropsychological assessments.

As for adults, Barbaresi tells me that many learn they have ADHD only when their child is diagnosed. There are some excellent resources to help them and their spouses live with the disorder—the website of CHADD (Children and Adults with Attention Deficit Disorder), the newly released book Fast Minds and adhdmarriage.com are just a few examples. Parents of kids should read this excellent advice from pediatrician/blogger Claire McCarthy, MD.

If we could immunize infants at birth, far more could be protected from infections.(DFID-UK Dept for International Development)

Right now, immunizations against most infections begin at 2 months of age. But that leaves newborns at risk for infections like rotavirus, whooping cough and pneumococcus during a highly vulnerable time.

In resource-poor countries, this is a serious problem: Many children see a health care provider only at birth, so may miss their chance to be protected. Worldwide, each year, more than 2 million infants under 6 months old die from infections, especially pneumonia. If we could immunize infants at birth, it would be a huge win for global health.

Unfortunately, though, newborns don’t respond to most vaccines. Their immune systems are too immature—which is why few vaccines for newborns exist.

But back in 2006, a lab led by Ofer Levy, MD, PhD, of the Division of Infectious Diseases at Boston Children’s Hospital, demonstrated that while a newborn’s immune response is weak to nonexistent, one piece rallies robustly: a receptor on white blood cells known as Toll-like receptor 8 (TLR 8). It’s one of 10 known TLRs that are part of our innate immune response—our first, rapid defense against infections.

Also in 2006, as it happens, VentiRx Pharmaceuticals was founded. The Seattle-based company focuses on the development of small-molecule compounds that specifically target TLR8. Rob Hershberg, MD, PhD, the company’s founder and CEO, saw Levy’s publications and recognized a scientist who appreciated TLR8’s appeal. He flew to Boston and began to collaborate with Levy’s lab, providing a panel of synthetic TLR8 stimulators known as benzazepines, already in clinical trials for several cancers with the aim of enhancing anti-tumor immune responses.

“I told him that our compounds would be better than anything he’s worked on,” Hershberg recalls.

Indeed, one of them, VTX-294, proved more potent than anything ever tested. In a study reported last week in the online open-access journal PLoS ONE, it induced an exuberant production of cytokines (chemicals that rally the immune response) in newborns’ white blood cells, at levels at least 10-fold that of the best activator of TLR8 known previously.

“VTX-294 not only produced an equal cytokine response in newborns, it was sometimes actually more effective in newborns than adults,” Levy says.

The compound also triggered production of so-called co-stimulatory molecules that enhance immune responses. Better still, even very small amounts of VTX-294 strongly activated antigen-presenting cells, specialized white blood cells that engulf pathogens and display bits of them to the long-term-memory part of the immune system, creating a memory of the invader. Activating these cells is critical for a vaccine’s effectiveness.

“This one receptor seems to lead to more adult-like responses—immediate, short-term responses that are more appropriate for fighting infections,” says David Dowling, PhD, co-first author on the study.

Could VTX-294 make vaccines effective right at birth? Dowling and Levy hope so. With encouraging results in newborn infants’ cells, they now hope to formulate the compound, or a similar TLR8 stimulator, and test it as a vaccine adjuvant in newborn monkeys—a model in which the lab has expertise, and whose responses to TLR8 closely resemble humans’.

“We’re excited about the benzazepines because they are already in the clinical pipeline. That advances the potential for using them in a clinical study in human newborns, once they have been proven safe in animal studies.”

For further background on the Levy lab’s work, see this blog post from 2010.

Ed note: The Obama administration is expected to unveil plans for a decade-long Brain Activity Map project next month. This is Part One of a two-part series on brain mapping.

How is information routed in the brains of children with autism? (Image: Jpatokal/Wikimedia Commons)

It’s now pretty well accepted that autism is a disorder of brain connectivity—demonstrated visually with advanced MRI techniques that can track the paths of nerve fibers. Recent exciting work analyzing EEG recordings supports the idea of altered connectivity, while suggesting the possibility of a diagnostic test for autism.

But what’s happening on a functional level? A study published this week zooms out to take a 30,000-foot view, tracking how the brain routes information in children with autism—in much the way airlines and electrical grids are mapped—and assessing the function of the network as a whole.

“What we found may well change the way we look at the brains of autistic children,” says investigator Jurriaan Peters, MD, of the Department of Neurology at Boston Children’s Hospital.

Peters and Maxime Taquet, a PhD student in the hospital’s Computational Radiology Laboratory, analyzed EEG recordings from 19 different brain regions to track the brain’s electrical cross-talk. They studied two groups of autistic children: 16 with classic autism and 14 whose autism is part of a genetic syndrome known as tuberous sclerosis complex (TSC). They compared these readings with EEGs from two control groups—46 healthy neurotypical children and 29 children with TSC but not autism.

The above image, generated by Taquet and Peters and published in BioMed Central, gives a snapshot of the findings. The 19 brain areas where electrodes were placed are arranged on the periphery of each circle according to their proximity to each other. Compared with neurotypical controls, both groups of children with autism spectrum disorders (ASDs) have multiple redundant connections between adjacent brain areas, but fewer connections going across, linking far-flung areas. (Both groups with TSC show sparser connections overall; those with TSC and ASD have a “double hit.”)

Seeing the big picture

So what does it mean to have a brain network that favors short-range over long-range connections? It’s a pattern that seems consistent with autism’s classic cognitive profile. Think of a child who excels at specific, focused tasks like memorizing streets, but who can’t integrate information across different brain areas into higher-order concepts.

“A child with autism may not understand why a face looks really angry, because his visual brain centers and emotional brain centers have less cross-talk,” Peters speculates. “The brain cannot integrate these areas. It’s doing a lot with the information locally, but it’s not sending it out to the rest of the brain.”

“The brain’s doing a lot with the information locally, but it’s not sending it out to the rest of the brain.”

Using the language of network wonks, Peters and Taquet observed “resilience” in the brains of the children with autism—the ability to find multiple ways to get from point A to point B through redundant pathways. “Much like you can still travel from Boston to Brussels even if London Heathrow is shut down, by going through New York’s JFK airport for example, information can continue to be transferred between two regions of the brain of children with autism,” says Taquet.

Sounds good, right? But, Taquet continues, “In such a network, no hub plays a specific role, and traffic may flow along many redundant routes.”

While good for an airline, resilience may indicate a brain that responds in the same way to many different kinds of situations and is less able to focus on the stimuli that are most important. It’s consistent with cellular and molecular evidence for decreased “pruning” of brain connections in autism.

“It’s a simpler, less specialized network that’s more rigid, less able to respond to stimulation from the environment,” says Peters.

Here’s Peters presenting the work in detail at the 2012 Autism Consortium meeting:

Under a recently announced Autism Center of Excellence Grant from the National Institutes of Health, Peters and colleagues will repeat their analysis, taking EEG recordings prospectively under uniform conditions.

Meanwhile, parallel work suggests that it might be possible to alter autism networks. A team at Cincinnati Children’s Hospital has shown that treatment with Afinitor (everolimus) improves brain connectivity in people with TSC, as indicated by advanced MRI images of brain architecture. And a clinical trial, conducted by Boston Children’s neurologist Mustafa Sahin, MD, PhD, with the Cincinnati team, may soon tell us whether Afinitor improves cognition and features of autism.

Part Two of the series next week will look at fetal brain mapping.

Gretchen Hamn (L) and Margie Young screen a premature infant for retinopathy of prematurity. (Photos: Katherine C. Cohen)

We’re in the Neonatal Intensive Care Unit at South Shore Hospital. Six tiny, swaddled preemies are ready to be examined, their eyes numbed and their pupils dilated with special drops.

Gretchen Hamn, NNP, and medical assistant Margie Young go from isolette to isolette. Young tends to the first baby and gently positions him for his exam. Hamn pulls over a cart and extends a kind of hose with a camera at the tip. This she places directly on each of the baby’s eyes, taking a digital video of his retinas. His heart rate alarm goes off, a sign that he’s not happy with this exam, and he lets out a weak cry. Within a minute or so, the exam is over, and Young tucks him back in.

Hamn is screening the six babies for retinopathy of prematurity (ROP), a major cause of blindness (blind Motown artist Stevie Wonder had it). ROP screening is required for babies born at or before 30 weeks gestation or weighing 1500 grams or less.  The more premature the baby, the greater the risk: About 10 percent of babies born at 32 weeks’ gestation, and as many as 95 percent of babies born at 23 weeks, develop ROP. If ROP is caught early enough, it can be treated with laser therapy or medication.

Hamn now reviews the video, freezing it from time to time and saving still images—six different views—that will help ophthalmologists at Boston Children’s Hospital determine whether the baby is developing ROP. Later she’ll transmit these images to Boston Children’s through a secure system.

The first two babies are free and clear, but Hamn readily spots a telltale light line that indicates ROP on the third baby’s retina. It’s a sign of abnormal growth of the blood vessels that feed the retina. The leaky, tangled vessels form a rigid band of tissue. If this worsens and is left untreated, it could cause the retina to detach and the baby to go blind.

Doctors used to come to South Shore Hospital’s NICU to do this exam manually, looking directly into the retina through the pupil and drawing by hand pictures of what they saw. “They would have to use a speculum to open the eye and a probe to move the eye around and look through a magnifying glass,” says Hamn. “The baby would be crying the whole time. Now, I can take a picture directly, and I like that everyone is seeing the same thing.”

Later, in her office at Boston Children’s, ophthalmologist Carolyn Wu, MD, calls up the images on her computer screen (in urgent cases, they can be viewed on iPhones) and identifies which babies have ROP, and at which stage. She can track their progress on repeat camera screenings, done at least weekly while the babies are in the NICU. “Most ROP goes away,” says Wu. “Less than 10 percent of babies who are screened develop ROP that requires treatment.”

At left, a peripheral view of a healthy retina. At right, a retina with ROP (note the semicircular light band along the right side, beyond which no blood vessels grow).

Any baby with ROP findings warranting referral is transferred from South Shore Hospital to Boston Children’s NICU for further evaluation and treatment. After hospital discharge, all babies who qualified for ROP screening (whether or not ROP was found) see Wu or one of her colleagues in person for a manual exam, either in Boston or in the outpatient clinic in Weymouth.

Physicians used to look directly into the eye and draw what they saw by hand.

The telemedicine system, which Boston Children’s hopes to take to other hospitals in its network, solves a major problem for South Shore Hospital. Multimillion dollar lawsuits around the country, involving babies that went blind, have led many community ophthalmologists to drop ROP screening from their practices. If ROP is missed, or caught but not treated soon enough, physicians are held liable—even when patients don’t come to their appointments.

“We had an ophthalmologist, but his practice opted to no longer perform this service because of the malpractice insurance costs,” says Hamn. “If we couldn’t establish a way for the infants to be screened, we would have had to start transferring them to Boston Children’s for screening.”

Boston Children’s Hospital, with its large Ophthalmology team, is often asked by NICUs around Massachusetts to perform ROP screenings. But even for nearby South Shore Hospital, the screenings would take the Boston physicians half a day, between travel time and waiting while the babies were cared for and for the drops to take effect.

“Previously, we had to say ‘no’ to a lot of NICUs. We just didn’t have the capacity,” says David Hunter, MD, PhD, ophthalmologist-in-chief at Boston Children’s. “Now, the nurses can do the screening when it makes sense to them, without the intrusion of us coming in, and without our ROP specialists having to travel around the state. Patients can stay at the community hospital, and families can be closer to their new baby.”

Tele-ROP, as the project is called, began with work Wu did as a fellow nearly a decade ago with Boston Children’s ophthalmologist Deborah VanderVeen, MD. She tested the digital retinal camera in the NICU in 43 infants and found it compared well with her manual exams, missing no instances of treatable disease.

The collaboration represents a new business model for both hospitals. Health insurers reimburse South Shore’s NICU for the screenings, and the NICU, in turn, pays Boston Children’s ophthalmology department under a separate annual contract.

“Initially it seemed like a foreign concept for one hospital to pay another for this service,” says Gordon Massey, MBA, Ophthalmology administrator. “But given the high liability risk and the better access to screening, outlying hospitals are starting to understand the wisdom of the practice.”

The Tele-ROP program is part of a larger telehealth and telemedicine initiative led by Boston Children’s Hospital’s Innovation Acceleration Program. A similar initiative called TeleConnect allows critical care staff at Boston Children’s to evaluate emergency room patients at South Shore when a transfer is contemplated.

“This type of virtual clinical evaluation is a care delivery model of the future,” says Chief Innovation Officer Naomi Fried. “We look forward to creating similar partnerships with community hospitals for a variety of medical conditions.”