News in Brief
In 2005, Christopher Gordon, MD, traveled to Venezuela to help a colleague treat patients who had unusual facial malformations.
What started as a medical charity mission developed into an odyssey of scientific discovery that uncovered a novel syndrome and is revealing new information about how the human face is formed.
Gordon, a plastic and reconstructive surgeon at Cincinnati Children’s, initially encountered five people. Four women of varying ages and a teen boy had been born with ocular hypertelorism — a wide gap between their eyes — plus a variety of deformations to their eyelids and noses.
Gordon worked with Venezuelan colleague Leopoldo Landa, MD, DMD, to repair the worst of the malformations. While the challenging surgeries helped return a sense of normalcy to the patients, Gordon soon learned there was more to the story.
Further investigation revealed 19 people living in and near Valencia del Rey who were born with similar facial malformations. All the cases involved members of four interrelated families – indicating that a new genetic mutation was at work.
Gordon brought DNA samples from 15 of the affected people back to Cincinnati Children’s. Working with Bruce Aronow, PhD, co-director of the Computational Medical Center, and Steven Potter, PhD, a researcher in the Division of Developmental Biology, he delved into the genetic factors causing the malformations.
Their early work showed a connection to the TWIST1 gene, known to play a major role in craniofacial development. The efforts resulted in the discovery of “Valencia del Rey Syndrome.”
Information about the new syndrome was presented in 2007 and 2008 at the annual meetings of the International Society of Craniofacial Surgery and the American Cleft Palate-Craniofacial Association. But there’s more to the story, Gordon says.
Aronow and Potter are developing a “map” that will show how each of the approximately 30,000 genes in the mouse genome are activated or deactivated during craniofacial development. This map will be similar in many ways to an atlas of kidney development they recently developed.
Initial work on the craniofacial map indicates that the cause behind Valencia del Rey Syndrome may not be tied strictly to an abnormal gene. Instead, the deformations may be caused by problems with the mix of micro RNA that orchestrate how genes behave during embryonic development.
“Everybody used to call micro RNA ‘junk DNA,’” Gordon says. “Now, we are going to look more carefully at these non-coding elements to see what this ‘junk DNA’ actually does.”
Meanwhile, Potter also has been working to develop a line of transgenic mice that express Valencia del Rey Syndrome, complete with the suspected TWIST1 gene mutation and related micro RNA. More details about Valencia del Rey Syndrome likely will be published this year.
“This appears to be a whole layer of control of genes that nobody even dreamed did anything five years ago and now it’s the brave new world,” Gordon says.
Researchers who have worked with Gordon to identify the new Valencia del Rey Syndrome include Leopoldo Landa, MD, DMD, Gerald J. Cho, BS, Catherine Ebert, BS, Cristina Jimenez-Betancourt, MD, Bruce Aronow, PhD, S. Steven Potter, PhD, and Christopher Runyan, MD, PhD.
Scientists here have shown that developing red blood cells can be used to produce life-saving lysosomal enzymes. The finding could offer a treatment option for children with Hurler syndrome, says Dao Pan, PhD, a researcher in the Division of Experimental Hematology/Cancer Biology at Cincinnati Children’s.
Pan was first author on the groundbreaking study, published in November in the Proceedings of the National Academy of Sciences.
Her team reported that transplanting genetically modified hematopoietic stem cells into mice caused their developing red blood cells to produce the enzyme IDUA. Children with Hurler syndrome are unable to produce the enzyme, which is vital to the development of healthy organ and nerve tissue.
“The idea behind this is gene insertion so that after one treatment a person would be cured,” says Pan. “In the mouse models receiving this treatment, the pathology of the peripheral organs tested was completely normalized. And although not as complete, we also saw significantly improved neurological function and brain pathology.”
Pan says the study has positive implications for lysosomal storage diseases beyond Hurler syndrome. This approach to gene therapy carries considerably less risk of stimulating cancer genes, which has been a concern with some forms of gene therapy.
The study included collaboration with other researchers at Cincinnati Children’s divisions of Human Genetics, Bone Marrow Transplantation and Immunology.
For a full report on the study, go to www.pnas.org
The genetic basis of a dangerous heart disorder that sometimes kills young athletes is not related to a single gene, but may include multiple mutations, according to researchers at Cincinnati Children’s.
The study of arrhythmogenic right ventricular cardiomyopathy was published February 9 in the Journal of the American College of Cardiology. The findings, based on 198 participants, raise questions about whether some people with genetic risk factors for the disease are being overlooked.
Beyond the single gene, known as PKP2, the heart condition also may include multiple mutations in a single gene or in many genes at the same time — particularly those in “cell junctions” where cells are held tightly together.
“This study has a significant impact on clinical genetic testing, as simple single-gene analysis, particularly for PKP2 alone, is too narrowly defined and the potential for inaccurate interpretation high,” says Jeffrey A. Towbin, MD, executive co-director of the Cincinnati Children’s Heart Institute and senior author of the multicenter study. “Furthermore, the moderate number of genes that encode for the primary working components of cell junctions strongly suggests that all genes in this pathway should be screened in all subjects.”
When Cincinnati Children’s acquired a 3-Tesla MRI scanner in 1994, researchers here got a nearly decade-long head start in mapping the developing brains of children.
Now a five-year, $6.43 million federal grant will support the work needed to share those learnings with other researchers throughout the U.S. and the world. The new Pediatric Functional Neuroimaging Network will help accelerate the use of functional MRI scans as a tool to diagnose disease, guide surgery and improve behavioral therapy.
Functional magnetic resonance imaging scanners create images of real-time activity within brain cells. These fMRI images reveal precisely which parts of the brain “light up” during motor activity, when listening, or even when thinking or experiencing emotions.
Today, many hospitals employ 3-Tesla MRI scanners. But a decade ago, Cincinnati Children’s was the first pediatric institution to do so, says Scott Holland, PhD, director of the Pediatric Neuroimaging Research Consortium at Cincinnati Children’s.
During those early years, experts here developed baseline information and procedures that are used to this day, including a set of standard brain measures that have been cited in more than 300 research papers worldwide. The new neuroimaging network will develop even more resources for researchers.
Cincinnati Children’s, UCLA and the University of Arizona will serve as pilot sites for databases, test procedures and software to be shared with medical centers nationwide, Holland says. Among the plans: developing an open collection of baseline fMRI data to be gathered from about 150 healthy children who will be tracked to measure their language development and attention skills.
As more centers use fMRI scans to accelerate research, the potential clinical benefits are extensive, Holland says.
More precise diagnoses will likely follow for conditions such as autism, bi-polar disorder and attention-deficit disorders, Holland says.
Longer term, novel approaches to stem cell therapy offer hope that brain damage from injury, stroke, Alzheimer’s disease and other conditions can be repaired. As scientists pursue stem cell therapies, fMRI scans will play crucial roles in guiding treatments and measuring success.
“Some have said we will not see the ability to repair a damaged brain in our lifetimes. But I’m not quite so pessimistic. I do believe that in our lifetime we will be able to make repairs to at least some areas of the brain,” Holland says.
Gone missing: Dr. S.K. Dey and team discovered a link between prematurity and a protein deficiency caused by the missing Trp53 gene.
Some cases of premature birth may be caused by mutations in a gene that normally helps protect the body from genetic instability, according to new research from the Division of Reproductive Sciences at Cincinnati Children’s Hospital Medical Center.
The study, recently published in the Journal of Clinical Investigation, reports that more than 50 percent of the pregnancies in genetically engineered mice lacking the protein p53 ended in premature birth and high rates of neonatal death.
“Preterm birth and prematurity are problems that pose huge long-term social and economic liabilities, and there is an urgent need for research with new approaches to combat this public health concern,” says Sudhansu K. Dey, PhD, division director and the study’s senior investigator.
Premature birth is responsible for 30 percent of all neonatal deaths and is a significant cause of long-term disability. However, the genetic and physiological reasons for preterm births remain poorly understood.
In the new study, scientists analyzed the role of Trp53, a tumor-suppressing gene that expresses the p53 protein. Trp53 is sometimes called “the guardian angel gene” because it plays an important role in preserving genetic stability and preventing mutation.
Dey and his team developed a mouse model in which the Trp53 gene was deleted in the uterus, thus removing uterine p53’s roles from the pregnancy process. The female mice had normal ovulation, fertilization and embryo implantation. But the deficiency of p53 prompted decidual cells that surround implanted embryos to undergo premature senescence and terminal differentiation. This, in turn, led to increased activation of the COX2 enzyme, which is known to trigger early muscle contractions and premature birth.
The researchers say finding this connection between the loss of Trp53 gene and premature birth is striking, because COX2 activity can be inhibited by the drug celecoxib. Dey says future prematurity studies should focus more closely on p53 and the reproductive processes it helps control.
Details of the study can be found at www.jci.org. First author Yasushi Hirota, MD, PhD, is a member of Dey’s laboratory. Also participating were Takiko Daikoku, PhD, and Huirong Xie, PhD, of the Division of Reproductive Sciences, and Heather Bradshaw, PhD, of the Department of Psychological and Brain Sciences, Indiana University. Susanne Tranguch, PhD, assisted with early phases of the study.
Growth potential: a new facility developed by Drs. James Wells (L.) and Chris Mayhew helps researchers grow iPSCs from a patient’s own skin cells.
Cincinnati Children’s has become the first medical center in Ohio, Kentucky or Indiana to launch a facility capable of reprogramming mature human cells into embryonic-like stem cells – which can become any cell type in the body.
The ability to produce induced pluripotent stem cells (iPSCs) will give researchers at Cincinnati Children’s, the University of Cincinnati College of Medicine, and other laboratories in the region powerful new tools to study the causes of disease and to grow replacement tissues for future therapies, says James Wells, PhD, director of the facility and a researcher in the Division of Developmental Biology at Cincinnati Children’s.
“This technology is a bit like the internal combustion engine in terms of how it will drive future advances in stem cell biology,” Wells said. “It allows us to use cells from patients to study what goes wrong at the genetic and cellular level to cause their disease – whether it’s muscular dystrophy, diabetes or any number of degenerative diseases. This technology could allow us to fix genetic defects and use these cells to generate healthy cells and tissues to treat or cure the patient.”
Pluripotent means the stem cells have the theoretical ability to become any of the more than 200 cell types found in the human body. The stem cell team already has coaxed iPSCs into forming pancreatic cells that make insulin, retinal cells of the eye, nerve cells of the brain, intestinal cells, liver cells, and cardiomyocytes that can be seen beating under a microscope.
Because the stem cells come from the patient, they should be safe to transplant back into the patient without fear of rejection, Wells says. Using iPSCs also avoids the ethical concerns that surround stem cells derived from embryos.
“Given the rapidly developing pace of this technology,” he says, “it’s easy to envision a day when pediatric hospitals like Cincinnati Children’s will be able to provide services for generating and banking pluripotent stem cells from specific patients for future therapeutic use.”
To generate induced pluripotent stem cells, researchers take skin biopsies from healthy people or patients with specific diseases and grow the skin cells in a Petri dish. Scientists begin the reprogramming process by inserting specific genes into a cell’s nucleus, instructing the mature cells to essentially reverse their life cycle and become unspecialized “embryonic-like” cells. It takes two to three months in a Petri dish to make a single batch of iPSCs, says Chris Mayhew, PhD, co-director of the facility.
The stem cell facility opened in January, offering a full range of pluripotent stem cell services, including access to human pluripotent stem cell lines, generating iPSC lines, cell line maintenance, and training for scientists wanting to use cell lines in their own laboratories.
So far, Cincinnati Children’s has invested about $600,000 to open the facility. The medical center is discussing plans to expand the facility as demand for stem cell lines grow. Additional information about the facility, including applicable fees, is available at http://research.cchmc.org/stemcell.
Double whammy: Dr. Bruce Trapnell’s work led to discovering an inherited form of a rare lung disease and a potentially better treatment.
In October 2007, a 6-year-old girl was referred to Cincinnati Children’s to receive treatment for pulmonary alveolar proteinosis (PAP), a rare and life-threatening condition that occurs when too much surfactant builds up in the lungs.
The “common” form of PAP occurs only six or seven times in one million people. In about 90 percent of these cases, the patient develops an antibody that interferes with the natural process of clearing excess surfactant from the lungs. Without treatment, patients essentially drown from a substance normally considered beneficial to proper lung function.
Testing revealed that the young girl did not have the tell-tale PAP antibody, yet clearly was suffering from the disease. Bruce Trapnell, MD, director of translational pulmonary medicine research at Cincinnati Children’s and director of the Rare Lung Diseases Network, set out to discover why.
The effort produced two important results: the first description of an inherited form of PAP (published November 2008 in the Journal of Experimental Medicine) and a blood test that will make it easier to detect other, similar cases. Meanwhile, early research continues into a possible genetic therapy for the condition.
Researchers determined that the girl was born with a mutation of the CSF2RA gene, which severely disrupts the function of a protein called GMCSF. This allowed surfactant levels to build up to dangerous levels.
“These are the first data to demonstrate familial PAP in humans and the critical role of the gene CSF2RA,” Trapnell says.
Whole lung lavage therapy to drain excess surfactant from the lungs improved the girl’s condition. Without treating the underlying GM-CSF disruption, however, she will need repeated lavage treatments.
Doctors are seeking FDA approval to employ an experimental inhaled GM-CSF therapy that has been used with some success in other PAP cases. Bone marrow transplantation is another treatment, although one of last resort, Trapnell says.
In the meantime, scientists at Cincinnati Children’s have developed a test that uses GM-CSF levels as a way to detect the inherited form of PAP. So far, doctors have used the test to diagnose eight children with familial PAP – including the girl’s 8-year-old sister, who so far has not shown symptoms of the disease.
Researchers here also are testing, in mice, a possible genetic therapy that could reduce or eliminate the need for repeated whole lung lavage treatments, Trapnell says.
To continue its commitment to improving health outcomes, Cincinnati Children's has announced plans to launch the James M. Anderson Center for Health Systems Excellence.
The Center is named for the hospital’s recently retired president and CEO, who in his 13-year tenure helped make Cincinnati Children’s a national leader in quality improvement efforts. The Center will advance the hospital’s work in quality and safety, capacity management, family-centered design, disease-based care, population health and bench-to-bedside integration.
The Anderson Center will be led by Uma Kotagal, MBBS, MSc, senior vice president, Quality and Transformation
Cincinnati Children’s Hospital Medical Center is one of eight pediatric institutions and 45 hospitals of any kind to be ranked among the nation’s “top hospitals,” based on results of the annual Leapfrog hospital survey.
The survey of 1,206 hospitals is the only public, national comparison of hospitals on mortality rates, infection rates, safety practices and cost-efficiency.
