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+ | ====== Presentation - A new approach to treating intraphagocytic CWD bacterial pathogens in sarcoidosis, | ||
+ | |||
+ | {{ youtube> | ||
+ | |||
+ | |||
+ | **Type:** Conference presentation\\ | ||
+ | **Presenter: | ||
+ | **Conference: | ||
+ | **Location: | ||
+ | **Date: | ||
+ | **Additional content:** [[https:// | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | ===== Transcript ===== | ||
+ | |||
+ | |||
+ | Thank you John, and thank you to the academy for inviting me to | ||
+ | come. | ||
+ | |||
+ | Well the first two slides are just links to some of the papers that | ||
+ | we've published on these topics. They are there for your references. | ||
+ | |||
+ | Our FDA coordinator also told me to make sure that I point out | ||
+ | that there are FDA applications current for both Sarcoidosis, | ||
+ | designations in the drugs in Sarcoidosis, | ||
+ | Treatment Lyme Disease Syndrome(what most of you would know | ||
+ | as chronic Lyme) active; and the numbers are all at the bottom | ||
+ | and you can find a copies of all of those applications on the | ||
+ | Internet if you want to look in more detail at the regulatory issues. | ||
+ | |||
+ | |||
+ | The disclaimers. Many of the disease states that I am going to | ||
+ | cover in this presentation, | ||
+ | generally accepted as being caused by pathogens. Much of this | ||
+ | presentation is based on leading edge science and not on weight | ||
+ | of evidence. The Phase 2 clinical trial is ongoing. | ||
+ | Even when shown the science and the microscopy, some experts | ||
+ | still disagree to the existence of persistent pathogens. | ||
+ | |||
+ | The FDA has now designated trials for long term use of | ||
+ | Minocycline and Clindamycin in the treatment of Sarcoidosis but | ||
+ | not in the other indications I am going to discuss. We are going to | ||
+ | Phase 3 trials over the next year or two. | ||
+ | |||
+ | Now in addition to our previous papers, the list of which I've just | ||
+ | gone through, many of the slides have Pub Med ID numbers on | ||
+ | them. Those are citations to support the science in any specific | ||
+ | slide. So if there is something on a specific slide that you feel I'm | ||
+ | reaching a bit with, make sure you look at the Pub Med ID | ||
+ | citations first. | ||
+ | |||
+ | And there are also a few new slides resulting from recently | ||
+ | published peer review papers which are not in the syllabus and | ||
+ | which have not been reviewed by AAEM. These have that little red | ||
+ | logo at the bottom saying "NOT IN SYLLABUS." | ||
+ | |||
+ | |||
+ | So here is the first one, "Not in Syllabus." | ||
+ | part is in the syllabus but I changed the text on the bottom, as you | ||
+ | will see on the next slide. | ||
+ | |||
+ | The quotation at the top, from a gentleman called John Arbuthnot, | ||
+ | from Sixteen Hundred and Ninety two. Believe it or not, this | ||
+ | quotation really forms the basis of evidence-based medicine. This | ||
+ | is the gentleman that wrote the first book on statistics of the laws | ||
+ | of chance in 1692 and as you would all know, without statistics and | ||
+ | without the concepts of statistics, we wouldn' | ||
+ | evidence-base that we have at the moment. | ||
+ | |||
+ | What John said ... [read quote from slide]. | ||
+ | |||
+ | The primary difference between mathematical science, which is | ||
+ | primarily what I'm going to deal with in this presentation, | ||
+ | evidence-based medicine is that one is definitive and one is | ||
+ | interpretive. Mathematical science tries to define relationships | ||
+ | between metabolites. Tries to define what's going on. Evidence- | ||
+ | based medicine tries to interpret the results of observations in a | ||
+ | reliable manner. | ||
+ | |||
+ | As we enter the 21st century, the tools to reduce some important | ||
+ | medical dilemma to mathematical precision are now available in | ||
+ | Molecular Genomics. Now one thing I want to point out is that | ||
+ | true science has no concept of weight of evidence. It doesn' | ||
+ | matter how many times you add up the balance in your checking | ||
+ | account, you can start at the bottom of the page and work up, you | ||
+ | can start at the top of the page and work down, the numbers you | ||
+ | are going to get are exactly the same and any body who has done | ||
+ | high school arithmetic can sit down and check your calculations | ||
+ | for you. So therefore, there is no need for weight of evidence. | ||
+ | |||
+ | As a hypothesis is advanced, it can be tested and it stands until it is | ||
+ | rejected or improved. E=MC2 has been improved many times | ||
+ | over the years, but the basic E=MC2 is still there, still in place. | ||
+ | If the problem is deterministic, | ||
+ | |||
+ | This is a new slide, and as an example of how molecular and | ||
+ | evidence-based knowledge are symbiotic and the need for both | ||
+ | fields to work in closer cooperation, | ||
+ | published my answer to a question which had been posed in July | ||
+ | |||
+ | |||
+ | (2006) by Dr DS Grimes. Dr Grimes posed the hypothesis, "Are | ||
+ | statins analogues of Vitamin D?" | ||
+ | |||
+ | |||
+ | Now that's my paraphrase and I'm being a little bit cruel but I | ||
+ | wanted to give you a quick encapsulation of what the hypothesis is | ||
+ | about. This is a hypothesis which cannot be solved by evidence- | ||
+ | based medicine. It cannot be solved because the variables that are | ||
+ | involved, the number of variables that are involved is too high and | ||
+ | they are not appreciated by the investigator. | ||
+ | |||
+ | When you have too many degrees of freedom, your statistical | ||
+ | analyses of the epidemiology just break down. However, the | ||
+ | evidence-based dilemma is easily solved by Molecular Biology and | ||
+ | I'll show you this later in the presentation. I'm going to be talking | ||
+ | about statins. That was actually in the syllabus. | ||
+ | |||
+ | |||
+ | But I wanted to point out that biochemists are also failing. [Read | ||
+ | slide to ' | ||
+ | [Continue reading slide to knowledge] Yet the insights that are | ||
+ | resulting from science that the biochemists are producing [continue | ||
+ | slide]. | ||
+ | |||
+ | First I need to say little bit about Th1 inflammatory disease. [Read | ||
+ | slide first Paragraph] | ||
+ | Unfortunately, | ||
+ | only in the tissues and it's not an endocrine hormone. It doesn' | ||
+ | circulate through the bloodstream. [Read 2nd Paragraph to tissue] | ||
+ | if you want to do a biopsy [finish 2nd Paragraph]. | ||
+ | |||
+ | Consequently, | ||
+ | historically been measured in order to try and infer whether a | ||
+ | patient is presenting with a type Th1 inflammation, | ||
+ | inflammation. A type Th1 inflammation is typically those which | ||
+ | result from infection, such as Tuberculosis, | ||
+ | those are Th1 or they cause Th1 immune responses. Th2 is more | ||
+ | typically those which result from what we call allergies. However, | ||
+ | none of these other cytokine are specific and this has led to | ||
+ | considerable confusion. People think in terms of Th1 and Th2, but | ||
+ | basically all of the autoimmune diseases are Th1. | ||
+ | |||
+ | Louis Pasteur once noted that in science, chance favors the | ||
+ | prepared mind. There are 2 factors: Chance, it's all based on luck | ||
+ | (chuckle), being in the right place at the right time. But the | ||
+ | prepared mind is important. You have to be able to observe what | ||
+ | you see, when you are there. We were lucky, we were able to | ||
+ | break that particular nexus and realized that all of these diseases | ||
+ | we were dealing with were in fact, Th1 diseases. | ||
+ | |||
+ | ... Suicidal idealation, this is not something I've heard anybody | ||
+ | speak about, so far at the conference. It's a big problem with us. | ||
+ | As the immunopathology takes over, the cytokine storm hits. | ||
+ | Suicidal idealationoccurs in a significant number of these people | ||
+ | and it's treatable. As a matter of fact, it's avoidable. | ||
+ | |||
+ | Now those of you that know about the Marshall Protocol and have | ||
+ | been following what we have been doing over the last five or six | ||
+ | years would know that we've conducted this on the Internet as an | ||
+ | open study. Any physician such as yourselves can register and get | ||
+ | full access to the database of all the reporting from the patients in | ||
+ | the study going right back to day one, right back to about 2001. | ||
+ | A year ago, this was heresy. Everybody said you can't do an open | ||
+ | study. You can't do an adaptive study. You can't change the | ||
+ | conditions as you are going along. You can't do anything on the | ||
+ | Internet. | ||
+ | |||
+ | Well, things change. The drug pipeline is now nearly empty and | ||
+ | the FDA is getting quite concerned that not only is the drug | ||
+ | pipeline nearly empty, but the drugs that are there don't work | ||
+ | properly anyway. | ||
+ | |||
+ | And so I put a quote in there now which is given by the FDA | ||
+ | Deputy Commissioner for Medical and Scientific Affairs, who is | ||
+ | actually in charge of clinical trial evaluation at the FDA, Dr Scott | ||
+ | Gottlieb, from an actual conference that was held earlier this year | ||
+ | on adaptive trial design. And basically, I'll save time by saying that | ||
+ | he says [paraphrase] " | ||
+ | these things, guys." And whenever I read the stuff he writes, it | ||
+ | makes me think of the things we are doing. | ||
+ | |||
+ | Now we published our initial results in 2004 in the Th1 syndrome | ||
+ | called Sarcoidosis. Sarcoidosis is a rare disease and it's a disease | ||
+ | that we chose to investigate first. We were lucky to choose this | ||
+ | one, it happens to be a prototypical case for all of the Th1 | ||
+ | diseases. And there are a number of things in Sarcoidosis which | ||
+ | makes the analysis of the disease state very much easier than it is | ||
+ | in some of the more complex conditions. | ||
+ | And in particular, by the time the inflammation has advanced to | ||
+ | the stage where it forms self-perpetuating granuloma, there are | ||
+ | very few antibodies being formed. So there is no longer the red | ||
+ | herring of the antibody formation and perhaps the antibodies | ||
+ | making people sick. We knew the antibodies weren' | ||
+ | people sick because there weren' | ||
+ | something else that was making people sick, probably a cytokine | ||
+ | storm. Where was it coming from? | ||
+ | |||
+ | That was the other Pasteur piece of luck. We happened to be | ||
+ | studying the correct disease that turned out to be the prototype for | ||
+ | many, many other Th1 diseases. | ||
+ | |||
+ | So at Karolinska institutet in Stokholm, at DMM 2006, I gave the | ||
+ | following figures for the recovery rate in several key autoimmune | ||
+ | diagnoses. These were extracted from the Phase 2 and 3 reports. | ||
+ | These are people that have mainly been on the protocol for twelve | ||
+ | months or so on average. | ||
+ | |||
+ | As you can see, Rheumatoid Arthritis has very good success. Eight | ||
+ | have a primary diagnosis of Rheumatoid Arthritis, seven of them | ||
+ | are reporting improvement in their condition. | ||
+ | |||
+ | With Hashimoto' | ||
+ | supplements or they don't. There the ratio is twenty out of twenty- | ||
+ | five are improving. | ||
+ | |||
+ | Osteo Arthritis is an interesting one. I was surprised how many | ||
+ | people with Osteo Arthritis we had in the cohort. | ||
+ | And then the ones that we are known for: CFS/ | ||
+ | Encephalmyelitis. Let me stick with Chronic Fatigue Syndrome. | ||
+ | Seventy-seven with about forty reporting ongoing resolution. | ||
+ | Cardiac Arrhythmia is an interesting one. This came up in a case | ||
+ | study yesterday. And I would like to have an opportunity to join this | ||
+ | group again in about five years time when we have more data and | ||
+ | a lot more history under our belts. And talking again about | ||
+ | cardiac arrhythmia, this is a very classic symptom of late stage Th1 | ||
+ | disease. | ||
+ | |||
+ | Sarcoidosis of course, ninety-two with fifty seven recovering. | ||
+ | |||
+ | Diabetes, five and three. | ||
+ | |||
+ | Uveitis, eighteen and twelve. | ||
+ | |||
+ | 34/20 in Fibromyalgia and 10/8 in Irritable bowel syndrome. | ||
+ | It is an open study, we don't put any preselection conditions on the | ||
+ | patients that want to join, and that's why we have accumulated | ||
+ | such a wide range of diagnoses. There are about 500 patients at | ||
+ | the moment that are regularly reporting and about ten times that | ||
+ | number that we are aware of... of course, that don't report. | ||
+ | |||
+ | There are a few more diagnoses on this slide. It is in your syllabus | ||
+ | so I won't go over them in too much detail. Point out Psoriatic | ||
+ | Arthritis is a new one, also Multiple Sclerosis. We have quite a few | ||
+ | Multiple Sclerosis patients now, at least it is getting up to statistical | ||
+ | significance. Most of those are being looked after by Dr Greg | ||
+ | Blaney in Canada. | ||
+ | |||
+ | Tinnitus resolves. Usually acute Tinnitus resolves quite quickly and | ||
+ | then takes quite a lot longer to resolve fully, several years to | ||
+ | resolve fully. Like peripheral neuropathy, Tinnitus is one of the slow | ||
+ | symptoms to resolve. | ||
+ | |||
+ | Juvenile ADHD, I've got two out of two and I've already chatted | ||
+ | with the autism, the people that are interested in autism. That was | ||
+ | quite a surprise to us. Both of those patients had primary diagnosis | ||
+ | in other areas. One had a Lyme disease diagnosis, the other had | ||
+ | Sarcoidosis and Uveitis diagnosis. The uveitis being key there. The | ||
+ | patient was going blind. All of the problems have resolved. As the | ||
+ | primary inflammatory diagnosis resolved, the attention and other | ||
+ | problems, psychological problems, resolved as well. Resolved | ||
+ | spectacularly. Both are back at school and doing very well. | ||
+ | |||
+ | Well, five steps basically. [Read to end of step 2] | ||
+ | Olmesartan is licensed for sale throughout the world as an | ||
+ | angiotensin-receptor blocker. But it has significant activity in other | ||
+ | receptors. One of the receptors it is very active in is the VDR. It | ||
+ | activates the VDR. | ||
+ | |||
+ | [Read step 3, to " | ||
+ | 48 hours it is usually all they can handle. And then increasing to | ||
+ | 100mg over about three months. | ||
+ | |||
+ | [Read step 4] The choice is made based on suicidal ideation. | ||
+ | Clindamycin tends to exacerbate any suicidal ideation or | ||
+ | depression that is present and we avoid it in the early stages of the | ||
+ | protocol with people who have that tendency. | ||
+ | |||
+ | [Read step 5 to 3 antibiotic combo] "Low dose?", | ||
+ | Azythromycin, | ||
+ | days when they start. They eventually work up to about half of an | ||
+ | Azythromycin tablet as ultimately the bacterial load is totally | ||
+ | removed, and then they can just guzzle the antibiotic like candy, | ||
+ | like a healthy person can. | ||
+ | |||
+ | But initially, when the immune system is working, those antibiotics | ||
+ | do an incredible job of killing the bacteria. | ||
+ | |||
+ | |||
+ | So, this was a warning that my FDA liaison — contact — said | ||
+ | " | ||
+ | |||
+ | [Read warning to apoptosis] programmed cell death [continue | ||
+ | warning]. | ||
+ | |||
+ | Immunopathology. That is the word that is being used instead of | ||
+ | " | ||
+ | cytokine storm that occurs in acute episodes. " | ||
+ | first heard Rolf Zinkernagle use it at Karolinska and it is becoming | ||
+ | more and more commonly used. It is basically what happens to | ||
+ | the body when the immune system is doing its job. It includes | ||
+ | apoptosis, cytokene storm, all of the other effects on the body from | ||
+ | the immune system doing its job. Immunopathology. | ||
+ | [Read Steps needed]. | ||
+ | |||
+ | The moment pathogens start being recognized and start being | ||
+ | killed, your white and red blood cell counts are going to go all | ||
+ | over the place. | ||
+ | |||
+ | [Read Step 1 to receptors], which is rather handy to reduces | ||
+ | fibriotic tissue deposition. | ||
+ | |||
+ | Now we use special antibiotics. You might not think they are | ||
+ | special, but they are special in their interaction. The antibiotics | ||
+ | have a direct action on a part of the bacterial genome which is | ||
+ | called the ribosome. The ribosome, if you cast your mind back to | ||
+ | molecular biology, is where the messenger RNA from gene | ||
+ | transcription, | ||
+ | |||
+ | In bacteria, they only have one ribosome. The human body has | ||
+ | two ribosomes. Bacteria only have one, called the 70S ribosome, | ||
+ | and the antibiotics that we use block the action of the 70S | ||
+ | ribosome. They block the ability of the bacteria to produce protein. | ||
+ | Particularly to use the protein that they use to evade the immune | ||
+ | system. Because clearly, the bacteria wouldn' | ||
+ | within the phagocytes unless they had a mechanism evolved | ||
+ | probably over centuries that allows them to evade phagocytosis. | ||
+ | So the rate of bacterial death is controlled by inhibiting the protein | ||
+ | synthesis, using only intermittent low doses of bacteriostatic | ||
+ | antibiotics. | ||
+ | |||
+ | The other advantage of going after the ribosome is a small | ||
+ | amount of antibiotics kills a small number of bacteria. In fact, one | ||
+ | molecule binds into one ribosome. So it is not quite linear, but it is | ||
+ | a proportional response. | ||
+ | |||
+ | So why? Why does this intervention work when all the previous | ||
+ | antibiotic therapies used for these diseases didn't induce recovery? | ||
+ | |||
+ | [Read 1] | ||
+ | In other words, there is a model. We can fit the disease that we | ||
+ | observe to a model. So when I say that five MS patients is a good | ||
+ | sized sample, its because they are behaving exactly as the model | ||
+ | predicts. So we have the extra statistical guidance from the model | ||
+ | as well as from the data. | ||
+ | |||
+ | It works because [Read 2]. | ||
+ | [Read 3] The VDR, which was long thought to be ' | ||
+ | with ' | ||
+ | immunity. And I'll talk a LOT more about this as we go forward. | ||
+ | [emphasis repeat] Vitamin D is at the heart of innate immunity. | ||
+ | [Read 4]. That is part of the model. We have to know how the | ||
+ | people get sick, and how the sickness progresses over the years. | ||
+ | [Reference 5]. For example, sequencing the bacterial genomes | ||
+ | have shown that many of the common bacteria, even Staph | ||
+ | aurious, has got plasmids. Plasmids are little self-replicating loops | ||
+ | or sticks of DNA that can exist and replicate on their own without | ||
+ | the main chromosome. And many bacteria have these plasmids. | ||
+ | The plasmids can persist and if they are not destroyed by the | ||
+ | immune system, they can interact with other species of bacteria. | ||
+ | Toward the end, I will show you exactly how that happens with a | ||
+ | bacterium species called antrhax. | ||
+ | |||
+ | So the plasmids are persistent and prolific. So when you have a | ||
+ | chronic disease which is accumulating over a lifetime, certainly | ||
+ | over many years, you're not going to have just one species that is | ||
+ | active. You are going to have a number of species that are active. | ||
+ | You are going to have a number of plasmids that are active. You | ||
+ | are going to have a number of viruses that are active. | ||
+ | The ubiquitous EBV. I think I can find a paper for just about any | ||
+ | disease you like name which blames EBV as the cause of that | ||
+ | disease. No. But EBV is very hard to kill off. Its plasmids is just two | ||
+ | genomes long; something like a 160,000 base pairs long; it's very, | ||
+ | very small; very, very hard for the immune system to recognize and | ||
+ | kill; and it persists. And it interacts with any other species of | ||
+ | pathogens in exactly the same way as it interacts with the human | ||
+ | genome. And it will cause mutations. The bacteria cause | ||
+ | mutations. | ||
+ | |||
+ | And the last reason the intervention works is [reference 6] because | ||
+ | the MODEL recognizes that neo-natal pathogens persist in the | ||
+ | brain. [Repeat intended] Neo-natal pathogens persist in the brain. | ||
+ | |||
+ | Well, now we get into some pretty pictures. | ||
+ | These are pictures of a receptor, it is a G-Protein Coupled | ||
+ | Receptor that goes through a membrane. And each of the little | ||
+ | colored balls are atoms. Each of the similarly colored atoms form | ||
+ | part of an amino acid, which together make the protein which is | ||
+ | folded into the receptor. | ||
+ | |||
+ | Well it's not very easy analyzing that sort of diagram, so | ||
+ | biochemists tend to draw everything in terms of spirals and loops. | ||
+ | Each one of these spirals is a cascade of amino acids. It is shown | ||
+ | diagramatically as a spiral so that we can see more easily what it | ||
+ | is actually doing. | ||
+ | |||
+ | We also have a more precise 2-dimensional representation that | ||
+ | you will find in some of my papers. And here we have the actual | ||
+ | amino acid of the protein (see lower right "Leu 293" highlighted in | ||
+ | video) and it shows which are the atoms or ligand of the chemical. | ||
+ | In this case it is olmesartan but it could be any of the vitamins D. | ||
+ | It shows which of the atoms interact with the ammino acid residues | ||
+ | (see lower right O1 red atom highlighted in video), and it also | ||
+ | shows the hydrogen bonds when they exist as well. Making it very | ||
+ | easy to try and figure out whether we are dealing with an agonist, | ||
+ | or an ANtagonist. Much harder to do that in 3-dimensions. | ||
+ | |||
+ | |||
+ | I want to talk about the nuclear receptor type one family because it | ||
+ | turns out that this family is most closely related to the operation of | ||
+ | the immune system — both the innate immune system, and the | ||
+ | adaptive immune system. | ||
+ | |||
+ | The key receptors for which we have known structure models. In | ||
+ | other words, we not only know that the bacterial genome looks like | ||
+ | this but we also know in 3-dimensional space that x-ray | ||
+ | spectroscopy has told us exactly where each atom is in the | ||
+ | molecule. In this case, we're talking about the human genome. But | ||
+ | it's the same theory, we've got the VDR (Vitamin D Receptor), the | ||
+ | Progesterone Receptor, PPAR-alpha (which is one of the lipid and | ||
+ | immune system mediators), PPAR-gamma (which is also lipid and | ||
+ | immune system), Androgen Receptor, the Estrogen Receptor, | ||
+ | glucocorticoid receptor, Thyroid-alpha-1, | ||
+ | mineralcorticoid receptor. | ||
+ | |||
+ | Now surprisingly, | ||
+ | as spirals (I guess maybe I should have done a slide of it for you), | ||
+ | but they are all very, very similar. And that is why they are the type | ||
+ | 1 nuclear receptors. | ||
+ | |||
+ | And you know molecules that will go into the VDR usually only go | ||
+ | into PPAR-gamma and some of the other type 1 receptors as well. | ||
+ | They affect more than one function of the body. | ||
+ | |||
+ | |||
+ | So nuclear receptors are responsible for the transcription of the | ||
+ | DNA genes to strands of RNA, which are then translated into | ||
+ | proteins in the ribosomes. And they are very important. | ||
+ | I've put a link there to a simplified set of flash animations for those | ||
+ | of you that want a crash course on how this all works. It is a very | ||
+ | simple crash course. I really recommend you have a look at it. | ||
+ | (https:// | ||
+ | |||
+ | |||
+ | Now we're going to look at some simplified 3-D animations of the | ||
+ | transcription molecules, just to give us an overview. | ||
+ | |||
+ | What we have here, we have a strand or double strand of DNA | ||
+ | (highlight blue/ | ||
+ | are the base pairs that run across (highlight on video shows | ||
+ | vertical ball lines at bottom center of diagram) the two backbones | ||
+ | of the DNA. Across the center you have the hydrogen bonds that | ||
+ | hold the DNA together (highlight moves L-R across center of | ||
+ | vertical ball lines). Hydrogen bonds that are peeled apart is when | ||
+ | the RNA is produced. The RNA is basically ½ of the DNA double | ||
+ | spiral. | ||
+ | |||
+ | So when the nuclear receptors do their job and transcribe a gene, | ||
+ | what they are actually doing is breaking the hydrogen bonds and | ||
+ | producing the RNA in a very complex and clever fashion which | ||
+ | doesn' | ||
+ | statistically drift around and come together in exactly the right way. | ||
+ | Nuclear receptors typically take days to effect their action. | ||
+ | Key to nuclear receptors are the zinc fingers here (video highlights | ||
+ | upper left center large yellow/ | ||
+ | zinc, the yellow, sulpher-disulfides. Actually cystines to be honest. | ||
+ | And they are a key part to positioning the helixes which go through | ||
+ | the (video highlights lower left solid light grey spiral) DNA and find | ||
+ | the exact chain that needs to be translated based on the exact | ||
+ | mapping of attractive and repulsive forces and then do the DNA | ||
+ | transcription. | ||
+ | |||
+ | It is an amazing system. I've shown here that there two receptors | ||
+ | because usually one nuclear receptor doesn' | ||
+ | form a homodimer but it usually forms a Heterodimer. So you have | ||
+ | a VDR coupled with a retinoid-X receptor and then the two of them | ||
+ | transcribe genes. There is also a cofacter that gets involved as | ||
+ | well. Quite complex and we really don't know a lot about it yet. | ||
+ | I mean we now have the genes to transcribe, but we don't know | ||
+ | exactly which co-factors go with which receptors. | ||
+ | |||
+ | |||
+ | The biggest surprise we got when we started doing this modeling, | ||
+ | was the high affinity of the ARBs and Statins for VDR and PPAR- | ||
+ | gamma, Nuclear Receptors which are both key to the immune | ||
+ | system. | ||
+ | |||
+ | Now these are very flexible, highly polar ligands. And we thought | ||
+ | they might have an affinity for other G-protein coupled receptor | ||
+ | membrane receptors, in other words receptors that go through a | ||
+ | membrane rather than exist in the nucleus of the atom. | ||
+ | |||
+ | But their affinity for the Nuclear receptors was a real surprise. | ||
+ | |||
+ | |||
+ | Here's a big table which represents months of computing. | ||
+ | But what we have done here is used special software that | ||
+ | computes the interaction between thousands of atoms and figures | ||
+ | out for each of the (video highlights drug names in the sartan | ||
+ | group) ARBs and each of the Statins (video highlights drug names | ||
+ | in the statin group), which receptors they are going to have an | ||
+ | affinity for — if any — and which receptors they are going to | ||
+ | switch on or switch off. | ||
+ | |||
+ | And if we just look at the statins first, thinking back to the question | ||
+ | posed by Grimes in The Lancet: "Are statins analogues of vitamin | ||
+ | D?" Well the first thing that pops out is that the VDR here (video | ||
+ | |||
+ | highlights VDR column head), there is a huge difference between | ||
+ | the statins. | ||
+ | |||
+ | Simvastatin (video highlights 4 at base of the VDR column) hs got | ||
+ | quite a low number which means quite a high affinity, but | ||
+ | Rosuvastatin, | ||
+ | have any affinity for the VDR at all. Pravastatin that is effectively no | ||
+ | affinity. Lovastatin would have a little affinity if a low dose is used | ||
+ | in vivo. | ||
+ | |||
+ | So there is a huge difference between the statins. Just thinking of | ||
+ | |||
+ | the statins as a group is a concept that is dangerous clinically, let | ||
+ | alone to try and extrapolate that to talking about the statins | ||
+ | functioning as a hormone would. | ||
+ | |||
+ | But you can also see if you take Simvastatin, | ||
+ | a high affinity for the VDR, it's got 10x higher affinity for the PPAR- | ||
+ | gamma, same for PPAR-alpha as the VDR. The Gluco-corticoid | ||
+ | receptor -the home for cortisole- it has a high affinity for, also the | ||
+ | MCR. The Progesterone receptor, the Alpha-Thyroid and the Beta- | ||
+ | Thyroid. Simvastatin is a very, very active statin. | ||
+ | |||
+ | Whereas Atorvastatin for example, primarily hits PPAR-gamma and | ||
+ | alpha and incidently hits the Gluco-cortisole axis for the GCR. | ||
+ | However, some of the ARBs are a little bit better behaved than that. | ||
+ | Telmisartan is very poorly behaved. It totally shuts off the VDR the | ||
+ | moment you give it to somebody. This is NOT good. | ||
+ | |||
+ | Olmesartan, here (video highlights 10 in the VDR column) has got | ||
+ | a moderately low affinity for the VDR, and that is one of the | ||
+ | reasons why we have to use a higher dose when we are using it to | ||
+ | modify the VDR than when we are modifying the Angiotensen- | ||
+ | receptor where it has a much higher affinity. But it is nicely | ||
+ | controlled in the PPAR-gamma and -alpha (video highlight across | ||
+ | Olmesartan Estimated Ki row) and GCR. It hits the progestrone | ||
+ | receptor but it doesn' | ||
+ | |||
+ | Beta-Thyroid it hits but we're not really sure what Beta-Thyroiod | ||
+ | does yet. What we know about Beta Thyroid is that if you breed | ||
+ | mice that don't have the beta thyroid receptor, then they are born | ||
+ | deaf. Otherwise they seem to be fine. (Audience chuckles) So we're | ||
+ | still trying to figure out what the Beta Thyroid does. | ||
+ | |||
+ | The ability to breed mice with gene knock-outs without these | ||
+ | receptors is a PRIMARY new tool that has become available to the | ||
+ | biochemist. It is invaluable. Unfortunately with the GCR, if you | ||
+ | knock out the GCR the mice never survive past gestation. So we | ||
+ | don't know a heck of a lot about the GCR either except it is at the | ||
+ | root of the Cortisole axis of the adrenal. | ||
+ | |||
+ | But anyway, it is a big table and I have it printed on a sheet of | ||
+ | paper and I have to refer to it all the time, so I'm not going to | ||
+ | expect any of you to commit that to memory. | ||
+ | |||
+ | Now I'm going to look at a very simple hormonal system. The | ||
+ | adrenal axis. And up here (video highlights top word | ||
+ | " | ||
+ | looking at the GlucoCortocoid Receptor, the nuclear receptor, with | ||
+ | a promotor which is " | ||
+ | receptors, and then the promotor and the receptor together bind | ||
+ | to the DNA and transcribe the gene. | ||
+ | |||
+ | The GlucoCortocoid Receptor is responsible for producing | ||
+ | Corticotrophin Releasing Hormone (CRH highlighted), | ||
+ | turn produces the Pro-Opeo-Milleno Cortin and when that is | ||
+ | metabolized, | ||
+ | produced. ACTH of course you know, that catalyzes the conversion | ||
+ | of Cholesterol into Cortisol. Then Cortisol goes up and docs into | ||
+ | the GlucoCortocoid Receptor (highlight shows arrow line path left | ||
+ | and up to GCR) and you have a feedback loop, which keeps the | ||
+ | Cortisol levels of the body at roughly constant levels. | ||
+ | That is a very simple, straight forward hormone loop. | ||
+ | |||
+ | |||
+ | Unfortunately, | ||
+ | would expect for something that is at the heart of the immune | ||
+ | system. It has adapted over many, many millennia. | ||
+ | The "not in Syllabus" | ||
+ | shifted from what is printed in your syllabus. Also, since that | ||
+ | syllabus was published, there has been new studies showing that | ||
+ | the Androgens (video highlights lower left corner word | ||
+ | " | ||
+ | 1,25-D by the enzyme CYP24. | ||
+ | |||
+ | But basically, the body starts off with 7-dehydro-Cholesterol, | ||
+ | is part of the sterol subsystem. It is a cholesterol derivative (video | ||
+ | highlights upper left 7-dehydro-Cholesterol), | ||
+ | to pre-Vitamin D by energy. Conventionally thought to be UVB, but | ||
+ | the biochemists will easily tell you it doesn' | ||
+ | can even be an enzyme. Enzyme at this point, we have no idea | ||
+ | what that enzyme would be if it is an enzyme. But it certainly | ||
+ | doesn' | ||
+ | highlighted). All you need is a contra-rotatory electrocyclic reaction | ||
+ | which occurs in other substances and which is pretty well | ||
+ | characterized. | ||
+ | |||
+ | (Vitamin D highlighted) Then, Pre-Vitamin D is formed into Vitamin | ||
+ | D by a Sigmatrophic shift. A very small shift of the electrons (????). | ||
+ | Vitamin D is converted by the enzyme CYP27A1 -or- CYP2R1 and | ||
+ | both of these are P450 digestive system enzymes into 25- | ||
+ | hydroxyvitamin-D (highlight drops to 25-hydroxyvitamin-D) and this | ||
+ | is the one that most of you are measuring when you measure | ||
+ | somebody' | ||
+ | the 25-hydroxyvitamin-D. | ||
+ | |||
+ | (Highlight drops to 1, | ||
+ | converted to 1, | ||
+ | either CYP27A1 or CYP27B1, both of them will hydroxyllate. And | ||
+ | that 1, | ||
+ | *activate*) the VDR and allow the VDR to do the gene transcription | ||
+ | that is at the heart of innate immunity. | ||
+ | |||
+ | |||
+ | And then finally, the 1,25-D is inactivated (highlight opens on | ||
+ | lower left " | ||
+ | CYP24 enzyme so that you don't end up with too much of it in the | ||
+ | body. | ||
+ | |||
+ | And that is what goes wrong in Th1 disease. You end up with too | ||
+ | much 1,25-D in the body because the VDR inactivation path — | ||
+ | something goes wrong with it. | ||
+ | |||
+ | |||
+ | Well, OK. Here we have some pretty pictures. We have atoms and | ||
+ | bonds. The grey atoms (highlight upper left picture, left grey atom | ||
+ | selected highlight in video) are carbons, the red ones are oxygen, | ||
+ | that green is a fluorine, That's a hydroxy OH there (highlight | ||
+ | moving from green to lower center red/grey center bottom), the | ||
+ | light blue is the H of the hydroxy. And this molecule is | ||
+ | Dexamethasone in exactly the configuration where it binds into the | ||
+ | Gluco-Corticoid Receptor (GCR binding pocket), you know the | ||
+ | adrenal axis, the Gluco-corticoid receptor. | ||
+ | |||
+ | And here (video highlights lower right figure center), we see 1,25- | ||
+ | Dihydroxyvitamin D competing with Dexamethasone for the | ||
+ | binding pocket of the GlucoCortocoid receptor. | ||
+ | |||
+ | 1,25-D has a very high affinity for the adrenal axis. This is new, it | ||
+ | is not in the syllabus, it's taken from a paper which was accepted | ||
+ | for the nuclear receptors conference next week, actually. | ||
+ | |||
+ | |||
+ | So what does that mean? If we go back to our nice simple adrenal | ||
+ | axis, what does that mean? | ||
+ | |||
+ | Well it means that (highlight focuses on top black box 25-D and | ||
+ | 1,25-D) 25-D and 1,25-D can both bind into the GlucoCortocoid | ||
+ | Receptor and displace Cortisol from doing that. | ||
+ | |||
+ | When it does that, the amount of CRH and particularly ACTH is | ||
+ | down regulated, and you end up with Adrenal Insufficiency | ||
+ | (highlight on lower black box " | ||
+ | |||
+ | |||
+ | OK, the vitamins D also compete for the Thyroid binding pocket. | ||
+ | I'm talking about the alpha thyroid here, the important one. | ||
+ | There we have T3 as it docs into the alpha thyroid to activate the | ||
+ | alpha thyroid (highlight shows green end molecules on the top left | ||
+ | illustration). These are the iodine molecules, three of them of | ||
+ | course. | ||
+ | |||
+ | Here we have 1,25-D competing (highlight center of lower R | ||
+ | figure) with T3 for the alpha thyroid Binding Pocket. It wants to | ||
+ | dock in exactly the same binding pockets as the T3 would. And by | ||
+ | doing that in high enough concentration, | ||
+ | |||
+ | binding. It will stop the alpha thyroid from working properly. | ||
+ | We end up with, among other things, hypothyroidism. | ||
+ | |||
+ | So I've done a summary slide here of the operation of the VDR. It | ||
+ | is key to both the endocrine and immune systems. | ||
+ | The VDR is responsible for decreasing parathyroid Hormone | ||
+ | Transcription. [Reference slide to TLR4], and therefore the | ||
+ | bacterial response. | ||
+ | |||
+ | Toll-like Receptor 4 is responsible for sensing | ||
+ | lipopolysaccarhride. Toll-like Receptor 2 is responsible for | ||
+ | sensing the presence of other bacteria protein. When the VDR is | ||
+ | not working, because you have administered vitamin D and are | ||
+ | experiencing the immuno suppressive action of the vitamin D, | ||
+ | when the VDR is not working, you do not have a functioning TLR2 | ||
+ | and TLR4 system. | ||
+ | |||
+ | But you also lose the antimicrobial peptides. It transcribes the | ||
+ | cathelicidin antimicrobial peptide (cAMP) and it's also responsible | ||
+ | for beta defensins. The beta defensins are absolutely key to the | ||
+ | proper operation of small intestine. The small intestine, in fact, | ||
+ | the whole GI tract is critically dependent on the defensins and | ||
+ | especially the beta defensins and the cathelicidins to work | ||
+ | properly. When you knock out the VDR with immunosupression | ||
+ | — either a steroid or ' | ||
+ | And finally, the VDR is responsible for binding the interluken 2 | ||
+ | (IL2) promoter. Now you all probably know that you measure | ||
+ | interluken 2 when you want to measure a Th1 reaction. Well, that | ||
+ | is why, because the VDR actually produces the interluken 2, even | ||
+ | if you can't measure it. | ||
+ | |||
+ | I've got some other functions there, I guess the main one there is | ||
+ | it regulates the TACO gene, which is responsible for | ||
+ | mycobacterium tuberculosis intraphagocytic survival, and it | ||
+ | promotes transcription of Insulin Receptors. | ||
+ | |||
+ | Let's skip the rest because we're running a little late bit short in | ||
+ | time. | ||
+ | |||
+ | |||
+ | The current status of the VDR is that the VDR is responsible for | ||
+ | TLR2 and TLR4 expression, as well as cAMP... hey, I just said that | ||
+ | on the previous slide! Sorry. | ||
+ | |||
+ | What we've got here is two pictures and we have all the vitamin | ||
+ | D's (video highlights left image) superimposed. We've got 1,25- | ||
+ | Dihydroxyvitamin-D, | ||
+ | (highlight arrow and red atom in lower right of left image) here, | ||
+ | the only one that can activate the VDR. Various other atoms can | ||
+ | activate the GCR or de-activate the GCR and the thyroid, but the | ||
+ | only one that will activate the VDR is this one (highlight again on | ||
+ | arrow and red atom) on the 1, | ||
+ | all the vitamins D fit into the receptor in almost identical | ||
+ | positions. Whether it is 24,25-D, 25,26-D or 1,25-D. Even | ||
+ | vitamin D itself fits in there as well and they are all competitive. | ||
+ | If you're giving people 40mg, if you're giving people vitamin D | ||
+ | such as such as to get the blood concentration at 25-D to 40 | ||
+ | nanograms per ml, then you're sitting with 25-D in most of your | ||
+ | VDRs and they are NOT activated, it is immuno-suppressive. The | ||
+ | patient will feel better short term because the inflammation is | ||
+ | suppressed. Long term, with the bacterial pathogens running right, | ||
+ | it's a different situation. | ||
+ | |||
+ | The picture on the right hand side just shows olmesartan binding | ||
+ | into the VDR pocket and you can see if you look at it carefully, you | ||
+ | can see that the olmesartan hydroxyl here (video highlights upper | ||
+ | right atoms O1 and O2 in lower right of right image) are actual | ||
+ | capable of activating the VDR in the same way as 1,25-D does. | ||
+ | |||
+ | |||
+ | So, we've got some little pictures here. We have 2 molecules. | ||
+ | What we have here is the steroid rings (video highlights right | ||
+ | image, upper right rings of molecule) of prednisone. This is | ||
+ | actually prednisone. | ||
+ | |||
+ | We have the steroid rings of prednisone, and over here (video | ||
+ | highlights middle two rings on left figure) we have the steroid rings | ||
+ | of " | ||
+ | steroid rings.... I want to show you the only difference between the | ||
+ | secosteroid and the steroid is one bond. It's this carbon to carbon | ||
+ | bond across here (highlight shows critical top left ring closure of | ||
+ | right image, in 2nd ring from left). And it is missing across here | ||
+ | (highlight now shows open ring in left image in the 2nd ring from | ||
+ | left) in the seco-steroid. And that is why it is a secosteroid rather | ||
+ | than a steroid. | ||
+ | |||
+ | It is a very subtle change, it actually gives the [vitamin D] [not VDR] | ||
+ | more flexibility to move in a socket and that is one of the reasons | ||
+ | why it binds into so many of the nuclear receptors. The structural | ||
+ | similarity (video highlights cortisone bond again) between | ||
+ | prednisone and vitamin D basically come down to that one carbon | ||
+ | bond. And that is why it is a secosteroid and not a corticosteroid. | ||
+ | |||
+ | So I have a slide here on Vitamin D in Bone Remodeling because I | ||
+ | know all of you are going to say "well, If I withdraw vitamin D from | ||
+ | my patients, their bones are going to get weaker." | ||
+ | some up to date citations you can go away and look at, which | ||
+ | show that actually " | ||
+ | at all. It's the Calcium Sensing Receptor and the Parathyroid | ||
+ | hormone that are responsible for Calcium homeostasis. And | ||
+ | secondly, even the cannabinoid receptors play a key role in bone | ||
+ | remodeling and bone mass. That paper is only a few weeks old. | ||
+ | The sex hormones are also players in bone density, I think you | ||
+ | know that one. | ||
+ | |||
+ | And that elevated levels of 1, | ||
+ | have found to be associated with Th1 immune disease, actually | ||
+ | encourage osteoclastic actions and breakdown of bone and | ||
+ | deposition of bone into soft tissue. The last thing you want in these | ||
+ | patients is high levels of 1, | ||
+ | |||
+ | So this has got a "not in syllabus" | ||
+ | had in the syllabus was a lot more caustic. This is diluted. | ||
+ | |||
+ | Public-Health Consequences of Regarding ' | ||
+ | ' | ||
+ | " | ||
+ | and hormonal activity. And we put the seco-steroid | ||
+ | ' | ||
+ | the rare disease, Rickets. And as physicians, you would know the | ||
+ | side effects from administration of steroids. | ||
+ | |||
+ | So the CDC now says we are heading towards half of all US | ||
+ | seniors being Diabetic by the year 2050. | ||
+ | |||
+ | And, Oh, steroids often induce obesity. I'll leave you to connect the | ||
+ | dots. | ||
+ | |||
+ | I haven' | ||
+ | figure out how Sarcoidosis patients could be made sick in the | ||
+ | absence of antibodies, this paper was published back in late 2001 | ||
+ | on the Internet, and what it showed was Rickettsia Helvetica inside | ||
+ | Phagocytes (video highlights upper right image E at two arrows). | ||
+ | Persistent inside phagocytes, not broken down by phagocytosis but | ||
+ | actually living in the phagocytes of Sarcoidosis patients. | ||
+ | That was the Eureka moment for me. I should have known it, there | ||
+ | is plenty of other literature talking about mycobacterium being | ||
+ | intraphagocytic, | ||
+ | |||
+ | |||
+ | And then the real studies that you all will want to see if you are | ||
+ | interested in the actual pathogens, were the Wirostko Studies from | ||
+ | Columbia University in the late 80's. There are bout 30 or 40 | ||
+ | electron transmisional microscopy photographs showing stained | ||
+ | bacteria. Tiny, tiny colonies (video highlight shows lower left arrow | ||
+ | circle of bacteria, then moves to second to left arrow colony, to | ||
+ | middle arrow pointing to colony and then to upper right arrow) of | ||
+ | stained bacteria in the phagocytes. This is a quarter of a | ||
+ | macrophage. | ||
+ | |||
+ | And they were very thorough, they did macrophages, | ||
+ | lymphocytes and neutrophils. And they found that in the | ||
+ | Sarcoidosis patient, they found the intraphagocytic bacteria | ||
+ | persistent in all of them. | ||
+ | |||
+ | And in fact, the nucleus here (video highlights heavy bolded arrow | ||
+ | left of center pointing to nucleus) is breaking away a little bit near | ||
+ | this larger colony of bacteria (video highlights second lower left | ||
+ | small arrow). That's why it has the big arrow on it. | ||
+ | |||
+ | Fascinating photographs. Very important if you want to understand | ||
+ | the actual bacterial pathogens, the L-forms that cause these | ||
+ | diseases (cell wall deficient bacteria called L-forms for the Lister | ||
+ | institute where they were first identified). They are tiny pathogens. | ||
+ | They are so small. They are hundredths the diameter of the | ||
+ | macrophage. I've got 200 nanometers here (video highlights lower | ||
+ | right slide legend). We're talking about cocciodes, tiny little dots | ||
+ | that are about 10-15 nanometers in diameter. | ||
+ | |||
+ | |||
+ | These are pictures that show the diagrammatically show the | ||
+ | survival of bacteria in the phagocyte. I've covered these in my 30th | ||
+ | anniversary of Lyme meeting and with your permission, I'll skip over | ||
+ | this. You can find it in any book. (because we're running late on | ||
+ | time). | ||
+ | |||
+ | Bacterial protein synthesis, and remember I talked about the 70S | ||
+ | Ribosome, the bacterial Ribosome. Here we actually have the | ||
+ | structure of the bacterial Ribosome, it is primarily made up of RNA, | ||
+ | unlike the human ribosomes which are primarily protein based. | ||
+ | But the 16S RNA (video highlights the lower left 16S rRNA on | ||
+ | figure), which you would all recognize as being the PCR, the | ||
+ | substance which is used as the target for most PCR tests. 16S rRNA | ||
+ | forms the 30S side of the ribosome (video highlights upper left 30S | ||
+ | figure subhead). The top of this 30S we have a heliacal structure | ||
+ | (video highlights top left ribbons) which is responsible for translate | ||
+ | but actually for ... translating the mRNA into a protein. | ||
+ | The actual translation is done on the 50S side, you can see a | ||
+ | protein (video highlights lower right quadrant) coming out the | ||
+ | bottom here and it's in yellow. The protein transferase center | ||
+ | (video highlights middle, slightly right) is right in the center which | ||
+ | you see, and there we have tRNA (video highlights blue grape | ||
+ | cluster mid top) which is donating the amino acid into the growing | ||
+ | protein. | ||
+ | |||
+ | |||
+ | And this is an Xray structure, which was produced from the Max | ||
+ | Planck group in Germany, and this x-ray structure shows a | ||
+ | number of antibiotic molecules found in, you can look at them in | ||
+ | your syllabus', | ||
+ | tetracycline. And in fact, the tetracycline binds right at the top | ||
+ | (video highlights top of 30S Sub-unit, see Orange color), and | ||
+ | inhibits RNA translation. | ||
+ | |||
+ | |||
+ | On the 50S side, you can see how the protein is assembled and | ||
+ | exits the exit tube a little more easily. And in particular, the | ||
+ | important thing is here, you will notice that Clindamycin (video | ||
+ | highlights center formation), just the light orange one, sits right at | ||
+ | the PTC. And the Azythromycin sits a little bit below it, so they are | ||
+ | actually symbiotic antibiotics. | ||
+ | |||
+ | All three antibiotics that we use are symbiotic. That means that | ||
+ | each of them progressively reduces the function of the [bacterial] | ||
+ | ribosome. That means that when you give them together, they are | ||
+ | not competing with each other, they' | ||
+ | symbiotic. Very important. Something that the genome, the | ||
+ | bacterial genome, has told us quite clearly. | ||
+ | |||
+ | |||
+ | So now we talk about the species. | ||
+ | |||
+ | Which species of bugs is it? | ||
+ | |||
+ | Well, it is not a single species. We're dealing with a polymicrobial | ||
+ | disease. If you look at the various diseases, and the bacteria that | ||
+ | have been reported with them all, the common ones like Staph- | ||
+ | aureus and Propionibacterium-acnes, | ||
+ | granulosum, seem to be the ones that crop up most of all, with the | ||
+ | nasty bugs, micobactera cropping up far less frequently. And | ||
+ | certainly less than 100%. | ||
+ | |||
+ | So we're almost certainly dealing with a polymicrobial disease. | ||
+ | And depending on the exact mix of pathogens, determines which | ||
+ | of the Th1 diseases, which of the Th1 symptom syndromes the | ||
+ | patient will progress to. Whether it turns into Rheumatoid Arthritis, | ||
+ | Multiple Sclerosis, or Anorexia Nervosa. | ||
+ | |||
+ | It's become obvious that most bacteria species are not | ||
+ | homogenous. They' | ||
+ | self-replicating plasmids which carry DNA and genes. Borrelia | ||
+ | burgdorferi has got a large number of plasmids, in fact, nearly half | ||
+ | of its genome exists on 21 self-replicating plasmids sub-units. | ||
+ | Now I'm not saying that makes it any more strong of a pathogen, | ||
+ | but it certainly adds quite a lot to the "Pea Soup" which I like to | ||
+ | think of as mix of DNA which accumulates in the chronic diseases. | ||
+ | Yet even Staph. epidermidis gives rise to plasmids. It's got about | ||
+ | 10% of its DNA spread over six self-replicating plasmids. | ||
+ | |||
+ | These can be shared between species. But the plasmids are not | ||
+ | targeted by antibiotics. Antibiotics don't target plasmids. Only the | ||
+ | innate immune system can go after the plasmids. So unless the | ||
+ | plasmids are destroyed by the immune system, they will persist in | ||
+ | chronic intra-cellular infections. | ||
+ | |||
+ | And I think of it as a "DNA Pea-Soup." | ||
+ | |||
+ | |||
+ | Plasmids do transmit DNA horizontally. Notice the citation here, it | ||
+ | was published in the Proceedings of the National Academy of | ||
+ | |||
+ | Sciences in 2004. And what you had was, you had a patient that | ||
+ | got very, very ill with a species of Bacillus cereus. Now, Bacillus | ||
+ | cereus, we all know is a [relatively] harmless bacteria. It's a | ||
+ | Bacillus that doesn' | ||
+ | (video highlights B.cereus yellow circle on figure, upper right of | ||
+ | center). | ||
+ | |||
+ | Whereas just a little bit further around on the phylogeny here, we | ||
+ | have Bacillus-anthracus (video highlights red spike circle far upper | ||
+ | right). And what distinguishes Bacillus-anthracus is 2 plasmids. | ||
+ | One plasmids contains the ability to evade the immune system, the | ||
+ | proteins that give it the ability to evade the immune system, the | ||
+ | other plasmids carries the ability to produce a cytokine storm and | ||
+ | kill the host. | ||
+ | |||
+ | Now what happened in this case was the two plasmids from | ||
+ | anthracus were transferred into cereus and formed an extremely | ||
+ | toxic combination. | ||
+ | |||
+ | |||
+ | And you can see that the mice that were just challenged with | ||
+ | cereus, they all survived (video highlights upper center double red | ||
+ | circles on figure 4). | ||
+ | |||
+ | Those that were challenged with anthrax (video moves down to | ||
+ | yellow circle dropping line) -which color is anthrax? yellow- most | ||
+ | of them died. | ||
+ | |||
+ | BUT they died a lot quicker if they were the hybrid (video highlights | ||
+ | green circle line) of the anthrax plasmids and the cereus genome. | ||
+ | This is a big, big problem! | ||
+ | |||
+ | Why is it a problem? | ||
+ | |||
+ | Well, (video returns to first horizontally slide) if you look further | ||
+ | around on this phylogeny (video highlights B thuringiensis | ||
+ | israeliensis, | ||
+ | thuringiensis Israelensis. That one is sprayed onto agricultural | ||
+ | crops as a herbicide. Sorry, it is an insecticide. | ||
+ | |||
+ | Anyway, you might have noticed, for example, Garth Nicholson | ||
+ | found a higher incidence of autism in the agricultural areas. This | ||
+ | fellow (video highlights B thuringiensis israeliensis) is sprayed in the | ||
+ | agricultural areas. | ||
+ | |||
+ | If the chronic infection allows the plasmids to spread, these people | ||
+ | will get very ill. | ||
+ | |||
+ | The final thing that I want to show is that the pathogens actually | ||
+ | persist in the brain. | ||
+ | |||
+ | This [slide] is taken from a paper by Rolf Zinkernagle, | ||
+ | lucky to meet at Karolinska, the home of Team Nobel. Rolf gave | ||
+ | the keynote speech there back in May [2006]. And what they | ||
+ | found they' | ||
+ | young age (video highlights A - neonate mice figure upper right | ||
+ | figure), neonatal in fact, with a virus. And this is injected before the | ||
+ | mice have an adaptive immune system. | ||
+ | |||
+ | As you all know, the adaptive immune system in humans and mice | ||
+ | takes some time to kick in (video highlights top time line center, | ||
+ | showing Time after rLCMV/ | ||
+ | coming up to indicate the adaptive immune system has kicked in | ||
+ | after about 7 days. | ||
+ | |||
+ | But when the mice are born, the only thing they have to protect | ||
+ | themselves is the innate immune system. You know, the thing we're | ||
+ | knocking out with ' | ||
+ | |||
+ | Anyway, what Rolf did was, he showed that if they injected this virus | ||
+ | during this period, it remained dormant in the mouse. And later, | ||
+ | when a similar virus was used to challenge the mouse, It killed | ||
+ | them (video highlights upper right dead mouse figure). | ||
+ | |||
+ | Whereas mice that were challenged in adulthood by the same | ||
+ | virus (video highlights lower left time line, far left), injected by the | ||
+ | same pathway were not killed when they were re-challenged, | ||
+ | fact, they survived primarily. | ||
+ | |||
+ | This is a fascinating paper, it is quite detailed with citations there at | ||
+ | the bottom [of the slide]. And Rolf is working on dispelling a myth | ||
+ | of autoimmunity — or response to self — by showing occult | ||
+ | viruses can, in fact, can exist and they can indeed persist in the | ||
+ | brain. Very important when we are trying to understand the | ||
+ | symptoms of our patients. | ||
+ | |||
+ | And here is the slide from Professor Bach, Jean-Francois Bach, | ||
+ | which was presented in Budapest in 2004. Jean-Francois Bach | ||
+ | was the person who proposed the hygiene synthesis. | ||
+ | But what he found was that bacteria, the particular strain of mice | ||
+ | called non-obese diabetic mice (NOD), where typically 60% of | ||
+ | them died (video highlights upper right dark dot line) from | ||
+ | diabetes — type 1 diabetes during their lifetime — that if he | ||
+ | injected them early enough with a mix of common bacterial | ||
+ | proteins, that they survived (video highlights cyan and yellow end | ||
+ | point line). | ||
+ | |||
+ | And the ones that survived best were the ones that got the | ||
+ | bacterial proteins earlier in life than later in life (video highlights | ||
+ | magenta square dotted line lower right). | ||
+ | Again, another fascinating insight into exactly how these diseases | ||
+ | persist and why some people get ill, and other people carry the | ||
+ | bacteria and don't get ill. | ||
+ | |||
+ | Because it is no secret that the NIH/NHLBI did a study in 2001 | ||
+ | where they tested with PCR, they tested the blood of controls. No, | ||
+ | they didn't use PCR, they cultured the L-form using Wayne State | ||
+ | Lyda Mattman' | ||
+ | were carrying L-forms in the blood. Supposedly a sterile | ||
+ | compartment. | ||
+ | |||
+ | This has since been confirmed by the Relman Lab, Dave Relman | ||
+ | up at Stanford published a paper in the last year, where he too has | ||
+ | noted that 60-80% of the population are carrying around bacterial | ||
+ | RNA in their blood. It should not be there. Many of them, most of | ||
+ | them in fact, are not ill or certainly not diagnosably ill. Some | ||
+ | however, regress to really serious illness. It all depends on the DNA | ||
+ | mix and how the mutations progress in life. | ||
+ | |||
+ | |||
+ | So just a few quick final thoughts that my colleagues at FDA felt I | ||
+ | had to put in because I am talking to clinicians here, [are] just the | ||
+ | simple stuff again. | ||
+ | |||
+ | Final thoughts, if you are thinking if your patient might in fact be | ||
+ | suffering from Th1 diseases, then the therapeutic probe is really | ||
+ | the gold standard. That's because it is greater than 95% response | ||
+ | rate. Most of the patients will immediately feel immunopathology. | ||
+ | They' | ||
+ | antibiotics. At that point you know that you are killing bugs. You | ||
+ | know that these people are responding. | ||
+ | |||
+ | The only thing I would say is 25-D levels above about 20ng/ml | ||
+ | you will be getting immuno-suppression there and it will be | ||
+ | suppressing the therapeutic probe. So you need to be somewhat | ||
+ | careful about the 25-D level before initiating a therapeutic probe. | ||
+ | Hypotension is not a concern, even though we are using an | ||
+ | angiotensin-receptor blocker. These are the graphs from the FDA | ||
+ | describing insert, the package insert [see slide figure]. As you can | ||
+ | see, the maximum drop is about 12 millimeters of mercury [12mm | ||
+ | Hg], and that value is independent of dose. You can see the dose | ||
+ | along the bottom here the response tops at 40mg. It is not a very | ||
+ | good hypotensive. Benicar is not a very good hypotensive. Luckily, | ||
+ | it does other things as well like protect the kidneys, and protect the | ||
+ | eyes and all the other things that you are reading about in the | ||
+ | clinical literature right now. | ||
+ | |||
+ | Hypotension is not a concern. | ||
+ | |||
+ | Dizziness. When the patients get dizziness, especially in the first | ||
+ | month, it's usually a sign of the disease process. It is not | ||
+ | hypotension. It's actually better to increase the Benicar to give | ||
+ | them a better blockade than to back off the Benicar. | ||
+ | There is no way you can start with a low dose and work up. You've | ||
+ | got to have those receptors being blocked, all the receptors being | ||
+ | blocked, or it doesn' | ||
+ | immunopathology with only a low dose. That means the patient | ||
+ | will get, " | ||
+ | dose of Benicar, but they won't get the palliative effects, they won't | ||
+ | get the renal-protective effects, until the dose goes up. | ||
+ | So it is very important to give them the correct dose so they are | ||
+ | actually going to make it through the therapy and kill those bugs | ||
+ | off. | ||
+ | |||
+ | The only thing I didn't mention was how long it would take: three | ||
+ | to five years for the seriously-ill patients to totally get their lives | ||
+ | back. Most of them are happy with some form of recovery. They | ||
+ | see the light at the end of the tunnel after about six months. Very | ||
+ | few have not seen the light by twelve months but actually, they are | ||
+ | symptom free or say they are symptom free at about two years. But | ||
+ | all that means is they are getting along from day to day very nicely | ||
+ | and much better than they were before. There is still a lot of | ||
+ | disease present, they are still getting a lot of reaction to the | ||
+ | antibiotics. | ||
+ | |||
+ | It takes about another two years to where they can just guzzle the | ||
+ | antibiotics like candy. At that point, the bacterial load is low | ||
+ | enough for them to pronounce recovery. | ||
+ | |||
+ | Thank you. | ||
+ | |||
+ | {{tag> | ||