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Pierre Zwiegers1,2, Grace Lee1, & Christopher A. Shaw1
                                                                                                                                                                                                                                                                                                      1NeuralDynamics Research Group, Univ. of British Columbia
                                                                                                                                                                                                                                                                                                      2Department of Medicine, Univ. of British Columbia




2-C-55                                                                                                                                                                                                                                                                                                                                                                                                                              Neural Dynamics Research Group




Objective                  We hypothesize that the secreted neuroprotective                                                                                     Previous Results                                                 B) Active Caspase 3 ICC
                                                                                                                                                                                                                                                                                            Primary Antibody:
                                                                                                                                                                                                                                                                                                                           A) Choline acetyltransferase (ChAT) labeling in murine lumbar spinal cord
                                                                                                                                                                                                                                                                                            Rb α- active caspase 3         WT                                        G37R                                                    G37R/Progranulin
protein, Progranulin (PGRN), delivered to motor neurons by lentiviral-                                                                                               A) MPTP Cytotoxicity in PC-12 Cells                                                                                    (Promega)
                                                                                                                                                                                                                                                                                            1:250
                                                                                                                                                                                                                                                                                            Secondary Antibody:

mediated translocation from the injection site will ameliorate motor neuron                                                                                                                                                                                                                 Gt α -Rb AF546 (Mol.
                                                                                                                                                                                                                                                                                            Probes)
                                                                                                                                                                                                                                                                                            1:200
loss in a genetic model of ALS. Using G37R mSOD mice, we aim to determine
whether LV-PGRN delivered before the onset of major behavioural deficits can
prevent, halt, or even reverse/stabilize mSOD-induced motor neuron death.                                                                                                                  [MPTP] µM

                                                                                                                                                                 Figure 1. (A) Cell survival assay (MTT
                                                                                                                                                                 colorimetric assay) in PC-12 cells evaluating the                                                                                                         B) ChAT quantification of lumbar spinal cord       Figure 2. Progranulin-mediated neuroprotective
Introduction                                                                                                                                                     protective properties of 4nM PGRN in the          C) TDP-43 ICC
                                                                                                                                                                                                                                                                                            Primary Antibodies:                           GFP                                 effect. Transgenic G37R animals at a later stage
                                                                                                                                                                 presence of 100-1000 µM of MPTP. There was a                                                                               Rabbit anti-TDP43                             PGRN                                just prior to disease phenotype expression (~ 11
- Encoded as an 8kb genomic fragment on chromosome 17                                                                                                            significant increase in the percentage of                                                                                  Dilution: 1:250
                                                                                                                                                                                                                                                                                            Chicken anti-β-tubulin                                                            months of age) as well as wild-type
- Secreted protein derived from 13 exons and comprised of 7.5 tandem repeats of a                                                                                surviving cells when PGRN was present for                                                                                  Dilution: 1:5                                  WT                mSOD G37R        conspecifics, received bilateral injections of
                                                                                                                                                                 each of the four doses of MPTP treatment.                                                                                  Secondary Antibodies:                                                             either Progranulin or GFP-containing lentiviral
  conserved 12 cysteinyl granulin motif with a MW of 90kDa in its glycosylated form                                                                              Mean ± SEM and Student t-test results are                                                                                  Goat anti-rabbit AF546
                                                                                                                                                                                                                                                                                                                                                                              constructs directly into the gastrocnemius
                                                                                                                                                                                                                                                                                            Dilution: 1:200
                                                                                                                                                                 shown. (B) Qualitatively, PGRN                                                                                             Goat anti-chicken FITC
                                                                                                                                                                                                                                                                                                                                                                              muscles (8.2x107 IU/mL).
                                                                                                                                                                                                                                                                                            Dilution: 1:200
                          Para-                                                                                                                                  neuroprotective action did not involve                                                                                                                                                                       (A) Choline acetyltransferase (ChAT) immuno-
                                        grnG             grnF        grnB             grnA              grnC          grnD       grnE                            prevention of caspase-3 activation in PC-12                                                                                                                                                                  labeling in the ventral horn of lumbar spinal cord
                          grn                                                                                                                                    cells treated with 1000µM MPTP. (C)                                                                                                                                                                          sections. (B) Motor neuron counts revealed a
                                                                                                                                                                 Similarly, ICC assays demonstrated that the                                                                                                                                                                  significant neuroprotective effect of progranulin
                                                                                                                                                                                                                                                                                                                            in the fALS group. Progranulin cDNA injected animals expressing mutant SOD1 exhibit more
- Proteolytic cleavage yields several 6kDa granulin peptides that exhibit a plethora of                                                                          observed MPTP toxicity did not involve the                                                                                                                 surviving neurons compared to the conspecific group receiving control GFP injections. Ongoing
                                                                                                                                                                 extranuclear translocation and/or aggregation
   effects on cellular physiology                                                                                                                                of TDP-43. 20µm; arrows point at active caspase 3 positive cells.
                                                                                                                                                                                                                                                                                                                            histological studies aim at assessing stress markers and glial markers of inflammation, and will be
                                                                                                                                                                 Scale bar is                                                                                                                                               communicated in the future.
- Putatively crucial in the long-term survival of neuronal cells
- Additional roles include:                                                                                                                                     Preliminary Results                                                                                                                                          Figure 3. Current ongoing measures of behavioural indices employed to assess the extent of
    · wound repair               · male-specific brain differentiation                                                                                                                                                                                                                                                       long-term neuronal protection conveyed by lentivirus-mediated Progranulin (PGRN) cDNA
                                                                                                                                                                                                                                                                                                                             upregulation in the lumbar spinal cord delivered intramuscularly at approximately 3.5 months
    · neovascularization         · anti-inflammatory properties                                                                                                     A)                                                                         B)                                                                            of age. Due to the expected sex differences in diseased phenotype expression, comparisons
- PGRN expression in an murine model of Alzheimer’s disease showed decreased                                                                                                                                                                                                                                                 were made within male (m) and female (f) groups distinguishing between wild-type (WT) and
                                                                                                                                                                                                                                                                                                                             transgenic (G37R) animals receiving 5x2 µL (4.0x108 TU/mL) injections of either the lentivirus
   neuroinflammation, reduced plaque burden and preservation of synapses                                                                                                                                                                                                                                                     containing Progranulin (PGRN) or GFP constructs in each gastrocnemius muscle. To
- In a zebrafish model, PGRN overexpression has been shown to rescue mutant TDP-43                                                                                                                                                                                                                                           date, animals have yet to fully express the expected disease phenotype. In both (A) Weight
  induced axonopathy                                                                                                                                                                                                                                                                                                         and (B) the Leg Extension reflex score, no significant trend within either sex has yet become
                                                                                                                                                                                                                                                                                                                             evident. In measures of (C) Rotarod and (D) Wire Hang performance, male animals
- Neuroprotective for cortical and spinal neurons against serum deprivation                                                                                                                                                                                                                                                  performed demonstrably poorer than females, however no significant temporal differences
- Nulll mutations implicated as a genetic basis for tau-negative frontotemporal dementia                                                                            Avg
                                                                                                                                                                            65   80   92   129 149     177 205 233 262   290 318 346   374   Avg
                                                                                                                                                                                                                                                     65   80   92   129 149   177 205 233 262   290 318 346      374
                                                                                                                                                                                                                                                                                                                             were found when intrasex comparisons were made. Mean +/- SEM shown, intra-sex analysis
                                                                                                                                                                    age (d)                                                                  age (d)                                                                         by one-way ANOVA.
- PGRN mutations or polymorphisms can be a modifier of disease course in amyotrophic
  lateral sclerosis in that an ALS phenotype presents at an earlier age of onset and is                                                                             C)                                                                                                                                                          α-GFP                                                        NEG Control
                                                                                                                                                                                                                                                                                                                                100x                                                         α-GFP
  coupled with a more rapid decline of survival                                                                                                                                                                                                                                                                                                                                              10x
- Post-mortem analysis of ALS tissue indicates increased PGRN expression in
  degenerating motor tracts in the spinal cord & brainstem
- Sortilin has been identified as the receptor mediating an endocytic pathway targeting
  extracellular PGRN to lysosomal localization                                                                                                                      Avg
                                                                                                                                                                            65   80   92   129 149     177 205 233 262   290 318 346   374   Avg
                                                                                                                                                                                                                                                     65   80   92   129 149   177 205 233 262   290 318 346      374
                                                                                                                                                                    age (d)                                                                  age (d)
 He & Bateman             Van Kampen & Kay           Ahmed et al                                Cruts & Van Broeckhoven            Hu et al
 J Mol Med 81, 2003       J Alz Assoc 7(4), 2011     J Neuroinlammation 4(7), 2007              Trends in Genetics 24(4), 2008     Neuron 68(4), 2010               D)
 Cruts et al             Sleegers et al              Van Damme et al                            Laird et al                        Irwin & Russo
 Nature 442, 2006        Neurology 71, 2008          J. Cell Biol. 181, 2008                    PLoS one 5(10), 2010               J. NeuroSci 276(1-2), 2008                                                                                                                                                                Figure 4. Immunohistological assessment for green fluorescent protein (GFP) following
                                                                                                                                                                                                                                                                                                                             lentiviral-mediated delivery. Male CD-1 animals received bilateral administration of a GFP-
                                                                                                                                                                                                                                                                                                                             expressing lentivirus into both gastrocnemius muscles (5x2µL lentiviral vector 4.0x108 TU/mL
                                                                                                                                                                                                                                                                                                                             per muscle). One-month following transfection, transduction efficiency was assessed via anti-
Experimental Design                                                                                                                                                                                                                                                                                                          GFP activity in lumbar cord motor neurons thus establishing the applicability of specific
                                                                 G37R mSOD or                                                                                                                                                                                                                                                retrograde targeting of motor neurons via intramuscular delivery of the viral vector.
                                                                C57BL/6 WT Mice                                                                                    Avg
                                                                                                                                                                           65    80                    177 205 233 262                 374   Avg
                                                                                                                                                                                      92   129 149                       290 318 346                 65   80   92   129 149   177 205 233 262    290 318 346         374
                                                                                                                                                                   age (d)                                                                   age (d)

                                                   5 weeks baseline behavioural data collection

                    Progranulin-expressing lentivirus                                             GFP-expressing lentivirus                                     Results Summary                                                                                                                               Discussion
                      bilateral intra-gastrocnemius                                             bilateral intra-gastrocnemius                                    -Exogenous administration of full-length PGRN protein in vitro, has                                                                            The search for putative means in prophylactically ameliorating motor neuron
                                injections*                                                               injections*
                                                                                                                                                                  shown to protect PC12 cells against a MPTP cytotoxic insult                                                                                   cell death in ALS is of crucial importance as current treatment modalities are
                                                                                                                                                                 -Late-stage delivery of the PGRN lentiviral construct in G37R mSOD                                                                             typically administered following disease onset at a stage where significant
           ♀ G37R mSOD n=12                                                       ♀G37R mSOD n=11                       ♂G37R mSOD n=11
                                              ♂G37R mSOD n=13
                                                                                                                                                                  animals has been shown to ameliorate motor neuron loss                                                                                        motor neuron loss may already have been established. If the current aims are
           ♀ C57BL/6 WT n=12                                                     ♀ C57BL/6 WT n=12                     ♂ C57BL/6 WT n=12
                                              ♂ C57BL/6 WT n=12                                                                                                                                                                                                                                                 achieved, PGRN-mediated genetic therapy may prove to be an effective tool in
                                                                                                                                                                 -Early targeting of lumbar cord motor neurons in mSOD animals has not
                                                                                                                                                                                                                                                                                                                ameliorating motor neuron degeneration. Previous work by our group has
                                                                               *5x2µL lentiviral vector 4.0x108 TU/mL per gastrocnemius muscle                    established any significant effect on behavioural changes as an ALS
                                                                                (Invitrogen)                                                                                                                                                                                                                    shown preliminary evidence for the cytoprotective actions of PGRN. The
                               Behavioural                                                                                                                        phenotype has yet to become established.                                                                                                      current behavioural observations are considered preliminary as the animals
                               monitoring                                            Histological +
                                                                                     Biochemical
                                                                                                                                                                                                                                                                                                                have yet to reach a point at which hind-limb paralysis becomes evident. It is
       Leg Extension Rotorod Wire Hang                                                  Analysis                                                                Future Directions                                                                                                                               expected, however, that the effect of progranulin in the measured behavioural
                                                                                                                                                                                                                                                                                                                indices will be marginal since (i) only lower motor neurons targeting the
                    Retrograde Transport of Vector                                   Sites of Injection                Progranulin Vector Construct             -Histological assessment following onset of an ALS phenotype to                                                                                 gastrocnemius muscle are transduced and (ii) postural and behavioural
                                                                                                                                                                 discern motor neuron viability and markers of neuroinflammation                                                                                adjustments by additional muscle groups may compensate for localized deficits
                                                                                                                                                                -Currently, additional work by our group is assessing whether                                                                                   prior to phenotypic ALS expression. Histological and biochemical examination
                                                                                                                                                                                                                                                                                                                of lumbar spinal cord will provide more conclusive evidence of neuroprotective
                                                                                                                                                                 lentiviral-mediated delivery of progranulin will exhibit                                                                                       activity.
           Kaspar et al 2003                                                   Injection site      Antal et al 2007                              Invitrogen
                                                                                                                                                                 neuroprotective activity in an environmental model of ALS-PDC,
 - Male B6.Cg-Tg(SOD1*G37R)29Dpr/J (Jackson Laboratory) animals were crossed with                                                                                work that will explore neuronal rescue in the context of a non-
                                                                                                                                                                                                                                 Acknowledgements
   congenic C57BL/6 females to generate Tg (+)ve and Tg (-)ve progeny, confirmed via                                                                             mSOD mediated toxic insult, which may be more telling for cases
   genotyping                                                                                                                                                    of sporadic ALS                                                  Special thanks to ALS Canada for making the current research
 - At approx 3.5 months of age, following isoflurane anesthesia, a GFP or PGRN lentiviral                                                                       -Additional work would need to explore the prophylactic efficacy endeavour possible. Additionally, thanks for the support and
   vector was administered to each gastrocnemius muscle with 5 x 2µL injections at                                                                               in targeting multiple neuronal populations and the subsequent   encouragement of members from Neural Dynamics Research
   4.0x108 TU/mL via Hamilton syringe
                                                                                                                                                                  effect on ALS phenotypic outcomes in genetic models.           Group as well as Drs D. Kay & J. Van Kampen from Neurodyn
 - Bi-weekly behavioral assays (Rotorod, Wire Hang, and Leg Extension reflex score) are
                                                                                                                                                                                                                                 Inc. for their invaluable insights and troubleshooting advice.
   employed to monitor the onset of an ALS phenotype                                                                                                                                                                                                                                                                                           If we knew what we were doing, it wouldn't be called research, would it? -Einstein

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Zwiegers can 2012

  • 1. Pierre Zwiegers1,2, Grace Lee1, & Christopher A. Shaw1 1NeuralDynamics Research Group, Univ. of British Columbia 2Department of Medicine, Univ. of British Columbia 2-C-55 Neural Dynamics Research Group Objective We hypothesize that the secreted neuroprotective Previous Results B) Active Caspase 3 ICC Primary Antibody: A) Choline acetyltransferase (ChAT) labeling in murine lumbar spinal cord Rb α- active caspase 3 WT G37R G37R/Progranulin protein, Progranulin (PGRN), delivered to motor neurons by lentiviral- A) MPTP Cytotoxicity in PC-12 Cells (Promega) 1:250 Secondary Antibody: mediated translocation from the injection site will ameliorate motor neuron Gt α -Rb AF546 (Mol. Probes) 1:200 loss in a genetic model of ALS. Using G37R mSOD mice, we aim to determine whether LV-PGRN delivered before the onset of major behavioural deficits can prevent, halt, or even reverse/stabilize mSOD-induced motor neuron death. [MPTP] µM Figure 1. (A) Cell survival assay (MTT colorimetric assay) in PC-12 cells evaluating the B) ChAT quantification of lumbar spinal cord Figure 2. Progranulin-mediated neuroprotective Introduction protective properties of 4nM PGRN in the C) TDP-43 ICC Primary Antibodies: GFP effect. Transgenic G37R animals at a later stage presence of 100-1000 µM of MPTP. There was a Rabbit anti-TDP43 PGRN just prior to disease phenotype expression (~ 11 - Encoded as an 8kb genomic fragment on chromosome 17 significant increase in the percentage of Dilution: 1:250 Chicken anti-β-tubulin months of age) as well as wild-type - Secreted protein derived from 13 exons and comprised of 7.5 tandem repeats of a surviving cells when PGRN was present for Dilution: 1:5 WT mSOD G37R conspecifics, received bilateral injections of each of the four doses of MPTP treatment. Secondary Antibodies: either Progranulin or GFP-containing lentiviral conserved 12 cysteinyl granulin motif with a MW of 90kDa in its glycosylated form Mean ± SEM and Student t-test results are Goat anti-rabbit AF546 constructs directly into the gastrocnemius Dilution: 1:200 shown. (B) Qualitatively, PGRN Goat anti-chicken FITC muscles (8.2x107 IU/mL). Dilution: 1:200 Para- neuroprotective action did not involve (A) Choline acetyltransferase (ChAT) immuno- grnG grnF grnB grnA grnC grnD grnE prevention of caspase-3 activation in PC-12 labeling in the ventral horn of lumbar spinal cord grn cells treated with 1000µM MPTP. (C) sections. (B) Motor neuron counts revealed a Similarly, ICC assays demonstrated that the significant neuroprotective effect of progranulin in the fALS group. Progranulin cDNA injected animals expressing mutant SOD1 exhibit more - Proteolytic cleavage yields several 6kDa granulin peptides that exhibit a plethora of observed MPTP toxicity did not involve the surviving neurons compared to the conspecific group receiving control GFP injections. Ongoing extranuclear translocation and/or aggregation effects on cellular physiology of TDP-43. 20µm; arrows point at active caspase 3 positive cells. histological studies aim at assessing stress markers and glial markers of inflammation, and will be Scale bar is communicated in the future. - Putatively crucial in the long-term survival of neuronal cells - Additional roles include: Preliminary Results Figure 3. Current ongoing measures of behavioural indices employed to assess the extent of · wound repair · male-specific brain differentiation long-term neuronal protection conveyed by lentivirus-mediated Progranulin (PGRN) cDNA upregulation in the lumbar spinal cord delivered intramuscularly at approximately 3.5 months · neovascularization · anti-inflammatory properties A) B) of age. Due to the expected sex differences in diseased phenotype expression, comparisons - PGRN expression in an murine model of Alzheimer’s disease showed decreased were made within male (m) and female (f) groups distinguishing between wild-type (WT) and transgenic (G37R) animals receiving 5x2 µL (4.0x108 TU/mL) injections of either the lentivirus neuroinflammation, reduced plaque burden and preservation of synapses containing Progranulin (PGRN) or GFP constructs in each gastrocnemius muscle. To - In a zebrafish model, PGRN overexpression has been shown to rescue mutant TDP-43 date, animals have yet to fully express the expected disease phenotype. In both (A) Weight induced axonopathy and (B) the Leg Extension reflex score, no significant trend within either sex has yet become evident. In measures of (C) Rotarod and (D) Wire Hang performance, male animals - Neuroprotective for cortical and spinal neurons against serum deprivation performed demonstrably poorer than females, however no significant temporal differences - Nulll mutations implicated as a genetic basis for tau-negative frontotemporal dementia Avg 65 80 92 129 149 177 205 233 262 290 318 346 374 Avg 65 80 92 129 149 177 205 233 262 290 318 346 374 were found when intrasex comparisons were made. Mean +/- SEM shown, intra-sex analysis age (d) age (d) by one-way ANOVA. - PGRN mutations or polymorphisms can be a modifier of disease course in amyotrophic lateral sclerosis in that an ALS phenotype presents at an earlier age of onset and is C) α-GFP NEG Control 100x α-GFP coupled with a more rapid decline of survival 10x - Post-mortem analysis of ALS tissue indicates increased PGRN expression in degenerating motor tracts in the spinal cord & brainstem - Sortilin has been identified as the receptor mediating an endocytic pathway targeting extracellular PGRN to lysosomal localization Avg 65 80 92 129 149 177 205 233 262 290 318 346 374 Avg 65 80 92 129 149 177 205 233 262 290 318 346 374 age (d) age (d) He & Bateman Van Kampen & Kay Ahmed et al Cruts & Van Broeckhoven Hu et al J Mol Med 81, 2003 J Alz Assoc 7(4), 2011 J Neuroinlammation 4(7), 2007 Trends in Genetics 24(4), 2008 Neuron 68(4), 2010 D) Cruts et al Sleegers et al Van Damme et al Laird et al Irwin & Russo Nature 442, 2006 Neurology 71, 2008 J. Cell Biol. 181, 2008 PLoS one 5(10), 2010 J. NeuroSci 276(1-2), 2008 Figure 4. Immunohistological assessment for green fluorescent protein (GFP) following lentiviral-mediated delivery. Male CD-1 animals received bilateral administration of a GFP- expressing lentivirus into both gastrocnemius muscles (5x2µL lentiviral vector 4.0x108 TU/mL per muscle). One-month following transfection, transduction efficiency was assessed via anti- Experimental Design GFP activity in lumbar cord motor neurons thus establishing the applicability of specific G37R mSOD or retrograde targeting of motor neurons via intramuscular delivery of the viral vector. C57BL/6 WT Mice Avg 65 80 177 205 233 262 374 Avg 92 129 149 290 318 346 65 80 92 129 149 177 205 233 262 290 318 346 374 age (d) age (d) 5 weeks baseline behavioural data collection Progranulin-expressing lentivirus GFP-expressing lentivirus Results Summary Discussion bilateral intra-gastrocnemius bilateral intra-gastrocnemius -Exogenous administration of full-length PGRN protein in vitro, has The search for putative means in prophylactically ameliorating motor neuron injections* injections* shown to protect PC12 cells against a MPTP cytotoxic insult cell death in ALS is of crucial importance as current treatment modalities are -Late-stage delivery of the PGRN lentiviral construct in G37R mSOD typically administered following disease onset at a stage where significant ♀ G37R mSOD n=12 ♀G37R mSOD n=11 ♂G37R mSOD n=11 ♂G37R mSOD n=13 animals has been shown to ameliorate motor neuron loss motor neuron loss may already have been established. If the current aims are ♀ C57BL/6 WT n=12 ♀ C57BL/6 WT n=12 ♂ C57BL/6 WT n=12 ♂ C57BL/6 WT n=12 achieved, PGRN-mediated genetic therapy may prove to be an effective tool in -Early targeting of lumbar cord motor neurons in mSOD animals has not ameliorating motor neuron degeneration. Previous work by our group has *5x2µL lentiviral vector 4.0x108 TU/mL per gastrocnemius muscle established any significant effect on behavioural changes as an ALS (Invitrogen) shown preliminary evidence for the cytoprotective actions of PGRN. The Behavioural phenotype has yet to become established. current behavioural observations are considered preliminary as the animals monitoring Histological + Biochemical have yet to reach a point at which hind-limb paralysis becomes evident. It is Leg Extension Rotorod Wire Hang Analysis Future Directions expected, however, that the effect of progranulin in the measured behavioural indices will be marginal since (i) only lower motor neurons targeting the Retrograde Transport of Vector Sites of Injection Progranulin Vector Construct -Histological assessment following onset of an ALS phenotype to gastrocnemius muscle are transduced and (ii) postural and behavioural discern motor neuron viability and markers of neuroinflammation adjustments by additional muscle groups may compensate for localized deficits -Currently, additional work by our group is assessing whether prior to phenotypic ALS expression. Histological and biochemical examination of lumbar spinal cord will provide more conclusive evidence of neuroprotective lentiviral-mediated delivery of progranulin will exhibit activity. Kaspar et al 2003 Injection site Antal et al 2007 Invitrogen neuroprotective activity in an environmental model of ALS-PDC, - Male B6.Cg-Tg(SOD1*G37R)29Dpr/J (Jackson Laboratory) animals were crossed with work that will explore neuronal rescue in the context of a non- Acknowledgements congenic C57BL/6 females to generate Tg (+)ve and Tg (-)ve progeny, confirmed via mSOD mediated toxic insult, which may be more telling for cases genotyping of sporadic ALS Special thanks to ALS Canada for making the current research - At approx 3.5 months of age, following isoflurane anesthesia, a GFP or PGRN lentiviral -Additional work would need to explore the prophylactic efficacy endeavour possible. Additionally, thanks for the support and vector was administered to each gastrocnemius muscle with 5 x 2µL injections at in targeting multiple neuronal populations and the subsequent encouragement of members from Neural Dynamics Research 4.0x108 TU/mL via Hamilton syringe effect on ALS phenotypic outcomes in genetic models. Group as well as Drs D. Kay & J. Van Kampen from Neurodyn - Bi-weekly behavioral assays (Rotorod, Wire Hang, and Leg Extension reflex score) are Inc. for their invaluable insights and troubleshooting advice. employed to monitor the onset of an ALS phenotype If we knew what we were doing, it wouldn't be called research, would it? -Einstein