The Challenge of Maintaining our Physician-Scientist Workforce

As part of the mini-symposium entitled The Challenge of Maintaining our Physician-Scientist Workforce, Dr. Flotte, who is Dean, Provost and Executive Deputy Chancellor at the University of Massachusetts Medical School, discusses strategies for recruiting and promoting physician scientists in the face of demands to sustain institutional funding and grow the institution’s overall research reputation

Cell and gene therapy for genetic diseases: inherited disorders affecting the lung and those mimicking sudden infant death syndrome

Some of the first human gene therapy trials targeted diseases of the lung and provided important information that will continue to help shape future trials. Here we describe both cell and gene therapies for lung diseases such as cystic fibrosis and alpha-1 antitrypsin disorder as well as fatty acid oxidation disorders that mimic sudden infant death syndrome (SIDS). Human clinical gene therapy trials for cystic fibrosis and alpha-1 antitrypsin have been performed using a variety of vectors including adenovirus, adeno-associated virus, and nonviral vectors. No human clinical gene therapy trials have been performed for disorders of fatty acid oxidation; however, important proof-of-principle studies have been completed for multiple fatty acid oxidation disorders. Important achievements have been made and have yet to come for cell and gene therapies for disorders of the lung and those mimicking SIDS

Gene Therapy 2017: Progress and Future Directions

Introduction: Gene therapy has changed dramatically in the 28 years since the first human gene transfer experiment in 1989. Alipogene tiparvovec, GlyberaR®, a recombinant adeno-associated virus (rAAV) product for lipoprotein lipase deficiency, and Strimvelis®, a lentivirus vector for severe combined immune deficiency are approved in Europe. An rAAV2 product for a congenital form of blindness is currently under review in the United States, likely to be followed by numerous other gene therapies

Codon Optimization for Alpha 1-Antitrypsin Disease

Alpha 1-antitrypsin deficiency is a genetic disorder caused by defective production of alpha 1-antitrypsin (AAT). Gene therapy approaches have been conducted in patients with AAT deficiency with successful AAT expression, but not to the therapeutic levels required to reduce the risk of emphysema. Codon optimization, a somewhat new and evolving technique, is used by many scientists to maximize protein expression in living organisms by altering translational and transcriptional efficiency as well as protein refolding. The purpose of this study was to develop single stranded and double stranded AAT gene constructs, test their protein expression in vitro, and compare with those levels expressed by the AAT construct that is currently in clinical trials. Three constructs were to be developed, yet only one construct was successfully cloned. This clone, optimized ds-CB-AAT, illustrated increased AAT protein expression as the transfection time increased. However, protein levels were appreciably lower in the optimized construct compared to the single stranded (long intron) AAT construct that is currently being administered in clinical trials. The data did not suggest that the optimized AAT construct does in fact express more AAT protein in vitro as expected. In order to achieve data that can be reproduced, the 2 remaining constructs need to be cloned and all of the isolated plasmid DNA should be prepared on the same scale to minimize any additional confounding variables

Assuring Integrity in the Residency Match Process

Integrity in medicine is essential. One of the most important competencies a medical student can master is to be honest at all times. Indeed, professionalism is a key competency in the identity formation and development of a medical student. At times, this competency becomes challenged during the resident matching process. The behavior of some students, faculty members, and program directors who participate in the residency program selection process (the Match) often falls short of this ideal when it comes to handling the process that will be most dispositive in directing the future careers of graduating medical students. Violations of both National Resident Matching Program (NRMP) rules and ethical norms have been reported in the literature and experienced by students. In this Invited Commentary, the authors recommend a series of reforms. Substantially more robust enforcement of NRMP rules should be considered, including the creation of an avenue for anonymous reporting by applicants who experience inappropriate pre-Match, post-interview communications

Muscle-Directed Delivery of an AAV1 Vector Leads to Capsid-Specific T Cell Exhaustion in Nonhuman Primates and Humans

With the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) approvals for Zolgensma, Luxturna, and Glybera, recombinant adeno-associated viruses (rAAVs) are considered efficient tools for gene transfer. However, studies in animals and humans demonstrate that intramuscular (IM) AAV delivery can trigger immune responses to AAV capsids and/or transgenes. IM delivery of rAAV1 in humans has also been described to induce tolerance to rAAV characterized by the presence of capsid-specific regulatory T cells (Tregs) in periphery. To understand mechanisms responsible for tolerance and parameters involved, we tested 3 muscle-directed administration routes in rhesus monkeys: IM delivery, venous limb perfusion, and the intra-arterial push and dwell method. These 3 methods were well tolerated and led to transgene expression. Interestingly, gene transfer in muscle led to Tregs and exhausted T cell infiltrates in situ at both day 21 and day 60 post-injection. In human samples, an in-depth analysis of the functionality of these cells demonstrates that capsid-specific exhausted T cells are detected after at least 5 years post-vector delivery and that the exhaustion can be reversed by blocking the checkpoint pathway. Overall, our study shows that persisting transgene expression after gene transfer in muscle is mediated by Tregs and exhausted T cells

Hepatic Changes Associated with Chronic Alcohol Exposure in an Alpha-1 Antitrypsin PiZ Mouse Model

The PiZ mutation in the alpha-1 antitrypsin (AAT) gene causes the PiZ mutant protein to be sequestered in the endoplasmic reticulum of hepatocytes, causing significant liver pathology in ~10% of PiZZ homozygous AAT disease patients. Current transgenic mouse models of the disease include the liver-specific over-expression of mutant PiZ protein. However, these animal models do not efficiently recapitulate the liver damage found in PiZZ homozygous patients. Since only a small percentage of patients develop liver disease and it is not reproducible in animal models of AATD, it suggests that there are other factors that participate in disease pathogenesis. Here, we propose that in the presence of alcohol, liver injury will be initiated and that the intensity of the disease will be exacerbated by the presence of accumulated PiZ mutant protein. To test this hypothesis, we have administered alcohol via the Lieber-DeCarli diet regimen to PiZ transgenic and control C57Bl/6 mice for 12 weeks. We found no difference in alcohol and non-alcohol fed mice in terms of elevations in liver enzymes (AST and ALT). We did find a difference in the degree of steatosis and inflammation in the livers of alcohol fed PiZ mice over those of control alcohol fed mice. These findings are consistent with a chronic low-level hepatic insult seen in chronic alcohol consumption. The difference between PiZ and control mice will allow us to test gene therapies that prevent the accumulation of PiZ aggregates within hepatocytes to determine if they will prevent the exacerbation of alcoholic liver disease

No Immune Responses by the Expression of the Yeast Ndi1 Protein in Rats

Background: The rotenone-insensitive internal NADH-quinone oxidoreductase from yeast, Ndi1, has been shown to work as a replacement molecule for complex I in the respiratory chain of mammalian mitochondria. In the so-called transkingdom gene therapy, one major concern is the fact that the yeast protein is foreign in mammals. Long term expression of Ndi1 observed in rodents with no apparent damage to the target tissue was indicative of no action by the host’s immune system. Methodology/Principal Findings: In the present study, we examined rat skeletal muscles expressing Ndi1 for possible signs of inflammatory or immune response. In parallel, we carried out delivery of the GFP gene using the same viral vector that was used for the NDI1 gene. The tissues were subjected to H&E staining and immunohistochemical analyses using antibodies specific for markers, CD11b, CD3, CD4, and CD8. The data showed no detectable signs of an immune response with the tissues expressing Ndi1. In contrast, mild but distinctive positive reactions were observed in the tissues expressing GFP. This clear difference most likely comes from the difference in the location of the expressed protein. Ndi1 was localized to the mitochondria whereas GFP was in the cytosol. Conclusions/Significance: We demonstrated that Ndi1 expression did not trigger any inflammatory or immune response in rats. These results push forward the Ndi1-based molecular therapy and also expand the possibility of using foreign protein