Podcast appearances and mentions of dan keller

It's the beginning of a new year, which means it's time for us to release one of our favorite episodes of the year, our predictions for this year! Join our hosts Christian Nossum, and Varun Jain of the Awesome Nossum Group at Wilson Realty and special guest Dan Keller of New American Funding as we tell you about our predictions for the 2025 local Seattle real estate market, national market, rents, and mortgage rates. If you like listening to the Awesome In Seattle Podcast, leave us a review. We would love to hear from you!

This week, we're taking a moment to look back on the Seattle real estate market in 2024. Join our hosts Christian Nossum, Joanna Beecher, and Varun Jain of the Awesome Nossum Group at Wilson Realty and special guest Dan Keller of New American Funding as we recap what happened in 2024 with the local Seattle real estate market and the national real estate market in 2024. We will discuss home prices, interest rates, the condo market, the rental market, and more! If you like listening to the Awesome In Seattle Podcast, leave us a review. We would love to hear from you!

In this episode, Sam Kamani interviews Dan Keller from Flux, a leader in decentralized infrastructure. Dan shares insights on how Flux is creating an alternative to centralized giants like AWS and Google, enabling users to run everything from AI to real-world assets on a fully decentralized platform. Tune in to learn about the challenges, opportunities, and the future of AI, DePIN, and Web3. Whether you're a founder or investor, this episode is packed with valuable insights! Key Timestamps [00:00:00] Introduction: Sam introduces Dan Keller and the focus of the episode. [00:01:00] Dan's Background: Dan shares his journey from tech C-suite to founding Flux. [00:04:00] The Problem with Centralized Infrastructure: How Google and AWS monopolize the industry. [00:06:00] What is Flux?: Overview of Flux's decentralized compute network. [00:09:00] Tackling the Speed, Security, and Scalability Dilemma: Dan explains how Flux achieves the trilemma. [00:12:00] Revenue Model: How Flux sustains its operations while empowering its community. [00:14:00] Real-World Use Cases: Examples of companies using Flux, from healthcare to blockchain projects. [00:18:00] DePIN and Real-World Adoption: The future of DePIN and regulation in the decentralized space. [00:25:00] AI and GPU Utilization: How Flux is enabling decentralized AI processing. [00:31:00] Real-World Assets (RWA): Dan's thoughts on the role of RWAs in the future of blockchain. [00:34:00] Challenges and Future Plans: Overcoming regulatory and technical barriers. [00:36:00] How to Get Started: Dan shares how listeners can start using Flux today. [00:38:00] Closing Remarks: Sam and Dan discuss the future of decentralized technology. Disclaimer Nothing mentioned in this podcast is investment advice and please do your own research. Finally, it would mean a lot if you can leave a review of this podcast on Apple Podcasts or Spotify and share this podcast with a friend. Connect ⁠https://runonflux.com/⁠ ⁠https://www.linkedin.com/company/influxtechnologies/⁠ ⁠https://www.linkedin.com/in/kellerdaniel/⁠ ⁠https://x.com/dak_flux⁠ Be a guest on the podcast or contact us - ⁠https://www.web3pod.xyz/⁠

Our featured interview on tonight's show is with pipe maker Dan Keller from Good Made Better. Dan is from South Dakota. Growing up working in the family hardware store where he was always finding solutions to fixing things, he ended up always wanting to make things. He now makes elegant handmade pens, pen holders, portable desks, blotters, blotting paper, book carry cases, and of course artisan pipes. At the top of the show we are continuing the virtual tour of Brian's pipes with his "f#@k you pipes".

In today's episode we are going go over some major changes in condo lending regulations, the effects this will have on condo buyers, and educate you on what every condo buyers should do before making an offer on any condo moving forward. Join our hosts Christian Nossum and Joanna Beecher of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we tell you what the condo lending changes are that impact buyers. If you like listening to the Awesome In Seattle Podcast, leave us a review. We would love to hear from you!

Dan and Fran Keller operated a successful and loving daycare until one day everything was turned upside down. A child came forward with a horrific story of abuse, sparking widespread panic and hysteria from all directions.Trigger Warnings: Satanic Panic Child Abuse Sexual Assault  Deadly Faith PATREON: https://patreon.com/DeadlyFaithPodcast?utm_medium=unknown&utm_source=join_link&utm_campaign=creatorshare_creator&utm_content=copyLinkDeadly Drip Merch https://www.bonfire.com/store/deadly-drip/?utm_source=facebook_messenger&utm_medium=store_page_published_share&utm_campaign=deadly-drip&utm_content=default Need A Podcast Editor? Reach out to Eric Howell the editor of the Deadly Faith podcast!Email: thepodcastdoctor@gmail.com Resources:National Domestic Violence Hotline 1(800)799-7233 Open 24/7Suicide Hotline Call 988 Open 24/7National Human Trafficking Hotline Open 24/7 1(800) 373-7888 Follow Us On Social Media The PodcastTik Tok @DeadlyFaithPodcastInstagram @DeadlyFaithPodcastLaciTik Tok @Laci_BeanInstagram @Laci__BeanLolaTik Tok @hellotherelolaInstagram @Spellbound_Shears

It's the beginning of a new year, which means it's time for us to release one of our most viewed episodes of the year! Join our hosts Christian Nossum and Joanna Beecher of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we tell you about our predictions for the 2024 real estate market. We will let you know what both local and national real estate “experts” are predicting for the national real estate market and the local Seattle area market, what the rate predictions are, real estate inventory predictions, and rent predictions. We will also let you know what out predictions are for 2024 and which areas of Seattle we think will be the hottest.

This week, we're taking a moment to look back on the Seattle real estate market in 2023. Join our hosts Christian Nossum and Joanna Beecher of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we recap what happened in 2023 with the local Seattle real estate market. We will look at the big picture of what happened with the national real estate market in 2023 too.

As we start the new year, we wanted to turn the tables on our podcast host and moderator, Dan Keller. Dan has hosted our Substantial Matters podcast series since it began more than five years ago. In this episode, we share some insight into his background, his experience, and how he came to host this series, starting as a laboratory researcher, to journalism student, to medical journalist and broadcaster. He talks about the rewards of reaching the Parkinson's community through podcasts, and shares his suggestions for new, as well as seasoned, listeners. We invite our listeners to share your feedback by visiting Parkinson.org/Feedback. We want to hear your thoughts so we may continue to improve our podcasts and explore topics that are relevant to you.

This week we are talking about real estate investing and how you can get into it even with a normal 5% down payment due to a recent change from Fannie Mae. Join our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we break down the numbers for what it would cost to own a duplex, triplex, or even a fourplex. If you want to contact Christian or Dan directly about investing in a cash flowing property you can email Christian at Christian@Awesomenossum.com or Call/text him at (206)949-3048 and you can contact Dan Keller from New American Funding by emailing him at Dan.Keller@nafinc.com or Call/Texting him at (425)350-7136. NMLS#115349

11/10/23: Rep Natalie Blais – her Veterans Day memories & legislation. MTA Pres Max Page with local union VP Julian DiGloria on the Andover educators' strike that began today. Betsy Stone with Richard Roy on his retrospective at Art for the Soul Gallery. Nick Simmons on his repurposing wood and purposing students. Jacki Ochs & Dan Keller on “Vietnam: The Secret Agent.”

Do you own a condo, are you thinking about buying a condo, or are you part of a condo association? If you fall into one of those categories, then you need to be aware of major changes that recently went into effect with lending for condos. Join our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we explain what the changes are, how these changes are affecting condos, and how to protect your investment.

Considered “atypical Parkinsonian syndromes,” over half of people with progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and multiple system atrophy (MSA) are initially misdiagnosed with Parkinson's disease (PD) due to similarities in early symptoms as well as lack of awareness of these rare, neurodegenerative diseases among many healthcare professionals and the general public.   This is the third of three podcast episodes within our atypical parkinsonism podcast series, organized in partnership with CurePSP and designed to address the unique care needs across the disease stages of PSP, CBD and MSA.  Jessica Shurer, Director of Clinical Affairs and Advocacy at CurePSP, and Nancy Montgomery, who cared for her husband who was diagnosed with progressive supranuclear palsy, cover common challenges experienced by people living with PSP, CBD or MSA and describe helpful resources and roles played by healthcare teams that support the quality of life of patients and family care partners.  Jessica Shurer, Nancy Montgomery, and podcast host, Dan Keller, have disclosed that they have no relevant financial disclosures.

Considered “atypical Parkinsonian syndromes,” over half of people with progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and multiple system atrophy (MSA) are initially misdiagnosed with Parkinson's disease (PD) due to similarities in early symptoms as well as lack of awareness of these rare, neurodegenerative diseases among many healthcare professionals and the general public. This is the second of three podcast episodes within our atypical parkinsonism podcast series, organized in partnership with CurePSP and designed to address the treatment interdisciplinary approach of PSP, CBD and MSA. In this second episode of the series, Heather Cianci, Outpatient Neurological Team Leader and founding therapist of the Dan Aaron Parkinson's Rehabilitation Center, Penn Therapy & Fitness at Pennsylvania Hospital in Philadelphia, Pennsylvania and Julia Wood, Director of Professional and Community Education at the Lewy Body Dementia Association, cover the treatment and interdisciplinary approach to care for atypical parkinsonism. Julia Wood, Heather Cianci, and podcast host, Dan Keller, have disclosed that they have no relevant financial disclosures.

Considered “atypical Parkinsonian syndromes,” over half of people with progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and multiple system atrophy (MSA) are initially misdiagnosed with Parkinson's disease (PD) due to similarities in early symptoms as well as lack of awareness of these rare, neurodegenerative diseases among many healthcare professionals and the general public.   This is the first of three podcast episodes within our atypical parkinsonism podcast series, organized in partnership with CurePSP and designed to address the overview, treatment and care of PSP, CBD and MSA.   In this first episode of the series, Dr. Alex Pantelyat, Associate Professor of Neurology at Johns Hopkins University School of Medicine shares an overview of atypical parkinsonism, overlaps and differences with Parkinson's disease, the red flags and how PSP, CBD and MSA are diagnosed.   Dr. Pantelyat has disclosed that he is a Scientific Advisory Board Consultant for MedRhythms, Inc. and a consultant for both Ferrer Internacional, S.A. and SciNeuro Pharmaceuticals.   Podcast host, Dan Keller, has disclosed that he has no relevant financial disclosures.

Does your current home not make sense for you anymore, but you have such a low mortgage rate that it is stopping you from buying a new house that is better suited for you? If you answered yes, then you might be “golden handcuffed” to your home and this episode is for you! Join our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we explain what your options are if you think are “golden handcuffed” to your low mortgage rate and current home.

In today's episode we are going discuss what an Assumable Mortgage is. Join our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we tell you the truth behind them.

Are you waiting for to buy so you can save for a larger down payment, are waiting for housing prices to drop, or are you waiting for interest rates to drop? Our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding will let you know what the cost of waiting to is, and why you should buy now if you are able to.

During our True & Blue segment, Huge talked to Chief Dan Keller from the White Lake Township Police Department. He joined Huge to tell us why he loves his job in law enforcement, told us about a great story out of his community, and much more. See omnystudio.com/listener for privacy information.

In part two of this podcast our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding discuss everything you will need to know about the Home Mortgage Process once your offer is accepted, what happens once you are a home owner, and beyond.

Are you curious about the Home Mortgage process? Join our hosts Christian Nossum of the Awesome Nossum Group at Wilson Realty and Dan Keller of New American Funding as we tell you everything you will need to know. Part one will answer all your questions about the beginning of the Home Mortgage process.

Featuring Denise Donoghue, Dan Keller, Dave Savage, Todd Bookspan & Deborah Byrd!

Featuring Denise Donoghue, Dan Keller, Dave Savage, Todd Bookspan & Deborah Byrd!

What if you could buy the house of your dreams for a lower price, AND a lower interest rate? Sounds like the best of both worlds, right? With homes in the Seattle area becoming less and less competitive, now is a great time to buy property, but interest rates are indeed higher than they've been in the past few years. This week the Awesome Nossum Group at Wilson Realty interviews Dan Keller at New American Funding to talk about some great options buyers have to get a great interest rate, and a great house.

Today we welcome Dan Keller to our podcast! Dan is a Seattle area and Top 1% nationally recognized mortgage loan officer and Regional VP of Sales/Performance Coaching. He is also an industry leader and speaker fired up to share his story and inspire others! BELIEVE - BATTLE - BECOME. This is both an educational and motivational episode you don't want to miss! If you are enjoying this episode, don't forget to leave us a review! Visit Dan Keller's Website and Social Pages By Clicking The Links Below! Website Facebook Linkedin Twitter CLICK HERE FOR OUR NEW INVESTING COURSE! --- Send in a voice message: https://anchor.fm/yvrremoshow/message

Host Monique Aiken is joined by David Bank, who has been on the ground with ImpactAlpha's New York “bureau” (Amy Cortese, Roodgally Senatus and Dan Keller), taking the pulse of investors and other stakeholders at Climate Week. Plus, the headlines. --- Send in a voice message: https://anchor.fm/impact-alpha/message

Host Monique Aiken is joined by David Bank, who has been on the ground with ImpactAlpha's New York “bureau” (Amy Cortese, Roodgally Senatus and Dan Keller), taking the pulse of investors and other stakeholders at Climate Week. Plus, the headlines. --- Send in a voice message: https://anchor.fm/impact-alpha-briefing/message

Are you a renter who often dreams of owning your own home? Someplace you can invest in and make truly your own? Well then this is the podcast for you! This week, the Awesome Nossum Group at Wilson Realty discuss why its a smart financial and personal decision to stop renting, and buy a home. Later in the episode we're joined by Dan Keller of New American Funding to the numbers, talk finances, and why now is still a good time to buy!

"How did you get to 200MM in production & serve 370 families last year?"   1:00 - How did you get to 200MM? Starting at 25MM to now...   2:20 - What are strategies & advice on how to shorten the learning curve to get where you are?   4:00 - Truly understanding how to build a team & what it actually looks like.   6:15 - Know your natural strengths/talents & leveraging them!   10:07 - The facts: BIG teams have double YOY. The industry is changing.   13:20 - Evolving your social media game for success.   15:20 - Budgeting your money - DO IT BETTER!   This a must-watch episode, thank you again to our special guests for sharing their wisdom with theREsource Nation! Love this podcast? Subscribe Today! https://theresource.tv Tag an industry friend or share it on an industry group! Join our thousands of FB fans: http://www.Facebook.com/TheREsource.tv Twitter: https://twitter.com/theresourcetv Instagram: https://www.instagram.com/theresourcetv

Prospect wrestling heads to team state in Bloomington with the opportunity to make history. Prospect has never placed at team state in its existence. Jacob Siciliano sits down with Head Coach, Dan Keller, and wrestler, Will Baysingar, to look back on the season and the opportunity ahead of them.

Regardless of your timeline for purchasing your next home. Your Credit Score arguably plays the largest role to what financing terms and options will be available to you! In this episode Addy and Dan Keller run through the 5 Biggest Factors that determine your credit score.  How is your credit determined?What can you do now to continue or improve your Credit Score trajectory?What personal approaches do Dan and Addy take on a daily basis to keep their credit scores in the optimal position to be leveraged?We are excited to Help, it is never too early to book a strategy session and build out a plan for your next property! Schedule Here:Need to Refinance or Get Pre Approved Now! Click to Get Started Online Today!Need Resources / Tools / Videos? Visit our Website: Addy Nett

Ever had your Grandfather give you the "in my day, we walked 5 miles in the snow, uphill both ways" talk? For younger generations, Financial Literacy often becomes unappealing subject due to this tone it is often presented in. Today we turn the table where Dan Keller, Mortgage Influencer and founder of the widely popular website: BudgetWithDan.com Interview Addy Nett on his perspective and journey with Real Estate, Credit and finally the concept of Career Freedom.  We are excited to Help, it is never too early to book a strategy session and build out a plan for your next property! Schedule Here:Need to Refinance or Get Pre Approved Now! Click to Get Started Online Today!Need Resources / Tools / Videos? Visit our Website: Addy Nett

Too much surprise; "Most homeowners are broke. They are equity rich and cash poor"Today we have a honored guest Dan Keller (one of the top Mortgage Originators in the Nation and the founder of budgetwithdan.com) to discuss how most homeowners are missing the mark on their journey to financial freedom. Dan shares his personal story of navigating through the Real Estate Crash of 08' and how he is making change within his family by educating his kids about money and following the 4 steps to financial freedom.We are excited to Help, it is never too early to book a strategy session and build out a plan for your next property! Schedule Here: https://calendly.com/addynett/mortgage-strategy-call-via-zoom

TW: CHILD SEXUAL ABUSE Welcome to Episode Four of the Texocity series presented by the 210 Culture Podcast with Donna as your host! In this episode of the Texocity series, Donna discusses the case of the Oak Hills Satanic DayCare of Austin, Texas ran by Fran & Dan Keller. Fran & Dan Keller were wrongly accused of sexually abusing children at their daycare with satanic rituals and other ways. FOLLOW US: Email: 210culturepodcast@gmail.com IG: @210culturepodcast FB: 210 Culture Media Twitter: @210culture

We are joined this week with special guest, Dan Keller of CrossCountry Mortgage (MLO# 115349), as we discuss all things refinancing. Why is now potentially a good time to do so? What's involved in the process? What's changing in the near term? Lots of great info here, so this is a must-listen!

In today’s episode I interview a good friend and top producing Loan Officer, Dan Keller.  We talk about the tactics mortgage professionals should use to become a trusted advisor, as well as how to focus yourself and your business to succeed in today's market environment. Dan Keller is a top producing mortgage professional based in Seattle, Washington.  He has been a Top 1% Originators according to Scotsman Guide for multiple years.  He is an affiliate professor in the School of Real Estate at the University of Washington, and has been blogging in the mortgage industry since 2010. Follow us on social media for marketing tips, and don't forget to "enable Mortgage Marketing Expert" on Amazon Alexa to get our Marketing Minute flash briefing.  MME is a founding member of the Industry Syndicate Podcast Network – the Industry Syndicate mobile app NOW AVAILABLE in Apple & Google app stores.

Joining us yet again is our special guest, Dan Keller at CrossCountry Mortgage (MLO# 115349). From rate locks to pre-underwriting, we discuss the top three financing-related questions we always hear from clients.

Water is an enemy that many homeowners have to deal with, especially in Seattle's wet climate. What do you do if you encounter water issues? And how can you prevent them in the first place? We discuss all that, plus have a special guest for the second half, Dan Keller at CrossCountry Mortgage (MLO# 115349).

In this episode, I speak with Dan Keller and Nick Tata about Manchester United, the Champions league and Europa league finals, some transfer rumors with the summer transfer window approaching, some pick em’s, and much more. Give Mike’d Up a listen and leave a voice message if you want! Go follow @mtfuino10 on twitter and @mikefuino on Instagram for podcast updates, and tune in next Wednesday for the weekly pod. Enjoy! PS: NHL STANLEY CUP GAME 2 IS WEDNESDAY NIGHT (5/29). --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/mike-fuino/support

We kick off Episode 5 with a story from Austin Texas, The Oak Hill Satanic Ritual Abuse case. Fran and Dan Keller owned and operated a daycare center in the Oak Hill neighborhood of Austin Texas and in 1991 their lives changed forever. The therapist of a three-year-old child being treated for behavioral problems due to her parents' divorce alleged that the Kellers had sexually abused the child. The allegations went from sexual abuse to ritual abuse as more children were questioned by social workers and therapists. Allegations of sacrifice, murder, drinking blood, and quick trips south of the boarder had parents paralyzed with fear. But how much is true and when do we stop believing the children and start listening to reason?Fear in American culture led for a push in believing the children, and victims, of sexual abuse. But as well intentioned, and absolutely needed, as that push was, it had unfortunate side effects. From aggressively misguided interview techniques, to a new set of laws that awarded money based on the amount of reported abuse cases, American social workers became a key player in the quickly growing Satanic Panic.

Suicide: Understanding & Healing The journey of a thousand miles must begin with a single step. Lao Tzu The Outer Limits of Inner Truth presents a two-part series on suicide. The program seeks to offer peace & healing to those who have lost someone to suicide as well as offer peace to those who are currently suffering from severe depression. National Suicide Hotline Talk To Someone Now – 1-800-273-8255 If you're thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States. Call 1-800-273-8255 Website Link:  Individuals Who Survived Attempting Suicide 10:10 – Elizabeth Cermak 20:16 – Tracey Fortner 30:13 – Shelly Lawson 34:02 – Alicia Raimundo Surviving Family Members 41:45 – Corrie LoGiudice 50:24 – Dan Keller 1:05:22 – Corinne McDermot 1:10:48 – Kate Rees

The 100th episode of Next in Nonprofits is a special conversation. Host Steve Boland welcomes five guests to the podcast, all fellow alumni from the Hamline University N5 Master of Nonprofit Management cohort. Michael Brink, Shannon Forney, Dan Keller, Derek Madsen, and Jason Viana joined the conversation. Most of this group graduated in 2011, and have been sharing their professional and personal lives since starting school together in 2009. Many nonprofit professionals don't have access to a peer group with such deep learning connections, and this conversation talks about the advantages of getting honest feedback, seeking support from within and outside an industry group, and much more!

One this episode Dan talks with certified public accountant, Dan Keller, about buying and selling hunting property while keeping an eye on your taxes. We discuss in detail about setting up your property basis and how that can benefit you if you ever decide to harvest timber off your property, as one example. We also talk about how families can pass on property to other family members without the recipient having to pay any capital gains tax. Tons of knowledge bombs will be dropped.

One this episode Dan talks with certified public accountant, Dan Keller, about buying and selling hunting property while keeping an eye on your taxes. We discuss in detail about setting up your property basis and how that can benefit you if you ever decide to harvest timber off your property, as one example. We also talk about how families can pass on property to other family members without the recipient having to pay any capital gains tax. Tons of knowledge bombs will be dropped.

Dan Keller of DugoutCaptain.com shares more ideas for making practices fun. This is Part 2 of a two-part series. Plus Justin Stone of EliteBaseball.tv answers the Question Of The Week about what it means to 'stay connected.' And Austin Wasserman of WassermanStrength.com explains the floor dumbbell press for youth baseball and softball players in the Wass Strength Tip Of The Week. Please let us (and others) know how you feel about the show by giving us an honest review & rating on iTunes!

Dan Keller of DugoutCaptain.com shares his ideas for making practice fun again. What exactly does that mean? And how do you do it? Tune in and find out. This is Part 1 of a two-part series. Plus Justin Stone of elitebaseball.tv answers the Question Of The Week about how to improve players' baseball IQ. And Austin Wasserman of WassermanStrength.com shares his own practice plan and post-game recap templates for youth baseball and softball players in the Wass Strength Tip Of The Week. Please let us (and others) know how you feel about the show by giving us an honest review & rating on iTunes!

[intro music]   Host – Dan Keller Hello, and welcome to Episode Ninety-seven of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller.   Today's interview features Dr. David Baker, Professor of Neuroimmunology at Queen Mary University of London in the UK. We spoke at the ECTRIMS conference last fall, where I asked him about his work with cannabinoid compounds – work that has led to a better understanding of the cannabinoid system as well as to candidate drug compounds to treat spasticity.   Interviewer – Dan Keller In terms of what you're doing now with cannabinoids, can you tell me what you are looking for, and what you've found?   Interviewee – David Baker Many, many years ago, we actually were probably the first people to show that cannabis can actually alleviate muscle stiffness in animal models of multiple sclerosis, which then kind of underpinned the push to look for cannabis in MS. So people with MS were smoking cannabis and perceiving benefit. The question was, why? And what they didn't really understand that there was going to be an unfolding biology. And a few years later after our first discovery that actually cannabinoids can cause relaxation of the muscles, we understood that the function of the cannabinoid system is to regulate nerve signaling. And so because the cannabinoid system does regulate the strength of synaptic signaling, then it's obvious that it can inhibit signs and symptoms because of this excessive neurostimulation. So at the time of that, then we realized that the receptor is a CB1 receptor, and the compound within cannabis is THC, and they're the same molecules that cause all the side effects. So you could never really disassociate away the high from the medical benefit. So we started to think, well, how can we try and get the medical benefit from the cannabinoid system and at the same time try and limit the side effect potential.   So what we thought is, well, if we can stop the cannabinoid molecules getting in the brain, then they won't cause the side effects. But maybe we can target the aberrant signaling in the spinal cord and the peripheral system to try and get the benefits. And so that was our intention. So we tried to make a CNS-excluded drug. And that's, in fact, what we did. We made a drug that was very, very water soluble, so you know, you use the mechanism of the blood-brain barrier to actually exclude it from the brain. So we made the compound, and a few weeks later, we kind of started putting it into animal models, not really doing it the pharmaceutical way, which would be a methodical testing. So we showed that it didn't cause any of the unwanted side effects that are associated with cannabis in the animals. And then we put it in a system where we had a spasticity in a multiple sclerosis relevant system, and the drug worked.   Now what we did know is that the drug was blocked by the activity of the CB1 receptor antagonist, so it looked like we'd made what we set out to make. So we were really excited. And from that point, we started to try and see if we could develop it as a drug. Unfortunately what we realized very quickly actually is that it doesn't work by the known cannabinoid receptor system, and I think what we stumbled across is a whole new biology of the cannabinoid system.   And so we've been developing this drug bit by bit. We set up a university spinout company to try and develop it as a pharmaceutical drug. And over the years, bit by bit, we've been pushing it forward. So it's very safe in animals. It has a massive therapeutic window. And with grant funding agencies etc. we've managed to be able to take it into phase I study where it passed with flying colors. We tested it in 60 healthy humans. And a few weeks ago, we started our first testing in people with multiple sclerosis. So we'll have to see how it works. But we hope by early in 2016 we'll have the answer. So it could be a symptom modifying drug, but it doesn't have any of the side effects associated with drugs such as, you know, Sativex or baclofen as well. So it's not sedating as far as we know.   The way that the drug works is a new mechanism. And what we can probably say is it serves to block the excitation of nerves. So it dampens down excessive signaling, which are probably the consequences or the causes of spasms and spasticity and possibly the symptoms as well and maybe pain. We just have to do more work to see if it will work that way.   MSDF Is this a hyperexcitable system? Or is it a hypoinhibited system where you're getting this spasticity?   Dr. Baker Well, I think spasticity is largely caused by loss of the inhibitory circuitry. So there's probably less GABAergic signaling. And so one can, you know, drive the inhibitory system, like you do with GABA, but likewise you can actually kind of block the excitation. And this mechanism actually probably only exists in pathology. So this is probably why there isn't the side effect potential that the real target that we're actually after really only occurs when the nervous system is going a bit haywire. So that's why we think we've got good safety margin.   MSDF And you had told me that this does not induce hunger, which I guess is another sign that it's not getting into the CNS?   Dr. Baker Having said all that, it was made not to get in the central nervous system, but in reality, it doesn't matter if it does get in the central nervous system. So in fact, about 15% of the drug does get into the central nervous system, which would be as good as many drugs that are CNS penetrant. I guess when we were starting, we were hoping that, you know, it was going to be excluded because we thought it was a cannabinoid receptor agonist, but in reality, it doesn't matter. And in fact what we know is actually this targeting into the lesions. So there's actually more goes into the area. And what this kind of spins on to some other work that we've done with some of our sodium channel work.   We've been developing new sodium channel blockers as potential neuroprotectants. And what we've done is certain molecules actually get excluded by CNS drug pumps, and what we'd noticed in MS is that some of these drug pumps disappear. So we made a drug that was actually targeted specifically to one of those drug pumps, which would normally mean it would be excluded from the brain, but what we showed is that with these new sodium channel blockers, that actually they physically target into the lesion where the pump disappears. And so again, you increase this therapeutic window between effect versus side effect, because again with the sodium channels, you need them for health. You block them, and you have side effects. But what we've found with the sodium channel blockers is that in the animal models, sodium channel blockers were neuroprotective, and we then took that idea forward actually into the clinical trial.   So we first of all thought the trials with sodium channel blockers had failed. Why had they failed? Well, the reason they failed was the trial outcomes weren't right, and suddenly actually because of this unpleasant side effect, 50% of the people didn't take the drug. So the trial was doomed before it ever started. And then what we had was we had the bloods of the people in the trial. So we looked two years after the trial had finished and was seen to be a failure, and we found that 50% of people weren't taking the drugs. But if you look to the people who were taking the drugs, we could see that there was less neurofilament in their blood indicative that there is less nerve damage. And so actually in reality, the trial actually was positive, but it was seen to be negative because of this failure to take the drug.   So the question was, how could we then develop that forward? So the clinical guy said, well, let's think how we could best do a quick trial. And they came up with the idea of the optic nerve being the ideal target. And so what they said to us was, can you, you know, model this in the animal model? So we developed a new animal model. So we took Vijay Kuchroo's 2D2 mice, which are preprogrammed to get optic neuritis, and then we just made their eyes florescent so we could just look in their eyes and see nerves in real time and in life. And as a consequence of using the transgenic, which targeted myelin oligodendrocyte glycoprotein, the cells would go in, cause optic neuritis, that would cause nerve death, and then we could monitor the nerve death just by looking into the eye, because each nerve was labeled with a fluorescent protein. We'd see one single nerve die.   And so we started to use that as a way of testing different drugs for neuroprotection. And we put a whole stack of different compounds, minocycline, sodium channel blockers, glutamate receptor antagonist, we did a few. And we got some hits with the sodium channel blockers, and we tried a few of the different ones, some of them better than others. And unfortunately the one that they chose for the trial is probably the worst one in the animals, but they decided that you had to load drug quickly, so they selected phenytoin. So we showed that the sodium channel could work in the optic neuritis, and then the idea was then we translate that and then do a trial with optic neuritis in the human.   So this was a trial that Raj Kapoor did. And so the idea was that people go blind, and then you go to the doctors. And then they were randomized to either get steroids, which is the standard treatment, or they'd get steroids plus a sodium channel blocker, which was phenytoin at the time. And that was done because you can dose very quickly. So the idea was to get people on drug very quickly. So within seven days of their first symptom, people were on active drug. And people were treated for about six months. And then they looked at the retinal fiber thickness. So as a consequence of the ganglion in the retina dying, the retina thins, and then you can measure that with a machine called OCT, optical coherence tomography. And that was slowed. So they saved 30% of the nerves from dying, even though there were people getting a steroid. So it tells us that really certain channel blockers are neuroprotective.   And then the question is, is how then can we show that in reality? So what we've done from there is we've actually gone on with another sodium channel blocker, which was called oxcarbazepine, which was much more effective in the animal models. And we've been trying to initiate a new trial design whereby we're looking for people who are on current DMTs by showing evidence of neurofilament release, which is indicative that their nerves are being destroyed, because as the nerves are destroyed, they liberate their contents, and then we can pick that up in the biological fluids. So the idea is that if they've got neurofilaments in their cerebrospinal fluid, they get the option of having a sodium channel blocker in addition to their DMT. And then we'll monitor them by serial lumbar punctures to see if the neurofilament levels decrease as a way of a trench push on the trial design for phase II.   Because if you're thinking about the standard phase III, phase II trial for neuroprotection, you're talking about a two- or three-year trial, which will take you two years to recruit the 600 people and another year to do the analysis. So you're really talking about a seven-year trial with 600 people. This trial design will kind of push it down probably to 12 months to 18 months with 60 people. So we can do 10 times more people and a lot quicker this way. So that's started where we've been recruiting, and we're still recruiting, but fingers crossed that would be another way forward in terms of developing neuroprotection. I think it shows how we've been trying to use our animal models to translate things into the human. Because at the end of the day, there has been really, really poor translation between the animal models and humans. And I guess the question is, is why?   MSDF We’ll pick up on that question in part two of our interview with Dr. Baker next time, when he’ll describe some of the deficiencies he sees in the design and interpretation of animal experiments and how they could be improved to better relate to clinical trials and the clinical situation.   [transition music]   MSDF Thank you for listening to Episode Ninety-seven of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations.   Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances.   [outro music]   We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org.   For Multiple Sclerosis Discovery, I'm Dan Keller.

[intro music]   Host – Dan Keller Hello, and welcome to Episode Ninety-eight of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller.   Today's interview again features Dr. David Baker, Professor of Neuroimmunology at Queen Mary University of London in the U.K. We spoke at the ECTRIMS conference last fall. In part one of our interview he raised the issue of why there has been very poor translation from animal models to clinical trials. Today, Dr. Baker, also known as the ”Mouse Doctor” for his work with animal models, lays out why this situation exists and what to do about it.   Interviewee – David Baker I think there’s many reasons why, and I think we all have our failings. And one can point the finger at the animal models, which a lot of the clinicians do, saying it’s the animal model’s fault, which is possible. But I think also we have to look at humans and how humans use their animal models. And then how humans translate the data from the animal models into the clinic, because I think there’s many failings along the line, and I think that’s one of the reasons for the failing between the two.   I think one of the failings is, in terms of the animal models, that when we do our animal models for these, we’re looking for mechanisms not treatments. And so about 70% of studies give drug before disease is ever induced, which never happens in a human. You know, you go after you’ve had one or two or more attacks before you’re given drugs. We also use the drugs in a way that are never used in a human, so people will do what they call a prophylactic drug where they’ll give it before the disease manifests itself. Or a therapeutic dose, which is probably when the animals are showing their symptoms. But in reality, a human would be getting steroids at that time point. They would never get a DMT. So you’re not comparing, you know, apples with apples. You’re comparing apples with pears, and I think that’s one of the problems.   And I think, you know, if you try and block an immune response from being generated, that’s quite easy compared to stopping an immune response once it’s been generated, because immunity’s about giving life-long protection against infections. And so I think it’s a different type of beast to target. So I think this is where the animal models could do it, because EAE is one of the few where you have this relapsing-remitting disease course. But it’s very, very rare that people actually start to treat in between attacks to block further relapses. I think that’s one of the problems.   The other big problem is the dose; the dose relationship between animals and humans. There’s a tendency we just keep giving more and more and more and more, and eventually the drugs will work. But you’ve got this problem that animals are very liable to be stressed, and we call it the building site effect, so construction site effect. And if you have lots of loud noises, it scares animals. They get very stressed, and your EAE just disappears. And likewise, if you just give lots and lots of drug, that probably tastes nasty. They get stressed out as well. And I think many of the so-called wonder cures – cures of the week – are because we’re just giving too much, which doesn’t have a relationship to what the human dose is going to be.   And then, likewise, I think we’ve got too much of a publication bias for the need to generate positive data. And I think what we then have to do is we have to look at the quality of the data. And I think there has been a lot of failure to replicate data. I think some of that is because some studies lack quality control, and the way I look at that – and I could be wrong; obviously it’s an opinion – but if you look at the way that EAE is scored (it’s normally a scoring system 1 to 3 or 1 to 4) and then you have your drug, which may be, you know, takes your control down from 3 down to a 1. But then, every now again, you look at the studies where it goes either way, and your controls are at 1 and it goes up to 3, and I ask the question how do you get a score of 1? Because if you had four animals, they’re all scoring 1. Or is it three animals score 0 and one score 4, and that will give you a score of 1. And I think if people were made to actually put the data about how many animals got disease, we’d be able to interpret those line graphs. Because I feel that, in many cases, some of those graphs lack quality control.   If you have a robust quality control system, your control group should be giving you roughly the same type of scores every time. But in individual papers you can see, in some groups you have a score of 1 in the control group. The next experiment it’s a score of 3. To my mind I think if you look at that, then those are probably the experiments are much more likely not to replicate. So I think you have to be, obviously, skeptical, but I really would like people to actually probably give us the information about how many animals got disease – what is their mean score – in addition to those line graphs. Because without that, they’re impossible to interpret.   So that’s, you know, kind of one problem of the animals. And then for the humans, you have the same problems. So they over-interpret the animal data. The people doing the clinical trials are very, very rarely the people who came up with the idea. So if there’s a weird side effect that you may know about, you know, that’s not translated to the person who’s actually doing the study, because they don’t talk to the basic scientists. Then they probably underpower the studies. They don’t necessarily pick the right outcome measurements. So I think there’s many failings in both sides of the equation, and it’s not always the animal model. But I think unless we kind of up our game, I think it’s going to be very difficult for the people who are working on animal models, because you know, there are treatments that come along for, you know, the immune part of multiple sclerosis.   And if you’re thinking about the ethical use of animals, it’s much harder to make the ethical argument that you should be using disease models which are very severe for the animals to try and work out fundamental parts of biology. And, therefore, I think we’ll find that you know the funding agencies start to say, well, why are we funding this work? So I think we need to have good quality work, because if we don’t have good quality work, it allows that clinical view that animal work doesn’t really deliver the treatments. And I think they can deliver the treatments, but we just have to use our animal studies wisely to ask questions rather than, you know, blindly saying this will work in multiple sclerosis because it works in EAE. That doesn’t make sense to me.   Interviewer – Dan Keller Do you have any succinct tips for people who are either reviewing papers on animal studies or people who are reading those papers once they’re published or even the general public reading a news story?   Dr. Baker Well my first tip would be probably – and this is okay as an opinion – but, you know, EAE data is nonparametric. It goes 1, 2, 3, 4; it’s not a continuous scale, so first tip is don’t use, you know, the t-test of parametric data on nonparametric data. And that does make a difference. There is a Nature paper published this year that was analyzed with a t-test. If you analyze it with a Mann-Whitney test, which you should have done, the data becomes nonsignificant. So rather than the take home message is, you know, this is a new wonder drug for multiple sclerosis, their answer should have been you have to go back and reproduce your EAE experiment because it didn’t work. So I think that would be the first tip. And then the second tip, I would really like people to say, tell us how many animals get disease and on what level and when, so we can interpret the line graph.   MSDF This is something that you routinely see in oncology done right. They talk about percent of responders, and among responders, what was the shrinkage of the tumor? They don’t average it out among all the people who dilute it out by not responding.   Dr. Baker Well I think one of the problems as well is we’ve also got this publication bias. We’ve got you know this urge to see positive data, and I think that skews the whole system.   MSDF Has anything changed since you came out with a response to the animal checklist?   Dr. Baker I think, sadly, no, but we’re actually doing the checklist again, so we will be able to see if things have changed. I don’t think it has. I think the message hasn’t gotten through. But I think – this is, again, another one of those nails in the animal model coffin that, if we don’t up our game, we’ll be seen to be doing an inferior quality work and eventually we’ll get discarded. So I know that some of the grant councils are, as you know, saying this is a condition of your grant. But I think you know it’s been slow to change, and I think one of the reasons is actually people who are leaders of the field actually are some of the people who are some of the worst offenders. So we’re leading by bad example rather than good example.   MSDF We don’t want to leave the listener with the impression that you’re against animal models. I mean, you’re known as “Dr. Mouse,” so you know I guess you just want to see them done well.   Dr. Baker Yes, I’m passionate. I mean, I really you know believe animal models have a real positive impact to do. And I’ve been really lucky in the recent years is that, you know, some of those animal models – and work we’ve done from animal models – is going through into humans and you know is starting to make the difference. So you know our work with the Cannabis was great. You know, it shows that you know our animal work has validity. Without the animal model stuff we’ll never really understand the biology. You can’t do all the experiments in humans. You do need experimental systems to be able to ask questions. And you need to be able to invent.   And you know there is some fantastic work. You know I’ve picked up the papers, and I get really excited by it, but I think, at the same time, we have to also be a drum to say, you know, try and improve the quality. Because, at the end of the day, it’s more likely that if you’re doing good quality animal experiments, that other people will be able to replicate it. And it will move the field on further and faster. And I think if people believe what we produce as being good solid work, then it’s going to be a win-win situation.   MSDF It would be nice to see sort of a meta-analysis of animal studies that are considered to have been done well versus those not and see which ones translated into advances in the human situation, because so many times they say, well, sure it works in animals, but it doesn’t work in humans. Well if it works in animals because it was set up not so well, then that might be a reason not to work in humans.   Dr. Baker Yes. I think you know the problem of animal models has got nothing peculiar to the multiple sclerosis field. It’s just a common theme. And I think that tells me it’s not a problem of animal models, because if it’s so common in every other discipline, it tells us it’s something how we use the animals is the fundamental problem. Now, you know for MS, we don’t really know. I mean, I think this going to be the – we’re at ECTRIMS now, and I think the whole world can change a little bit today, or in the next few days, because we’ve always thought of MS as being a T cell-mediated disease. Now that may be still the true answer, but now we’re starting to see ocrelizumab, which is a big B cell depleting antibody probably – I’m predicting – to have as good an effect as anything that the T cell you know brigade has ever done. And, in fact, if you look at most of the MS drugs, you would say that most of them actually are inhibiting B cell function.   Now, does that tell us that B cells are driving the disease? It may well do. Or it may well not. Now some people could argue – and they will – you know they’re the reservoir for the virus that causes multiple sclerosis. And then other people will say, well, actually the antigen-presenting cells. And let’s see, but I think what we’ll find is you know EAE will have to have changed its focus. We’ve been focusing our studies on T cell biology, but in fact, the T cell-inhibitory molecules haven’t really delivered. So is that right? And it may well be you know we have to think of a different biology. But EAE can certainly do that if need be.   So we’ll have to you know try and work out how do these B cell-depleting agents work. Is it you know via antigen presentation or not? I don’t know.   MSDF We’ve always thought of T cells as regulating B cells. Now it looks like they both regulate each other.   Dr. Baker I mean, I have my history in skin diseases, and when I first started working, actually my boss was more interested in B-regulatory cells. T-regulatory cells kind of hadn’t really existed at that time point. So I think we’re trying to reinvent the wheel. If we look throughout the literature, it’s a cross-talk between T and B cells are probably the answer. And we’ll see. Again, from our animal studies, we’ve had animal studies where we’ve manipulated the immune system making sure that has a positive effect. We’ve been able to translate that, so we have an N of 1 where we’ve got rid of somebody’s neutralizing beta-interferon antibodies by antigen-specific mechanisms. Now if we could translate that into MS, then we may have a way of treating MS. But we’ll see.   MSDF Very good, thank you. I appreciate it.   Dr. Baker Okay.   [transition music]   MSDF Thank you for listening to Episode Ninety-eight of Multiple Sclerosis Discovery. This episode is the final one in our series of MS podcasts. We hope that the series has been enlightening and has spurred further discussion about the causes of MS and related conditions, their pathological mechanisms, potential ways to intervene, and new research directions. We’ve tried to communicate this information in a way that builds bridges among different disciplines, with a goal of opening new routes toward significant clinical advances. Although we won’t be adding any new podcasts, the series will remain available on the MS Discovery website for the foreseeable future.   This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations.   [outro music]   We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org.   For Multiple Sclerosis Discovery, I'm Dan Keller.

[intro music]   Host – Dan Keller Hello, and welcome to Episode Ninety-six of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller.   Today's interview features Drs. Bibiana Bielekova, who is an investigator at the National Institutes of Health, and Mika Komori, a postdoctoral fellow in her lab. We caught up with the two physician-researchers at the ACTRIMS meeting in New Orleans earlier this year. At the meeting, Dr. Komori talked about a new and more sensitive way to evaluate what may be happening in the brains and spinal cords of people with progressive MS.   In a recent study, she examined samples of cerebral spinal fluid, or CSF, collected through a thin needle near the base of the spine. She was scouting for immunological biomarkers of progressive MS. In the analysis, a molecule called CD27, mostly from T cells, stood out, as did another marker specific to B cells. Even more revealing was the ratio of the CD27 molecule to the T cells. T cells are a big player in relapsing MS and not usually associated with the progressive, more neurodegenerative forms of MS. The unexpected results raise new questions about why immune-modulating drugs do not seem to be effective against progressive MS.   If validated, the new test may lead to better diagnosis and treatment of people with MS and other neurological disorders. And it may speed up clinical trials in progressive MS and reduce their cost. In fact, the same research team used their new biomarker test in a small phase 2 study of the anti-B cell drug, rituximab, delivered both intravenously in the blood and intrathecally in the spinal column. Unfortunately, the new biomarker test showed that the double delivery system did not work as expected to eliminate inflammatory B cells trapped in the brains of people with progressive MS. They stopped the study early for lack of efficacy.   In a change to our usual podcast format, Dr. Bielekova interviewed Dr. Komori about the specifics of the study and put the results in a larger context. Midway through the interview, Carol Morton, a past editor of MS Discovery Forum, asked both doctor-scientists about what the new test means for treating patients.   Interviewer – Dr. Bibiana Bielekova As a physician, when we see patients, we don’t really know what’s happening in their brains, right? We are using some tools that are supposed to help us to identify like, for example, MRI, but they are not perfect. So, how did you choose to address that problem?   Interviewee – Dr. Mika Komori So, when I saw patients, I can’t tell them that the drug, which are now available, is effective or not, especially for progressive MS patients, because currently so far all big clinical trials, they didn’t show any effects on them. Because of that result, we think progressive MS patients don’t have any intrathecal inflammation. So far we believe MS – multiple sclerosis – is inflammatory disease, but we don’t know if it’s true for progressive MS or not.   Dr. Bielekova Yes, and, in fact, it is because these tools are not that ideal, right? So, in fact, by using the tools that are available, such as MRI or these cerebrospinal fluid markers that have been developed more than 40 years ago, the conclusion is that there isn’t inflammation in progressive MS, right, because all of them are basically decreased, with exception of IgG index which, as you said, remains stable for many, many years. So somebody who had, for example, infection during childhood can have elevated IgG index for the rest of their life.   So that was really the reason why we wanted to develop something that is more sensitive. And also, I think, the question really was, does cerebrospinal fluid reflect what’s happening in the brain tissue? And can we somehow develop technology that can tell us what is happening in the brain tissue without taking, of course, the biopsy, which is extremely invasive, and we cannot really use it in people, right? So how did you address that problem?   Dr. Komori We developed a very good way to measure soluble biomarkers in the CSF with a new technique called Meso Scale Discovery.   Dr. Bielekova So I think we should probably step back a little bit and say that our goal was to really look at the biomarkers that can point towards a specific cell, right? Because there are proteins that can be released by all immune cells, such as for example, chemokines, and, in fact, the vast majority of cytokines. But we were especially interested in looking at the proteins than can specifically point to one particular cell type, and so you did something else to really measure that, right? In fact, we all helped you to do that because it was so difficult, right? So we employed the whole lab to do the separation of cells. And then you were looking at which cells are producing these biomarkers.   Dr. Komori Right.   Dr. Bielekova So tell us about those three that really panned out as the best.   Dr. Komori When we see the results of soluble CD27, soluble CD14, and soluble CD21, soluble CD27 correctly identified all inflammatory neurological disease and also only negative for noninflammatory neurological disease patients.   Dr. Bielekova Whereas all of the traditional markers together, if we put all of them together, they could identify only about two-thirds of the patients. We were really surprised, because – I mean, the field believed, as Mika had said, right, based on the fact you no longer have contrast-enhancing lesions; the treatments no longer work; you don’t have clear cytosis, meaning a large number of white blood cells in the cerebrospinal fluid – the field and us, we believed that what we are going to see, once Mika unblinds these two cohorts of close to 200 patients each that we will see that progressive patients have significantly lower amount of inflammation. But that’s not what she saw. She saw something completely different and surprising. So what did you see?   Dr. Komori Well we saw almost comparable level of intrathecal inflammation in both PPMS/SPMS to RRMS.   Dr. Bielekova Not almost, right? There wasn’t any statistically significant difference.   Dr. Komori No.   Dr. Bielekova So on the group level, we saw the same level.   Dr. Komori Absolutely. Yes, and it was so significant compared to a healthy donor and noninflammatory neurological diseases. So all healthy donor and neuro-inflammatory neurological diseases, they didn’t have high level of especially soluble CD27. But almost 90% of each MS subtypes had very high soluble CD27.   Dr. Bielekova But when you did the ratios…   Dr. Komori Then we did the ratio and calculated soluble CD27 per T cell in CSF. We found that even higher level of ratio results in progressive MS patients, both in primary progressive and secondary progressive. And for our MS patients the ratio is almost comparable to healthy donor and noninflammatory neurological diseases. That means, although we don’t see many immune cells in the CSF for progressive MS patients, those cells are in the CNS tissue. And it cannot move, but just shedding the soluble markers like soluble CD27 into the CSF. And we can detect that marker when we measure the CSF.   Dr. Bielekova And I think it really nicely ties with the beautiful pathology studies that have been published that demonstrate that patients with progressive MS no longer have this very dense inflammation around the vessel, which is the type inflammation that is capable of opening blood-brain barrier, right? Which means that that’s the type of inflammation that is associated with contrast-enhancing lesions. But instead, when pathologists looked at normal-appearing white matter, they could see, you know, one T cell here, one T cell there, right? It’s really difficult to quantify it on the pathology level, because they never assay the whole brain. But your assay is, in fact, looking at the entire brain. And what your assay is saying is that the number of cells is basically the same in all of these different stages of MS disease process. What is really different is where they are located, right?   So, in relapsing/remitting MS, they are located in the perivascular aggregates, not much in the normal appearing white matter. That’s where they open the blood-brain barrier. But in the progressive MS they are located in the brain. And I think our conclusion was that, in fact, this may be the major reason why current treatments are not working for progressive MS, because basically we would expect that only those drugs can work in progressive MS that have very good penetrance into the brain tissue.   Now, I think that we also have to realize that just the presence of the cells in the tissue doesn’t tell us that they are pathogenic, right? So it may be that they are there, but something else is driving disability. But on the other hand, the data we have, for example, from recently announced ocrelizumab trial is really suggesting that these cells are indeed pathogenic, right? So I think that we can say that progressive MS is neurodegenerative disease only if we can eliminate inflammation from the brain of progressive MS patients, and it does not translate into stopping disability or significantly inhibiting disability.   But the data that we have published, and we are still collecting, are really suggesting that current treatments, in fact, do not eliminate cells from the brain of progressive MS patients, right? So I think the question of compartmentalized inflammation versus neurodegeneration in progressive MS is really open. And I mean my view is that probably both of them are going to be important, right? I think that just because there are immune cells in the CNS tissue, it doesn’t necessarily mean that neurodegeneration is also not present. But I think the hypothesis that progressive MS is no longer inflammatory disease, and it’s pure neurodegenerative disease – I think that hypothesis is, at the moment, not confirmed, right, because we don’t have the experiment where we would eliminate the inflammation.   MSDF So both of you are physicians. Does this influence how you would treat people with progressive MS at all?   Dr. Komori Yes, absolutely. So from now, when I see high ratio results of progressive MS patients – soluble CD27 per T cell – if they have high ratio, then I will not treat them with current immunomodulatory drugs. But may be a good idea to try more effective drugs to penetrate in the brain. But if the progressive MS patients, although they have high soluble CD27 but low ratio results, then it will be worthwhile to use some immunomodulatory drugs for them.   Dr. Bielekova I would even kind of take a step back and say that in order to be able to use your tool for the treatment decision, I think we need to gain another type of knowledge which we don’t have yet and that is what are current treatments really doing on these type of assays and this type of pathology, right? So we really need to quantify each individual drug, how much it can affect intrathecal inflammation in patients with the open blood-brain barrier, where the drug actually can get into the tissue versus patients with closed blood-brain barrier, where potentially the penetrance is much, much, much more limited, right. I think that it brings back that case that I mentioned where, you know, we are using, for example, cyclophosphamide, and we are assuming that just because the drug is inhibiting immune response in the blood, it will inhibit immune response in the cerebrospinal fluid. And I think that those assumptions are just not tested, right? And, in fact, when we tested them, we realized that the effect on the intrathecal inflammation is extremely limited.   So I think that there is a knowledge that we need to gain, which is this knowledge of which MS drug is doing what. And, if we conclude that they are not doing a sufficient job, which I am afraid that’s going to be the conclusion, then we can use this technology to in fact develop new drugs, right? Because your technology is looking at the type of inflammation that cannot be measured by contrast-enhancing lesions. In fact cannot be measured by anything that we have available thus far, right? So how are we going to even try to develop new drugs for progressive MS?   Well, we can do it by doing large, Phase 3 trials like we have been doing thus far and looking at disability. But of course, that’s incredibly expensive, and it’s just very inefficient way to do it. So instead, doing small trials where you take patients because they have intrathecal inflammation, right. So you now measure; (A) how much inflammation; and (B) its compartmentalized inflammation. Then you can give them the drug, and then you say, ‘okay so now I’m going to measure’ – and you can do it in 3 months or 6 months, in much, much, much shorter time periods – and say, you know, ‘how much is this drug inhibiting intrathecal inflammation?’ And, in fact, that’s precisely what you have done in our RIVITALISE trial, right? Which, unfortunately, we stopped precisely because your assays determined that we are not achieving as much inhibition of inflammation as we were hoping to achieve. So I think that that makes drug development very efficient. And hopefully it will allow us as a society, to screen many, many more treatments on a yearly basis than what we can do currently.   Dr. Komori I think if we can measure the cell-specific or pathophysiology-specific biomarkers, we can combine treatments.   Dr. Bielekova Absolutely.   Dr. Komori If, like interferon, it doesn’t work, let’s try natalizumab. If not, let’s try this, but if we know that interferon works for this side of the pathophysiology, but natalizumab works for this side of the pathophysiology, then we can combine them to more effective treatment.   Dr. Bielekova Yes, and I think that I would say ‘more to come,’ right? So far Mika published data that relate to inflammation, but the lab is working very hard on biomarkers that reflect, for example, mitochondrial dysfunction, or neurodegenerative processes. And we absolutely believe that treatments will have to be combined, and that this, you know, basically assaying cerebrospinal fluid is going to be that tool that will, on one hand allow us to develop these new treatments, and on the other hand, allow us to treat patients smartly at the bedside.   [transition music]   MSDF Thank you for listening to Episode Ninety-six of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations.   Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances.   [outro music]   We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org.   For Multiple Sclerosis Discovery, I'm Dan Keller.