Problems to be Solved by h.o.p.e.

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Current lab research does not perform experiments on the scale of humans. This means experiments are done on thousands of cells measuring distances in micrometers and not the billions of cells over the scale of meters as necessary in human brain functioning. Current lab research typically tests simple treatments on a single layer of neurons laying on a flat, stagnant dish, or small neurospheres, which do not approximate human physiology (hydrodynamics, temperature, oxygen concentration, 3D, gradients, etc.), let alone capture the thousands of treatments needed for 3D nervous system organogenesis. Furthermore, current preclinical animal research uses delivery methods for its experiments not allowed in humans and certainly do not use clinically relevant, FDA-approved delivery methods. Animal models are also too slow because each mouse, rat, or primate must be killed and dissected to examine the cellular growth produced in an experiment, meaning the experiment cannot make adjustments during the experimental phase, which is not how clinical medicine is practiced. 

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Clinical trials include test treatments under human physiologic conditions, but an individual cannot subject him or herself to every clinical trial, especially because being in previous clinical trials is an exclusion factor for others. This also makes it impossible to test multiple treatments in parallel with one another. This is even more relevant if multiple combinations of drugs need to be tested to determine which combination works best, a process not currently allowed. Furthermore, a clinical trial (like animal research) cannot visualize cellular regrowth processes, let alone correct course midtrial based on the needs of the regrowth process. This is even more relevant given the regrowth of large cellular networks, at a rate of 1 millimeter per day, may require a thousand days to reach the necessary meter. No trial is conducted over this amount of time, which immediately halts any chance of success. Also, every injury has a different amount of missing tissue; yet the doses are circumscribed for an entire study cohort of patients. 

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Preclinical biological research must begin working on the human scale and use clinically realistic scenarios to achieve successful organogenesis of a unique, missing piece of an adult CNS. The ability to administer a comprehensive treatment this complicated must be practiced and rehearsed to ensure a safe, accurate procedure. Therefore, a life-sized, personalized model of the individual’s missing tissue must be created to perform multiple, parallel experiments with the goal of regrowing the individual’s specific missing tissue. 

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The regrowth simulation and regrowth regimen must be able to successfully regrow the missing tissue hologram template before any clinical trial would be deemed both safe and worthwhile.

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Technology to be Orchestrated

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3D Cell Cultures 

Scientific expertise now exists in regards to the importance of cells growing in three dimensions. It dramatically affects their size, shape, and function and even changes the genes and proteins they produce. 3D cell cultures have made significant progress in the technical requirements necessary for these experiments, which include incubators, fluid dynamics, cell media, scaffolding, etc. Furthermore, tissue engineering has expanded these 3D models to include multiple cell types representing a more physiologic environment in organs such as the lung and liver. However, no multi-cellular, 3D model currently exists for the human brain.

 

Human Physiology 

This personalized neurological repair model must be closer to human physiology than current lab cell culture models. There is already an enormous amount of intrinsic, unknown variables that make any model fraught with assumptions and translational failures. Therefore, this model will be incubated at the human brain temperature, and not at the current temperatures currently used in cell biology, which are degrees colder. The body is in constant motion, so the direction of flow will be calculated for the patient’s injury proximity relative to his or her circulating cerebrospinal system and vascular system. Current cell culture models have cells either lying stagnant in sitting media or sitting on a shaker, which provides bidirectional motion, but neither of these models actually exists in nature. Also, humans have lungs and a vasculature to deliver oxygen to cells, meaning cells do not live exposed to room air and atmospheric oxygen tension. For this reason, our model will exist at the correct exposure to oxygen and other metabolites. Also, cells in the brain are born, live, and grow in complete darkness. They are never exposed to light, therefore requiring our model to employ infrared optics to capture cell migration and growth in real time. Drug deliveries to current cell culture and rodent models are also not what will be used in the clinical protocols. Therefore, a skull with accurate foramens, complete vertebral column, CSF, and vascular entry points will be incorporated into the model. The distance from the individual’s potential drug delivery entry points to their missing tissue will be measured from the individual’s own physical exam. A safe delivery mode is required as the duration of drug delivery will likely last months. These delivery points need to be tested in a life-size model of the individual in exactly the way we will later administer the treatment protocol in hospital.

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Drug Delivery

The central nervous system has a blood brain barrier, which separates the vascular compartment from the rest of the brain and prevents most pharmaceutical drugs from entering the brain. After an injury, this barrier can be destroyed, but typically direct access to the central nervous system remains limited. There are numerous approaches to drug delivery, including 1) direct injection; 2) vascular injection (arterial or venous); 3) cribriform plate entry (through the nose); and 4) a lumbar puncture (bottom of the spinal column). Drug delivery by direct injection requires an operating room and destruction of neighboring tissue and can only reach a small amount of the brain. Utilizing a lumbar puncture, a cribriform plate, or a vascular approach also face logistical challenges. The field does not have a gold-standard drug delivery method, which would allow any therapeutic option to be delivered in the right place and for the right amount of time. However, an astonishing array of promising approaches have been produced in the last ten years, including linking nanoparticles - such as iron and nickel particles - to therapeutics, allowing their manipulation with magnets. Each therapeutic option will need to be matched with the right mode of delivery, as stem cells, enzymes, and small molecules all pose distinctly different challenges. 

Clinical Trials

Clinical trials have rigorous documentation for the dosing, length of a trial, and monitoring of side effects and outcomes. For any trial to proceed, these protocols and documentation must be approved. The applications to regulatory bodies such as the FDA can cost millions of dollars and are another burden to translation, as the culture is risk-averse to future litigation. Medical fields such as cancer treatment allow borderline lethal side effects, as death is the alternative outcome. But the FDA does have a regulatory pathway to expedite drug approval for severe, life-threatening illnesses. And although this proposal fits the Unmet Medical Need pathway, the regulatory bodies will have no appetite for any therapeutic regimen this complex for a patient who does not have death as an immediate consequence. Bioethics will usher this proposal through these risk-averse agencies.  

Goal of h.o.p.e. 

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The lab clinical trial section will orchestrate the regrowth of the patient’s missing tissue in multiple parallel attempts, acceleraing progress, which is not possible in clinical trials. It will coordinate the skills of diverse researchers orchestrating the regrowth regimen to regrow the damaged tissue, as determined by the 3D missing tissue hologram template. The final therapeutic repair strategy will have well over 20,000 decision points, requiring rehearsal. We must ensure the performance is feasible, monitoring for cancer formation, drug toxicity, and cell death, before entering a clinical trial for an individual. Clinical delivery barriers also must be solved with the cell biology challenges, requiring this model to be as close to human physiology as technically possible and also to have testable, life-sized, and personalized clinical drug entry points. 

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Every experiment needs a positive control, a negative control, and a dynamic range to show a statistically significant separation between experimental and control groups. This is less true for engineering, where the goal is visible and practical. This section is testing to see whether our tissue engineering perfectly overlaps with the negative space of the patient’s missing tissue. This is where we merge science and engineering to achieve our aims. Currently, science stops an experiment to measure its outcomes. In a clinical trial, a stop date is decided before the trial begins. However, to save time and cost, we will use our Missing Tissue Hologram as our negative control as well as our positive control. Similar to building a bridge, we will visually inspect the personalized model in real time to see if cells are migrating and connecting according to the Regrowth Simulation and Missing Tissue Hologram. Mid-experiment corrections will be done, similarly to what is done clinically when doctors make rounds for patients in the hospital and adjust medication doses as needed. All data will be fed back into the Pro-Growth Knowledge Base, the Regrowth Simulation, and a new Regrowth Regimen will be generated based on the latest Lab Clinical Trial results to further refine the algorithms until the right level of regrowth is achieved mirroring the Missing Tissue Hologram. Functionality of the tissue will be measured by electroencephalography (EEG) and transcranial magnetic stimulation (TMS). 

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Clinical trials in the United States require an enormous amount of documentation to proceed. This applies both to the FDA and a hospital’s own institutional review board. Documentation must be provided for the pharmaceutical grade of the drug, dosing, rationale, and purchase options as well as trial duration and numerous other categories. The h.o.p.e. Orchestra is seeking to produce a therapeutic proposal dwarfing any previous application in size and complexity. However, these regulatory institutions have no inherent interest toward anything so complex. The burden will be on us to show compelling evidence with sufficient data and rigor to then proceed to clinical use.

 

Impact of h.o.p.e. 

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Never before has cell biology been performed on the scale and scope of a human model; however, until we achieve the precision, comprehension, and complexity to the utmost perfection, our treatments will inevitably fail. The ability to answer and orchestrate these essential questions, overcome these barriers, and develop expertise in mastering extreme complexity is the future of personalized neurological repair. 
 
Testing combinations in a transparent replica of the patient’s injury will increase the speed of discovering therapies producing a plausible change in functional recovery. This transparency means we do not have to set a time-point for an experiment, which would result in losing time and resources; rather, we can course-correct the experiment until we achieve the desired cellular growth. This is not possible in a rodent, primate, or clinical trial approach. This has never been done before, and the novel insights produced will be extraordinary and immediately publishable. As the team learns and the model develops, there will be a feed-forward acceleration in the sophistication necessary to repair a patient’s injured CNS. No single patient can participate in every clinical trial, so this is a way to regrow the damaged part of the patient’s neuroaxis by utilizing all prevailing options.

 

Each technology used will be enhanced by having both comprehensive biology and the human scale applied to it, including bioreactors, tissue engineering, clinical delivery methods, 3D printing, etc. The individual patient will benefit from having every relevant facet of global technology applied to him or her to accelerate the goal of achieving functional regrowth of the damaged neuroaxis.