Motor neurone disease (MND) is an uncommon neurodegenerative disease that is terminal and has an insidious onset. With no known cause or cure, the disease triggers progressive death of motor neurones that causes increasing difficulties with mobility, communication, breathing and nutrition. Most research focuses on the disease process, but little is known of the illness experience from the perspective of those diagnosed with the disease. The aim of this study was to explore what it is like to live with MND and how people with the disease negotiate with others to exercise choice over the way they live. A grounded theory methodology was used to explore the life world of people diagnosed and living with MND. Data were collected via in-depth interviews, their stories and photographs, poems and books participants identified as important and fieldnotes. The textual data were analysed using constant comparative analysis. The majority of participants experienced difficulty with verbal communication. Some invited a third person to interpret their speech and others used assistive technologies such as Lightwriters and computers. Analysis revealed three constructs that, together, told the story of the MND illness experience. First, was the “diagnosis story” that described the devastating process of repeated tests had on the participants, shattering their trust in the competence of the health care system. The second construct revealed the process of living with MND as cyclical and repetitive requiring constant decision-making to adapt to the ongoing changes connected with the disease. The core theme and basic social process of “maintaining personal integrity” evolved as the third construct. This process underpinned and explained participants’ decision-making. Finally a substantive theory was conceptualised as the illness experience: “maintaining personal integrity in the face of ongoing change and adaptation”. This theory illustrates that the basic social process of maintaining personal integrity is central to decision and choice making while living with MND. The findings have implications for people with MND, their carers, health professionals and service providers. Recommendations include improved counselling services for people at the time of diagnosis; the introduction of nurse specialists to support health professionals, people diagnosed with the disease and their families; open, accessible, realistic health and funding policies.

Amyotrophic lateral sclerosis (ALS) is a progressive, lethal, degenerative disorder of the CNS. The hallmark of this disease is the premature and selective death of upper and lower motor neurons (MNs) in the brain and spinal cord, leading to fatal paralysis. Although the archetypal vision of neurotoxicity in neurodegenerative diseases is based on the idea that a specific neuronal population is particularly vulnerable to a cumulative toxic event (protein aggregation, mitochondria dysfunction, compromised axonal transport etc…), experimental evidence illustrate that ALS possibly does not arise strictly from damage within MNs. There is now convincing data supporting a non-cell autonomous mechanism in which neurodegeneration is influenced by the toxicity of non-neuronal cells in the vicinity of neurons such as astrocytes and microglia. Considering the accumulation of data implicating astrocytes in the pathogenesis of ALS (loss of GLT-1, secretion of toxic factor, enhanced inflammation, etc…), approaches aiming at replacing astrocytes at site of lesions constitute promising therapeutic strategies. Rapid progresses in the characterization of adult stem cell biology have generated considerable enthusiasm for the development of therapeutic strategies for CNS insults. Several observations support the hypothesis that stem cells may display a valuable influence on diseased host tissues by exerting a protective “chaperone” effect to neurons after differentiation in glial cells. Hence, we decided to study the neuroprotective potential of adult mesenchymal stem cells (MSCs) in ALS. In contrast to neural stem cells (NSCs) which localization in the central nervous system complicates their isolation, MSCs are easily isolated from the bone marrow. The relevance of using on MSCs in stem cell therapies of neurodegenerative disorders is also justified by their capacity to (trans)differentiate into neural cells. For this purpose, we exposed MSCs to growth factors involved in the astroglial differentiation of NSCs. The differentiation of MSCs was characterized by the acquisition of astrocyte morphology in addition to an increased expression of gene related to NSCs (nestin) and astrocytes (glutamine synthetase). The astroglial differentiation of MSCs is associated with the acquisition of a glial-like specific regulation of the production of GDNF, a potent neurotrophic factor for neurons. Then, we characterized the glutamate uptake in differentiated MSCs, a critical function of astrocytes. Our data demonstrate that the differentiation of MSCs is associated with an increased expression of the high affinity glutamate transporter, GLT-1. Thus, our in vitro results confirm the astrocytic differentiation potential of MSCs and we decided to use then in stem cell therapy of ALS. Indeed, we demonstrated that mechanism of stem cell recruitment is present in the spinal cord during the development of the disease by the secretion of stem cell factor (SCF). We injected MSCs derived from healthy animals into the cerebrospinal fluid of a transgenic rat model of familial ALS (expressing a mutated form of the human superoxide dismutase-1, hSOD1G93A) at disease onset. MSCs were found to infiltrate the nervous parenchyma and migrate substantially into the ventral grey matter by interacting with the SCF. At the site of lesion, MSCs differentiated massively into astrocytes around MNs. The intrathecal delivery of MSCs preserved motor functions and extended the survival of hSOD1G93A rats. Investigation of the lumbar spinal cord 35 days after graft demonstrated that the generation of healthy astrocytes from MSCs decreased motor neuron loss. However, this beneficial effect is not related to a decreased excitotoxicity by the rescue of GLT-1 expression but rather a decreased inflammation around MNs. Together, the data presented in this thesis highlight the protective capacity of adult MSC-derived astrocytes in the treatment of ALS.

Ungefär 200 personer insjuknar årligen i sjukdomen amyotrofisk lateralskleros (ALS), vilket ses som en ökning de senaste 30 åren. Att insjukna i en obotlig sjukdom bidrar till både fysiskt och psykiskt lidande. Det är viktigt att förstå patienters upplevelser av sjukdomen vilket det saknas information om. Syftet var att utifrån självbiografier, beskriva patienters upplevelser av att leva med ALS. En kvalitativ innehållsanalys beskriven av Lundman och Hällgren Graneheim gjordes. Datamaterialet bestod av sju självbiografier. Ur datamaterialet urskiljdes patienters känslor och upplevelser kring sjukdomen ALS i form av sex kategorier med tillhörande underkategorier. Kategorierna som framkom var; svårigheter kring den begynnande sjukdomen, tankar kring döden, sorg, bristande självkänsla, att känna sig utlämnad och att få insikt i sin sjukdom. Informanternas beskrev upplevelserna olika eftersom det fanns variationer av varje individs sjukdom. Att slutligen kunna se positiva stunder trots sin sjukdom var betydande. Ingen vet bättre än patienten själv hur den mest uppskattade omvårdnaden kan ges. Därför är det av vikt att lyssna på patienters upplevelser och deras egen berättelse av den upplevda sjukdomen. Erfarenheterna av sjukdomen var av olika karaktär men likheter kunde ses där många upplevelser var återkommande hos de flesta informanterna. / About 200 persons become ill annually with the illness amyotrophic lateral sclerosis (ALS), which can be seen as an increase in the last 30 years. Falling ill in an incurable illness contributes to both physical and psychological suffering. It is important to understand the patient’s experiences of the illness and this is a field where there is little or no information available. The aim of this study was to describe the patients’ experiences of living with ALS from autobiographies. A qualitative content analysis described by Lundman and Hällgren Graneheim was performed. The data material consisted of seven autobiographies. From the data material patient’s feelings and experiences of the illness ALS was discerned in terms of six categories with associated subcategories. The categories were; difficulties of the emerging illness, thoughts about death, sadness, lack of self esteem, to feel deserted and to reach insight into their own illness. The informants described experiences differently due to individual variations of illness. To eventually be able to see positive moments despite the illness was significant. No one knows better than the patient how the most appreciated nursing care should be. Therefore it is of importance to listen to patients’ own experience of the illness. The experiences of the illness varied but similarities could be seen where many experiences were recurrent among most informants.

Amyotrophic lateral sclerosis (ALS) is characterized by motor neuron degeneration resulting in progressive paralysis and death. The only known cause of typical ALS is mutations in SOD1; these predominantly missense mutations produce a toxic gain-of-function in the enzyme Cu/Zn superoxide dismutase (SOD1). The prevailing hypotheses regarding the mechanism of toxicity were a) oxidative damage from aberrant SOD1 redox chemistry, and b) misfolding of the mutant protein. The goal of this thesis was to investigate the molecular mechanisms of the mutant SOD1 (mSOD1) misfolding and toxicity. We proposed that oxidative damage to SOD1 itself could cause its misfolding and aggregation. To investigate this hypothesis, we subjected purified SOD1 in vitro to metal catalyzed oxidation. Oxidation of SOD1 produced aggregates reminiscent of those observed in ALS pathology. Aggregation propensity of zinc-deficient SOD1 and several mSOD1s known to have lower zinc-binding affinity was proportional to partial unfolding. Oxidation of SOD1 caused conversion of several His residues to 2-oxo-histidine. Because oxidation of SOD1 primarily affected the metal-binding His residues, we hypothesized that oxidation of wild-type, holo-SOD1 should lead to aggregation. Increasing the concentration of wild-type SOD1 in oxidation reactions produced aggregates similar to those observed earlier. Both wild-type and mSOD1 aggregation kinetics revealed an initial decrease in particle size rather than a monotonic increase using dynamic light scattering. This was consistent with the conversion of SOD1, normally an obligate homodimer, into monomers prior to aggregation. This observation was confirmed using analytical ultracentrifugation. The common aggregation pathway for wild-type and mSOD1 suggested a mechanism for sporadic ALS caused by SOD1 misfolding. To interrogate the in vivo misfolding pathway of SOD1, we used its high-resolution structure to create an antibody that reacts with monomer/misfolded SOD1 but not the native dimer. Upon verifying the reactivity of this antibody, we showed that monomer/misfolded SOD1 is found in a human case of familial ALS and in transgenic animal models of ALS. Misfolded SOD1 is found primarily in affected cells, motor neurons. Misfolded SOD1 is also initially absent, but appears prior to symptom onset. These observations together suggest a causal role for SOD1 misfolding through a monomeric intermediate in ALS pathogenesis.

Amyotrophic lateral sclerosis (ALS) is characterized by motor neuron degeneration resulting in progressive paralysis and death. The only known cause of typical ALS is mutations in SOD1; these predominantly missense mutations produce a toxic gain-of-function in the enzyme Cu/Zn superoxide dismutase (SOD1). The prevailing hypotheses regarding the mechanism of toxicity were a) oxidative damage from aberrant SOD1 redox chemistry, and b) misfolding of the mutant protein. The goal of this thesis was to investigate the molecular mechanisms of the mutant SOD1 (mSOD1) misfolding and toxicity. We proposed that oxidative damage to SOD1 itself could cause its misfolding and aggregation. To investigate this hypothesis, we subjected purified SOD1 in vitro to metal catalyzed oxidation. Oxidation of SOD1 produced aggregates reminiscent of those observed in ALS pathology. Aggregation propensity of zinc-deficient SOD1 and several mSOD1s known to have lower zinc-binding affinity was proportional to partial unfolding. Oxidation of SOD1 caused conversion of several His residues to 2-oxo-histidine. Because oxidation of SOD1 primarily affected the metal-binding His residues, we hypothesized that oxidation of wild-type, holo-SOD1 should lead to aggregation. Increasing the concentration of wild-type SOD1 in oxidation reactions produced aggregates similar to those observed earlier. Both wild-type and mSOD1 aggregation kinetics revealed an initial decrease in particle size rather than a monotonic increase using dynamic light scattering. This was consistent with the conversion of SOD1, normally an obligate homodimer, into monomers prior to aggregation. This observation was confirmed using analytical ultracentrifugation. The common aggregation pathway for wild-type and mSOD1 suggested a mechanism for sporadic ALS caused by SOD1 misfolding. To interrogate the in vivo misfolding pathway of SOD1, we used its high-resolution structure to create an antibody that reacts with monomer/misfolded SOD1 but not the native dimer. Upon verifying the reactivity of this antibody, we showed that monomer/misfolded SOD1 is found in a human case of familial ALS and in transgenic animal models of ALS. Misfolded SOD1 is found primarily in affected cells, motor neurons. Misfolded SOD1 is also initially absent, but appears prior to symptom onset. These observations together suggest a causal role for SOD1 misfolding through a monomeric intermediate in ALS pathogenesis.

Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease and is characterized by progressive paralysis leading to death, typically, within 3-5 years of the onset of symptoms. The majority of ALS cases are sporadic with no known causative agent; however, 5-10% of ALS cases are genetically inherited and termed familial ALS (fALS). Approximately, 15-20% of these fALS cases have been linked to mutations in the gene encoding human Cu/Zn superoxide dismutase (hSOD). To date, over 140 hSOD mutations have been discovered. The mechanisms by which mutant hSOD confers toxicity in fALS patients are still unknown. However, there is growing evidence that ALS is a type of protein conformational disease whereby cell damage or death is caused by the accumulation of protein aggregates in the cell. It is hypothesized that mutations destabilise hSOD and increase its propensity to aggregate. There is some controversy as to which hSOD species contributes to aggregation. Many believe that only apo or mismetallated forms of hSOD are able to aggregate. Due to the abundance of fully metallated or holo hSOD in the cell, we hypothesize that holo hSOD can also lead to aggregation. Holo dimer interface mutants A4S, A4T and I113T as well as G41D were found to be destabilized compared to holo pseudo wildtype (pWT) while zinc binding mutant H80R was shown to form fragments via an unknown mechanism. Holo dimer interface mutants A4S and A4T were also shown to have an increased propensity to aggregate compared to pWT, which correlates to their decreased stability as well a short disease durations.

Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease and is characterized by progressive paralysis leading to death, typically, within 3-5 years of the onset of symptoms. The majority of ALS cases are sporadic with no known causative agent; however, 5-10% of ALS cases are genetically inherited and termed familial ALS (fALS). Approximately, 15-20% of these fALS cases have been linked to mutations in the gene encoding human Cu/Zn superoxide dismutase (hSOD). To date, over 140 hSOD mutations have been discovered. The mechanisms by which mutant hSOD confers toxicity in fALS patients are still unknown. However, there is growing evidence that ALS is a type of protein conformational disease whereby cell damage or death is caused by the accumulation of protein aggregates in the cell. It is hypothesized that mutations destabilise hSOD and increase its propensity to aggregate. There is some controversy as to which hSOD species contributes to aggregation. Many believe that only apo or mismetallated forms of hSOD are able to aggregate. Due to the abundance of fully metallated or holo hSOD in the cell, we hypothesize that holo hSOD can also lead to aggregation. Holo dimer interface mutants A4S, A4T and I113T as well as G41D were found to be destabilized compared to holo pseudo wildtype (pWT) while zinc binding mutant H80R was shown to form fragments via an unknown mechanism. Holo dimer interface mutants A4S and A4T were also shown to have an increased propensity to aggregate compared to pWT, which correlates to their decreased stability as well a short disease durations.

<p>Ungefär 200 personer insjuknar årligen i sjukdomen amyotrofisk lateralskleros (ALS), vilket ses som en ökning de senaste 30 åren. Att insjukna i en obotlig sjukdom bidrar till både fysiskt och psykiskt lidande. Det är viktigt att förstå patienters upplevelser av sjukdomen vilket det saknas information om. Syftet var att utifrån självbiografier, beskriva patienters upplevelser av att leva med ALS. En kvalitativ innehållsanalys beskriven av Lundman och Hällgren Graneheim gjordes. Datamaterialet bestod av sju självbiografier. Ur datamaterialet urskiljdes patienters känslor och upplevelser kring sjukdomen ALS i form av sex kategorier med tillhörande underkategorier. Kategorierna som framkom var; svårigheter kring den begynnande sjukdomen, tankar kring döden, sorg, bristande självkänsla, att känna sig utlämnad och att få insikt i sin sjukdom. Informanternas beskrev upplevelserna olika eftersom det fanns variationer av varje individs sjukdom. Att slutligen kunna se positiva stunder trots sin sjukdom var betydande. Ingen vet bättre än patienten själv hur den mest uppskattade omvårdnaden kan ges. Därför är det av vikt att lyssna på patienters upplevelser och deras egen berättelse av den upplevda sjukdomen. Erfarenheterna av sjukdomen var av olika karaktär men likheter kunde ses där många upplevelser var återkommande hos de flesta informanterna.</p> / <p>About 200 persons become ill annually with the illness amyotrophic lateral sclerosis (ALS), which can be seen as an increase in the last 30 years. Falling ill in an incurable illness contributes to both physical and psychological suffering. It is important to understand the patient’s experiences of the illness and this is a field where there is little or no information available. The aim of this study was to describe the patients’ experiences of living with ALS from autobiographies. A qualitative content analysis described by Lundman and Hällgren Graneheim was performed. The data material consisted of seven autobiographies. From the data material patient’s feelings and experiences of the illness ALS was discerned in terms of six categories with associated subcategories. The categories were; difficulties of the emerging illness, thoughts about death, sadness, lack of self esteem, to feel deserted and to reach insight into their own illness. The informants described experiences differently due to individual variations of illness. To eventually be able to see positive moments despite the illness was significant. No one knows better than the patient how the most appreciated nursing care should be. Therefore it is of importance to listen to patients’ own experience of the illness. The experiences of the illness varied but similarities could be seen where many experiences were recurrent among most informants.</p>

Introduktion: Amyotrofisk lateralscleros (ALS) är en progressiv neuromuskulär sjukdom, som bryter ner det motoriska nervsystemet. Sjukdomen är vanligare hos män än hos kvinnor och i Sverige insjuknar cirka 200 personer varje år. Det är vanligt att drabbas av depression någon gång under sjukdomsförloppet. Sjuksköterskan har i sin profession uppgifter som syftar till att främja hälsa, förebygga sjukdom, återställa/bevara hälsa och minska lidande. Syfte: Var att belysa patientens upplevelse av livskvalité och depression vid ALS. Metod: Metoden som användes var Polit &amp; Beck (2012) niostegsmodell för en litteraturstudie. Databaserna som användes till litteraturstudien var CHINAL och PsycINFO. Artiklarna granskades och elva artiklar inkluderades i litteraturstudien då det svarade på syftet. Resultat: I resultatet framkom två huvudkategorier Emotionell påverkan och stöd. Kategorin emotionell påverkan framkom tre underkategorier möjlighet att bibehålla fysisk funktion, hanterbarhet och acceptans och betydelsen av upplevd kontroll. I kategorin stöd framkom två underkategorier socialt stöd och professionell hjälp. Det framkom att det fanns mycket frustration och rädsla i att förlora kontrollen av sin fysiska funktion. Detta påverkade livskvalitén och ökade risken för depression. De ALS-patienter som upplevde ett bra socialt stöd upplevde även en högre livskvalité. Slutsats: En ökad förståelse för hur patienter med ALS upplever sin livskvalité och hur deras psykiska hälsa påverkas kan vara till stor hjälp för sjuksköterskan i det hälsofrämjande arbetet.

Human neurodegenerative disorders are among the most difficult to study. In particular, the inability to readily obtain the faulty cell types most relevant to these diseases has impeded progress for decades. Amyotrophic lateral sclerosis is a late onset neurodegenerative disease in which the upper and lower motor neurons degenerate, leading to paralysis and eventually death. Recent advances in pluripotent stem cell technology now grant access to significant quantities of disease pertinent neurons both with and without predisposing mutations. The two studies described in this thesis demonstrate the feasibility of using MNs, generated from pluripotent stem cell lines harboring known ALS mutations, to establish in-vitro models of the disease. Specifically, we first used gene targeting to establish genetically controlled systems, able to identify causal relationships between a familial ALS mutation and in vitro phenotypes. Next, using transcriptional profiling, we identified novel pathways altered by the mutation and demonstrated functional consequences of these pathways' misregulation. Furthermore, by monitoring the physiology of the pluripotent stem cell derived MNs, we discovered an increased firing rate in the mutant MNs, and identified an FDA-approved drug, retigabine, capable of rescuing this defect. Lastly, to aid in the discovery of additional therapeutic compounds, we combined gene targeting, transcriptional profiling, and a fluorescent reporter human embryonic stem cell line to establish a well-controlled in vitro system capable of identifying genetic modifiers of the phenotypes described herein.