Posts Tagged ‘transplant’

Many cards in our favor, some we dealt ourselves

June 11th, 2010

In this recent blog post, I discussed how my recovery after stem cell transplant has been much faster than average, and there are probably many reasons why that might be.  No doubt the fact that my donor’s genetic markers matched my own perfectly—well, the genetic markers that hospitals check were a perfect match, anyway.  There are literally hundreds of minor proteins that immune systems use to determine if cells are self or not. But maybe many of those were matched more than average, just by chance.  I know I’m not out of the woods just yet, but there are some other possible reasons for my rapid recovery so far.

Greg and I are fortunate that he rarely needs to go to an office.  Greg is a computer programmer, web designer and database manager; he has to work in an office about five days a year, and he goes to work-related retreats and conferences a couple of weeks a year. Otherwise, he’s at home.  As a result, his exposure to infectious agents that in me might cause life-threatening illness is extremely limited.  Most people don’t enjoy this situation, and so I’m sure the average person undergoing stem cell transplantation is exposed to many more infections than I have been.

But Greg and I have been extremely diligent as well.  We’ve taken extreme measures to guard against infection.  We’ve not allowed anyone in our house.  All food, gifts, and mail is wiped down completely with bacteria- and virus-killing chemicals. (Yes, these are nasty . . . and that’s the point: Kill or be killed.)  We got a high-end HEPA filter used in hospitals and endorsed by the American Lung Association.  And these measures are all in addition to the regular extreme rules about cleaning, washing clothes, washing dishes, and such.  And of course, I was a virtual hermit the entire time (with a couple of approved exceptions, when we walked in the park with friends).

Maybe all of this was overkill, or neurotic, or unnecessary.  I know our lead nurse thought so; she promoted much more lax precautions.  We didn’t buy what she was selling, however.  Neither did my physician. And even if my physician had agreed that these extra steps were a waste of time,  I would’ve ignored him.  If ever there was a time for overkill, I’d say this has been that time.  When it’s time for my nurse’s stem cell transplant, she can be just as lax as she wants.

I have also been exacting in my drug schedule, and Greg has helped a lot with that.  And we’ve learned about the drugs I’m taking so we can play a role in my care.  That has been very important; on three separate occasions, my physician has prescribed a drug, and the wrong dose.  This has happened every single time I have undergone cancer therapy (and I’ve had a lot of cancer therapy).  They screw up the dose, and we’re the ones who suffer.  I learned this lesson during my days of AIDS activism:  Watch the physician’s every move and challenge when necessary; physicians are the top of the hospital’s class hierarchy, and no one else can challenge their actions (a stupid, archaic system that harms only one person: the patient).

Maybe our extreme safety measures had nothing to do with my unusually rapid recovery after the transplant.  Maybe my insistence that the nurses gown, and wash their hands in addition to using ethanol gel, and use sterile technique in all their dealings (especially when accessing my chest port) played no role in my acquiring no nosocomial infections, but I’ll bet it did.  The items on this list of things I insisted of my nurses are all things they normally never do, and I had to fight to get them to do them (as I always do).  I rarely see nurses wash their hands, and when I’ve asked them to do so, they say the ethanol gel is enough.  But of course nurses rarely use enough gel (research shows you have to use a lot), and the ethanol has to evaporate entirely (leaving dry hands) in order to kill microorganisms, and nurses rarely wait for this.  And of course, washing hands plus using ethanol gel would be better than either precaution alone.  Even the infectious disease physician on my team said these measures, including sterile port access, were not important, despite solid evidence to the contrary.  In arguing with me, that same infectious disease physician repeatedly said that the infection rate in the cancer infusion bay was “acceptable.” That rate, by the bye, is three percent for blood infection; I wonder how many people have to get sick with blood infections before he’d consider the rate unacceptable? Four percent?  Five?

In any event, I’d be willing to bet that all these things Greg and I have done—keeping away from people, wiping down all the groceries, learning about my disease, and demanding excellence from the hospital staff and physicians—surely all of these have had a huge impact on my health.  I’m sure some luck was involved, too.  So some of the cards were dealt to us by chance, but we dealt some of the cards, stacking the deck in our own favor.

It might seem weird that a physician and the main nurse working on a team together would not be on the same page about therapies, or how to reduce risk of infection, or whatever.  It certainly is unfortunate, but in my experience it’s not uncommon at all.   It’s surprisingly common for the members of a single team to have differing views about your care, and the members of that team don’t bother to coalesce their views into a single message.  The only sense I can make of this is that the egos involved are so unbridled that none of them are willing to budge.  Of course, this leaves the patient confused and often unable to make an informed decision.  And it’s cruel.  It’s especially cruel to the patients who cannot, for whatever reason, advocate for themselves.   I see no evidence that physicians’ very high view of themselves will change anytime soon.  And this single factor alone is one of the best of the many reasons why hospitals should have formally organized patient advocacy departments that are facilitating and conducting real patient advocacy, and not just walking patients through insurance paperwork (which is what most of them do now).
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Say “Goodbye” to all of this . . .

June 4th, 2010

Greg and I moved back to our home in Vermont today.  Now, instead of weekly visits to the hospital in Boston, we’ll only have monthly visits.  This would’ve come much earlier had it not been for the (likely) false diagnosis of CMV and the myelosuppressive therapy that ensued, which may well have been key to my contracting the C. difficile that knocked me down so far.  But despite all of this, I’m now doing quite well and feeling very strong.

Last Tuesday during my last weekly visit, I was in the room where nurses take vital signs, and a woman was sitting next to me. She was wearing a mask and gloves, and when this sort of thing happens—when two transplant patients are sitting next to each other—there’s this strange E.T.-and-Elliot thing that goes on; we just want to talk to each other.  Or in my case: I can tell they’d like to connect with me, and I usually resist this, being a curmudgeon and all.  But on Tuesday, the woman sitting next to me just jumped right in.  She started asking me questions about my progress since transplant.  I was in a pretty good mood that day, but had this happened on practically any other day, I’d probably have perceived this as rude prying.  On this day, I saw it as tolerable prying, so we had a chat.  During our discussion, she asked me how far along I was since transplant.  I told her just over two months; she was quite surprised.  She went on to say that she was six months out, and that I looked so good she thought I might be nine or more months since transplant, but certainly ahead of her.

I was pretty surprised by this reaction, and it made me realize that I just didn’t have any frame of reference for how well I’m recovering relative to the average patient.  I’ve always thought that I’ve been doing pretty well, but I’ve never really known.  So I asked my physician what he thought.  He said emphatically that I was doing much, much better than most in terms of recovery, energy level, activity level, and such.  In fact, except for the uncontrollable neuropathy and my problems with the treatment for that (more on that later), I don’t have many complaints.  I’m more energetic now than I’ve been in ten years, and my red blood cell count is still rather low, but rising steadily, so more energy is yet to come.

So, despite my setbacks—the main one being the serious blow I took from the C. difficile—I seem to have rebounded and my health status has more than “caught up.”  My blood cell counts look great for my stage, and my physician has actually started tapering my immunosuppressives, a month or two early.  That means my lymphocytes will come on board earlier (but still many months away), which means protection from viruses.  But this could also mean that Graft Versus Host Disease (GVHD) is going to hit soon.  But GVHD also means Graft Versus Lymphoma effect:  All my cells are me, including any remaining cancer cells that are almost certainly floating around.  If—or rather, when my new immune system recognizes that it’s in a body of foreign cells and initiates an attack on my whole body, that attack will be on any remaining cancer cells too.  In fact, because this attack is mediated by T-lymphocytes—and those cells normally communicate with B-cells when they initiate an immune response—this means that when GVHD does hit, those T-cells will preferentially seek out B-cells during their attack on my body.  As I have B-cell lymphoma, those lingering cancerous B-cells will very likely come into contact with those T-cells that are seeking to fight off my cells.  When this happens, the T-cells will recognize that my B-cells are foreign too, and some of those T-cells can kill my cancer cells on the spot (so-called, Cytotoxic T-cells).

So, GVHD is kind of a mixed bag.  But one thing is certain from the empirical literature: Long-term survivors of stem cell transplants have mild-to-chronic GVHD.  These people are far less likely to relapse, and people who have no GVHD are far more likely to relapse.  So even though I’m over some serious infection hurdles, and even though the majority of death risk is clustered in the first three months post-transplant, I’m about to start facing the next challenges.

But I’m happy to be healthy, at least for now.  And Greg and I are both very glad to be home.  But I think we will both miss our deluxe apartment in the sky-hi-hi.  And just for memento, here are some photos of the view we’ve lived with for the last 75 days:

The Prudential Building (tallest), and a couple of others that no one cares about.

Christian Science weirdos. Despite being cuh-ray-zee, their buildings are "truly beautiful to behold," including this lovely library.

More Christian "Scientists," with their absolutely lovely buildings (all the buildings in view are CS buildings in the famed "Church Park.") The shadow cast is from our sixties-built, 1984-style 12-story building (not run by the Christian Scientists . . . as far as we know).

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There’s mono, and then there’s mono

May 27th, 2010

In an earlier post I discussed cytomegalovirus (CMV) primarily in relation to its impact on the immunosuppressed—people with AIDS and those of undergoing a stem cell transplant, for example. As a prelude to that discussion, I mentioned that CMV causes mononucleosis.  This piqued a reader’s interest:

. . .[I] found it interesting that CMV was related to mono—I’ve had mono, though apparently tested negative twice before positive, but am CMV negative—thankfully!

Presumably, the test for mono the reader mentions was a test for Epstein-Barr Virus, and not CMV. Epstein-Barr Virus (EBV) is another herpes virus that is closely related to CMV, and EBV causes a disease named infectious mononucleosis.  CMV causes a disease very similar to mono, and many authorities call that disease infectious mononucleosis.  The Centers for Disease Control says the disease caused by CMV is a “mononucleosis-like illness,” whereas the National Institutes of Health states flatly that both EBV and CMV cause mono.  When I took microbiology, I apparently learned virology from the NIH school of thought.  But it seems more authorities discuss EBV in relation to mono, perhaps because EBV is more likely to cause disease at initial infection (even though many show no symptoms), whereas CMV usually causes no or very mild symptoms in people when they catch it.  But both are attributed with causing a disease of the same name.  So why the hell is that?

First, it’s important to note that these two viruses are quite closely related—on the evolutionary tree of life, I mean.  And so EBV and CMV share essentially all of their genes, with some minor variations (minor for sure when compared to the total genetic diversity of life, or even that among viruses). Because of this, it is no surprise that they cause similar disease.

Second, it’s also important to keep in mind that viral nomenclature is a complete mess.  The international rules of nomenclature that have been well-established in zoology and botany for nearly a hundred years (but deriving from rules that are centuries old) are simply not in place for viruses.  The best recent example of this is the HIVs.  When Montagnier in France first isolated a virus he suspected to cause the plague of immunodeficiency that was killing off mainly gay men, he named it LAV (for Lymphadenopathy Associated Virus).  Then Gallo in the USA named it HTLV-III (for Human T-Lymphotropic Virus III)—and that name is now used for a completely different virus. The virus that causes what would be named AIDS was also called ARV (Adenopathy Related Virus) for a time.  Ultimately, yet another name was established by international convention (sort of): HIV. But now we know that the thing we call HIV is in fact at least two distinct groups of viruses that entered the human population via separate events.  What a shambles.

I only point this out because this confusion about viral nomenclature spills over into disease nomenclature.  Lots of named diseases—”the flu,” “the cold,” “AIDS”—are in fact each caused by many different, often closely related but nonetheless distinct species.  And this unfortunate practice is not restricted to viruses:  Human “malaria” is caused by one of four quite distinct microorganisms, and the characteristics of the diseases they cause are just as distinct.  This is all to say that the tiny creatures that cause disease evolve just like the bigger creatures they live in. Species split, become isolated, acquire mutations independently, get different, and ultimately become two species.  Although the new species did “get different,” they also share almost all of their traits by inheritance.  Whatever characteristics the initial, ancestral species had, the two new descendant species will very likely share most of those same characteristics.  In other words, close relatives are a lot alike because they come from common stock—something we all know from our own families.  And this is why two differently named viruses can cause the same named disease (even though, in a perfect world, virologists would stop this nonsense).

So the reader is right:  One can have a diagnosis of mono without CMV, and it’s CMV—not EBV—that is so problematic for those with trashed immune systems.  All important points of clarification for those who might be facing a stem cell transplant.

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My “cold” is gone

May 14th, 2010

It appears that I’m over whatever I had. My nose has stopped running, and my slight cough has resolved as well. I felt a bit under the weather yesterday, but I’m feeling better today—not as good as before this scare, but I’m getting stronger again.

So much of this process is unknown, but a lot is known. One of the things we know is that slightly immature T-cells are responsible for initiating immune responses against viruses. When these T-cells come in contact with other cells that are infected with viruses (or that are otherwise presenting “foreign” chemicals), they do a variety of things that ultimately cause the infected cells to die. But this process takes time, and the infection can spread in the meantime. So, one of the things these immature T-cells do to help with future infection from the same virus is they give rise to more specialized cells. Some of the resulting differentiated T-cells are known as Cytotoxic T-cells (or sometimes CTs, or CD8 cells, where CD refers to a group of proteins on the surface of the cell membrane, deemed Clusters of Differentiation. CTs, or CD8 cells are also sometimes also called T8 lymphocytes, but I’ll just stick to CTs).

CTs are one of many kinds of so-called memory cells; they retain a special chemical affinity (a “memory”) for cells infected with a specific virus, and when the CTs encounter infected cells again, they kill them on the spot—a much faster solution than the slower process that happens the first time infection occurs. This, coupled with other systems, is why once we’ve had a virus, we’re forever immune.

The problem for me is, I don’t really have any T-cells at all. My new immune system is not developed enough to have created any mature T-cells or even any of the slightly immature T-cells needed to initiate the response described above. And that means I don’t yet have any Cytotoxic T-cells from my donor marrow. As CTs are long-lived memory cells, I presumably have circulating in my peripheral blood some of my original, native T-cells that survived the stem cell transplant, but that doesn’t appear to be true. We know this because of the results of my most recent chimerism tests—genetic tests that determine the proportion of peripheral blood cells that are of my genotype versus my donor’s genotype. (Remember that my blood is a chimera right now, like Dictyostelium—part original cells, part donor cells).

Those genetic tests, performed a month ago, show that when considering all of my T-cells, 97% are donor genotype. Those 97% are very immature (too immature to give rise to CTs), and the remaining 3% are what’s left from my former immune system. And while this 3% no doubt includes mature T-cells, and some CTs, they just aren’t very clinically effective for most people (so says my physician). Hammered from the chemotherapy of the transplant? The radiation? Too few to mount a defense? I’m not sure, but they’re impact is apparently thought to be minimal in any event.

But something has changed. I had these symptoms, and now they’re gone. Maybe I beat a virus somehow; maybe it was allergies. I guess I don’t care too much, except from an academic position. But one thing is certain: It couldn’t have been that crystal I shoved up my butt. I only did that an hour ago.

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Some not-so great news

May 12th, 2010

My last post was an honest and authentic expression of my thoughts and feelings about my current state of being.  I wasn’t hiding anything.  But there is something else going on.

This morning I awoke with a runny nose and some congestion.  This could be a minor bacterial infection, which would not likely be a problem to snuff out.  But, given that my mucus is clear, bacterial infection seems unlikely.  Viral infection is more consistent with that sign.  It could be one of a number of common viruses that cause runny nose.  For some of these, anti-viral treatments are available.  For many, the viruses don’t even have names, but they don’t cause dangerous infections either.  I’m hoping for one of these, of course.  It could be the flu, and (despite rapidly increasing resistance) that is treatable with osteltamivir.  But it could be something much more dangerous:  the seemingly innocuous, simple, common cold.

While the common cold causes the mildest of infection in immunocompetent people, in me, it could be a disaster.  Permanent scarring of the lungs is one outcome; death is another.  As no treatment for the common cold exists (though a number of experimental therapies are soon to help out), recovery relies on one’s immune system entirely.  Chicken soup may soothe, but it doesn’t cure.

Viral infections are defeated by lymphocytes.  The two main groupings of lymphocytes are T-cells and B-cells.  T-cells circulate in our blood, looking for proteins that are not self.  When one is found, the T-cell starts dividing, and some of those T-cells seek out B-cells.  The T-cells notify B-cells of the presumptive invader, and through one of the most amazing biological processes ever elucidated, germ-specific antibodies are produced.  Those antibodies ultimately cause cells infected with viruses to die (among other things).

So T-cells initiate (and later suppress) immune response.  B-cells primarily give rise to antibodies. The problem for me is that I don’t have very many of either of these cells.  Unlike neutrophils (white blood cells that primarily fight bacterial infection) and platelets, many developmental intermediates come between stem cell and mature lymphocyte, and it can take up to nine months for mature lymphocytes to appear after transplantation.  I do have a few lymphocytes from before the transplant, but it’s not clear that they will be of much use.

At this point, I just have to wait.  If matters get worse, I’ll get a nose swab tomorrow.  That might reveal a treatable virus or an untreatable virus.  Maybe I don’t have a virus.  I just don’t know right now, but in addition to being energetic and happy, I’m starting to get pretty scared.

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Some great news, biology, and cooperation

May 12th, 2010

I feel amazing.

I am so energetic, I can barely contain it.  Anyone who has spoken to me on the phone lately can attest.  For the last two weeks, my energy and strength has been rising every day, and now I feel better than I’ve felt in years.  In early 2007, I was in a brief remission, and I felt wonderful, like I’d felt years before—before the fatigue set it, which happened three full years before my diagnosis in 2006.  I now feel as good as I did during my remission, which can only be good news.

Reasons for my quick recovery are many: Being able to eat, no more diarrhea, and, most recently, the cessation of a particularly nasty treatment.  That treatment, with the drug ganciclovir, is for infection with CMV, cytomegalovirus, the a virus that in healthy people causes mononucleosis.  I was taking this drug probably because of a hospital error.  In order to explain, a brief digression into biology is required. (Regular readers shouldn’t be much surprised.)

CMV is one of the most commonly transmitted viruses on the earth.  The probability of contracting CMV rises with every year over one’s lifetime, and virtually everyone has it by middle age.  Despite this, I luckily tested negative in my pre-transplant blood tests.  Even more luckily, my donor was also negative.  This was great news, as CMV can cause blindness, serious lung problems, meningitis, and death in immunosuppressed people—facts that I remember all too well from my AIDS activism days in the late ’80s and early ’90s.  My early blood tests found no antibodies for CMV, and a highly sensitive test for CMV’s DNA, called PCR (for polymerase chain reaction), also showed negative initially.  However, three weeks into my transplant, a weekly PCR test was positive.  This was somewhat odd.

CMV is a herpes virus, and like all herpes viruses (including the virus that causes chickenpox [Herpes zoster]; Epstein-Barr virus; and of course, Herpes simplex I and II), CMV can hide inside cells that it infects, inserting itself into our cellular DNA.  When this is the case, a DNA test of blood might well be negative.  So if the CMV became active later, a previously negative PCR could become positive.  That part wasn’t the odd piece.  The odd part was my antibody negativity.

Antibodies are those amazing, disease-specific chemicals that our body produces in response to invasion by viral infections.  For every virus that infects us, we have a different antibody (well, almost).  But I was antibody negative for CMV, and that was the weird piece.  If I had been infected before, and the CMV had become quiescent, and then reactivated three weeks after my transplant, I would’ve been antibody positive the whole time.  But despite my suspicions of the apparently discordant blood tests, the positive PCR meant action had to be taken, and fast.  Because of the great risk of CMV infection, my physician rightly put me on ganciclovir immediately.

The great thing about ganciclovir is that it is very successful in defeating CMV.  I remember when ganciclovir came to market; it was a revolution for people with AIDS.  Prior to ganciclovir, having AIDS often meant the loss of sight, or worse.  And nothing could be done to stop CMV.  Ganciclovir changed all that.  But the bad news about ganciclovir is that it suppresses the production of blood cells, especially white blood cells.  After I began taking the ganciclovir, all of the components of my blood—my platelets, red blood cells, and white blood cells all crashed.  After an unusually fast and strong engraftment of my donor’s stem cells, which resulted in my having normal or near-normal blood counts for the first time in years, I was back to square one, and continuing to take the drug kept me there.  And to boot, after this blood cell crash, I contracted that awful Cdifficile infection. Administration of ganciclovir has a known association with infections like Cdifficile.  I had to be treated for the apparent CMV infection, but the treatment made me fragile.

Two weeks ago, my DNA test for CMV was negative, as it had been every time after the first test.  I asked my physician why I would not have anti-CMV antibodies if I had CMV (again, antibodies are always produced when we’re exposed to an infection, and we keep them forever).  After some discussion, my physician agreed that this was odd, and hypothesized that perhaps I’d acquired the CMV infection from one of my many pre- and post-transplant blood transfusions.  But that didn’t explain everything, and I left that meeting unconvinced.

Over the next week I puzzled over all my clinical data.  Why was I antibody negative?  Maybe it was because my immune system was so shot that it couldn’t produce any antibodies.  That is very likely true, but even so, I should still have residual (and easily detectable) antibodies from before the transplant, as they remain in the blood months after they are created.  Considering the DNA tests, I wondered how the ganciclovir could have eradicated the infection so quickly; I’d started taking the drug on a Thursday evening, and by the following Tuesday morning all evidence of the viral DNA was gone.  Ganciclovir is a good drug, but that good?  I asked about this the following week (last week).  My physician—who is remarkable in being open to discussion and input—considered my concerns and took a third look at the data, treating them all together.  The negative antibody test, the lone positive PCR result, and the rapid PCR negativity that never reversed—they just didn’t add up.  After this, my physician concluded that the first CMV test may well have been a false negative positive (this can happen with PCR, because this DNA test is extremely sensitive, and in labs where these tests are run routinely [like mine], contamination can be a serious problem).  As a result, we decided to stop the ganciclovir.  My blood cells, in theory, should begin to rise again.

So, yesterday when Greg and I went to the hospital for my weekly appointment, we were a bit disappointed that my blood cells had not rebounded more.  My hematocrit (one measure of red blood cells) was a bit higher, my white blood cells had gained 500 cells per squared cm (up from ~1,100), but my platelets were down from 80,000 to 50, 000 (both well below normal)—a mixed result.

But given how amazing I feel, I wasn’t too worried about this.  I did ask about the possibility of graft failure—a topic I’ll take up a bit later—but looking at the data on the proportion of “my” blood cells that are truly mine verses from my doner, everything looked excellent.

Stem cell transplant is an unlikely business.  Juggling all the variables—the risk of infection, the risk of Graft Versus Host Disease, the many drugs, the side effects of those drugs—managing all these can all be . . . well . . . at times impossible for both the physician and patient.  This procedure is truly at the bleeding edge of our knowledge, and much of what goes on, and why certain aspects of the therapy work or don’t, is yet unknown. When in a situation like this, in my experience two factors are indispensable: patient self-advocacy, and physician finesse.  Having cut my teeth on AIDS activism, I have no problem telling physicians that this is my body, and we must work together, as co-equal partners, to manage my illness, treatments, and recovery.  My current physician agrees, unusually, and we cooperate to achieve our common goal.  That cooperation is a big part of why I’m so energetic and healthy today.

And it’s good to feel great for the first time in a long time.

UPDATE:  See this post.

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Who loves the sun?

May 9th, 2010

I do.

Being from Louisiana, and now living just south of the arctic circle, I need the sun.   But I can’t be out in it.   Sunlight can stimulate my immune system (particularly the immune-boosting helper T-cells), which will lead to that conflict I wrote about in the last post, known as Graft Versus Host Disease in medical circles.   Unlike the case of an organ transplant—where there is risk of Host (the person’s immune system) Versus Graft (the transplanted organ) Disease—Graft Versus Host Disease (GVHD) is the reverse, sort of.   In this case, my new immune system (the graft) attacks my entire body (the host). Scary, eh?

Even scarier, if GVHD happens, the risk of relapse is much lower in my cancer.   So ideally, GVHD will happen a bit, but not too much.   Walking that tightrope is up to my oncologist, and he says he can do it. Again . . . scary.   But if all goes well, GVHD won’t happen for many months, during which the immunosuppressive drugs I’m on are slowly removed.

But direct sunlight could counteract the effect of the immunosuppressives, awaking my sleeping, new immune system.   For now, I’m something of a vampire, coming out of my lair only at dusk, making sure to avoid direct sunlight.   So because of all this, a good friend of ours, Karole Moe, who is an amazing artist and who just happens to live in Boston, dropped off some sunlight for us:

A Pollock-esque joy.  Bright rays fill the foreground, and dusky wisps fade into the background. Few things make me genuinely happy these days.   This does every day.

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Rapping about evolution, sociality, cheaters and slugs

May 8th, 2010

An interesting article appeared in the NY Times a couple of days ago. I have my doubts about the general appeal of a rap performance about evolutionary biology, but maybe it’s great. Who knows? You can investigate Baba Brinkman’s “The Rap Guide to Evolution” for yourself here and here.

Of particular interest, the article highlights one part of the show:

Dictyostelium is notorious, in some circles, for its strange life-style. Usually, an individual Dictyostelium lives alone as a single cell. But when food is scarce, the single cells come together and form a being known as “the slug”; this crawls off in search of better conditions. When it finds them, the slug develops into a stalked fruiting body, and releases spores. But here’s the mystery: not all members of the slug get to make spores — and thereby contribute to the next generation — so why do they cooperate?

Dictyostelium is an incredibly interesting group of organisms. A genus of usually solitary, single-celled amoebae, members of the group are also facultatively social. Individual Dictyostelium cells spend most of their life on the forest floor, eating bacteria. When bacteria become scarce, and the amoeba cells start to starve, they release chemical pulses that draw individual cells together. Once together, the cells form a mound of cells, all piled on top of each other. And then something amazing happens, the mound starts to crawl (yes, crawl) as one unit, across the forest floor. This slug is now, by any reasonable definition, a multicellular individual.

A beautiful image of a Dictyostelium discoideum slugs (bottom) and stalks with spore masses on top. Photo credit: Owen Gilbert

But that’s not the end of this startling story. After crawling away a bit (and by the bye, these slugs are visible and you can watch them crawl), cells at the leading edge organize themselves into a stalk, a pillar, via which the lagging cells in the slug will eventually ascend. The stalk cells die, and the other cells crawl up the stalk and become a mass of sporulating cells, leaving clonal offspring that might disperse from the impoverished environment more easily because of the (slight) height. (Well, in fact, this particular sequence is not universal. Some species of Dictyostelium do it differently, but the ultimate product, the formation of a slug and stalked spore body, is the same).

The comparison to wasp workers and queens is clear enough, but the comparison to our bodies is even clearer. Dictyostelium is a group with sterile worker cells and reproductive cells, and the group is composed of genetically identical cells ( . . . well, sometimes). We are a group of cells with sterile workers cells (our soma, all of our tissues and body parts) and reproductive cells (our germ, egg and sperm). The only difference (and it’s a big one, admittedly) is that our worker cell caste has differentiated into many subcastes—different sterile cell types and tissues composed of sterile cells—just like the workers of highly social wasps.

So Dictyostelium is sort of like Polistes: it has cycles of solitary and social, and it bridges the gap between completely selfish and altruist. (In fact, some of the most important work on Dictyostelium comes from the lab of two former(-ish) social wasp researchers). Given this, the next time someone tells you there are no transitionary intermediates that reveal major shifts in evolution, you can point them to Dictyostelium.

So the question: Why do Dictyostelium cells seemingly willingly, suicidally sacrifice themselves, forgo reproduction, and form the structure (the tissue) that is the stalk? The same question applies to worker wasps, and the cells in your finger. The beginings of the answer were provided by Darwin, but the mathematical framework wasn’t worked out for just over a century later, by über-famous social wasp researcher Bill Hamilton. Hamilton’s insight was as simple as it was brilliant.

It goes like this. Imagine an individual I will call the actor. The actor has two reproductive choices: She can reproduce directly by having her own offspring (thus leaving her genes and heritable tendencies, including her tendency to reproduce directly), or she can reproduce indirectly by assisting relatives have enough additional offspring such that they compensate for our actor’s sacrifice in direct reproduction. This works because relatives share genes. So, for example, our actor (let’s assume she’s a human now) could have one child, or help a sister have two additional children (over the children her sister would normally have absent our actor’s help). Because our actor and her sister share genes by descent, in each case, the same amount of genes are left by the our actor. If the actor has one child, she leaves half of her genes to the next generation. If the actor helps her sister have two additional offspring—because she’s related to her full sister by half, and thus related to her nieces and nephews by one quarter—then our actor leaves two times one quarter of her genes, or half, the same as if our actor had one child directly.

Some individuals in populations will have heritable tendencies for direct reproduction (the selfish tendency). Others (due to natural variation) will have heritable tendencies for indirect reproduction (essentially, helping, or being a worker, an altruist). Whichever individuals actually reproduce more, leaving more copies of their genes—including their heritable tendencies for either selfish direct reproduction or altruist indirect reproduction . . . whichever tendency happens to leave the most genes to the next generation will become more common, generation after generation. The other tendency will wane. Either tendency could be more successful, and this can change depending on other external, environmental factors. But whatever the context, if being a sterile helper results in more genes’ being shuttled into the next generation, that tendency will evolve. And the same goes for the tendency for direct reproduction. Neither tendency is universally better. Natural selection decides.

In Dictyostelium, this calculus is simplified, because the cells are (often) all clones of one another, so if one cell reproduces directly or by helping a clone reproduce, the reproductive success to each cell is the same. In this context, conflict-free cooperation can much more easily evolve. Of course, I’ve already pointed out in previous blogs that mutation can strike, and change the behavior of a cell, just like in our bodies. When this happens, the happy harmony is disrupted, and the cheater cell might corrupt the system by reproducing wildly, or otherwise refusing to engage the social contract. This happens in Dictyostelium, just as it does in us. All social systems have cheaters, cancer.

The harmony of Dictyostelium can also be disrupted when slugs are composed of genetically different cells, or even (sometimes) different species. When this happens, cells don’t easily sacrifice themselves and become stalk tissue. It’s easy to see why that behavior might not be favored by natural selection. In this context, becoming a sterile worker might mean very little or no indirect reproduction (for example, if the spores are all distant relatives of the stalk cell). If sterility and helping leave no genes indirectly, the behavior washes away over generations. The only tendencies that are left are the selfish: In a mixed group, fight for direct reproduction or perish. So, this generates great conflict, and individual cells in the slug try to position themselves such that they will be in the spore mass.

Because of this kind of conflict, it was long ago predicted that members of social groups should be able to recognize close relatives. Since that prediction—a prediction that derives directly from the mathematical evolutionary framework I describe above—many social creatures have been shown to recognize kin. You might think this kind of conflict (from genetically distinct cells) has little bearing on humans, but it’s exactly the kind of conflict that stem cell transplants can generate. The potential for that conflict is playing itself out in me now. My new cells have kin recognition abilities, and if they aren’t tricked into thinking my body is kin, a significant conflict may erupt.

So now, I’m like a mixed colony of Dictyostelium. Having hopefully exterminated the mutant cheater cancer cells, I now face yet another other social conflict. As time passes, the probability of that conflict rises.

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Conflict between the individual and the group

May 5th, 2010

Okay, I know.  I didn’t actually blog again last night.  Sorry for that, but since I’ve been feeling so, so, so much better, I’ve begun to realize just how much work I was laying aside.  I’ve been catching up.

So as a mini-catchup,  I’ll offer this symbol and some thoughts:

Polistes in Thoreau's attic

Polistes in Thoreau's attic

This is a nest of the genus Polistes—from the attic of the home where Henry David Thoreau was born. (Really.  You’ll just have to trust me on this, okay?)  Greg and I visited Walden Pond and toured Concord with expert historian Joseph Wheeler (grandfather of a good friend of ours, and son of the historian Ruth R. Wheeler, author of Concord: Climate for Freedom) just before I was admitted for my stem cell transplant, over seven weeks ago.

My greatest intellectual influences, without a doubt, come from the 1800s.  Marx, Engels, Darwin, Kropotkin, Emerson, Whitman, and of course Thoreau.   Like millions of other American High School students, I was especially influenced by the Transcendentalists.  But unlike some of my other 19th Century influences, the Transcendentalists—and especially Thoreau, I think—were caught in a kind of struggle.  They all wanted to forge a better world, and they all believed in cooperative alliances and effort; many joined communes and similar groups.  But the Transcendentalists were also great advocates of the individual, and the individual spirit.  This is especially true of Thoreau, who famously retreated from society, lived alone for a few years, and even went to jail in solitary protest against slavery.  At the same time, his writings and his message influenced Gandhi and MLK to reshape society through coordinated group action.  Thoreau is like Polistes.

Polistes is a one of the varieties of wasp I discussed in an earlier post, the kind in which groups of females, all able to have offspring, initially fight to become the egg layer and queen of the colony. There is little-to-no physical evidence of division of labor—no obvious anatomical queen and worker castes.  Eventually, the losers in combat settle down, sort of, and become workers.  But the social group is composed of would-be individualists, biding their time for an opportunity to shrug off their worker roll and take the queen’s throne.  It is a group that exhibits cycles of social behavior interrupted by periods of solitary behavior.  Polistes are the Transcendentalists of the wasp world, symbolically bridging the gap between selfish and altruist, individual and group.

This is how I see Thoreau. For humans as individuals, this might be a good, stable state.  For wasps, it’s unclear to me.  For the colony of cells in our bodies, such conflict is decidedly unwelcome—and when it happens, we call it cancer.

But are our individual cells slave to some purely communist totalitarian society?  Why wouldn’t they “prefer” individuality, a notion so decidedly American?  Does our body’s proper functioning demand that our worker cells (that form our kidney’s, lungs, livers, and, of course, blood) be oppressively chained to a social contract that forces them into a single roll (despite having all the genes needed to perform any roll), never allows them to reproduce freely (many are unable to divide after a point, and all are restricted), and then ultimately commit suicide (apoptosis) when the group so decides? What a dystopian nightmare!

So, as strange as it may sound, from a perspective of freedom, and rejoicing in the individual at all levels—ideas that ignited my intellect and set me on a path to activism and my current study so many years ago—I have sympathy for my cancer.  I cannot blame those cells for wanting to be free.

UPDATE:  See this post.

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Being Katharine Hepburn

April 29th, 2010

One of the drugs I’m on for immunosuppression makes me shake constantly.  It’s getting annoying. This side effect, coupled with the neuropathy in my hands, makes simple tasks, like lifting a fork, difficult.  I wonder if this is a glimpse into how people with Parkinson’s feel?  Probably nowhere nearly as bad, but it bites nonetheless.

The drug, tacrolimus, is not used widely for stem cell transplants, but is used generally for kidney transplants.  It’s strange that I’m struggling to rebuild my immune system, and I’m taking drugs to slow that process way down.  But this is part of the dance—coaxing the new cells to slowly, ever so slowly open their eyes, and think that what they see is self.  If they wake up too quickly, they’ll see clearly and attack.

A related immunosuppressive drug that I’m taking, sirolimus, is used probably by even fewer stem cell transplant centers, but the data on this drug are impressive.  As an inhibitor of the mammalian Target Of Rapamycin (mTOR; indeed, sirolimus is rapamycin), it blocks a complex cascade by which cells proliferate, and so all is slowed down.  The new cells are very sleepy.

I’m very lucky to have these drugs.  My current physician is rare in that he does clinical research, and he is actually good at it (this is rare among physicians).  These immunosuppressive drugs, coupled with other novel treatments, are the reason my hospital’s success with stem cell transplants is so much higher than the national average.  Every day I am grateful that I have the care I have (and my praising physicians is as rare as their conducting good research, so that should tell you how confident I am in my physician).

It is worth noting that both of these chemicals are natural derivatives of bacteria:  tacrolimus comes from one species of Streptomyces, sirolimus from another species of the same genus.  In fact, most of the chemotherapies I’ve had are naturally occurring biological products.  Vincristine—one of the first chemotherapies I ever took, and a potent inhibitor of cell division—comes from the Madagascar periwinkle, once placed in the genus Vinca, where the drug gets its name.  Adriamycin, a chemotherapy that damages DNA directly, is also derived from bacteria. And an experimental drug currently showing great promise, Gossypol, is an unaltered, direct extract of the cotton plant, found in the stems, roots and seeds.  This drug directly blocks bcl-2, the epicenter of my cancer’s existence, but more on that later.

I could go on and on.  Hundreds of our pharmaceuticals come directly from natural sources.   The only difference between so-called “natural” medicine and “western” medicine, again, is that the latter is subjected to careful testing, and the former is not.

I can’t believe I could type all that with this much shaking.

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