MND stem cell study identifies TDP-43 astrocytes as not toxic to motor neurones

Funded by the MND Association, international researchers have used stem cell technology to learn more about the relationship between motor neurones and their support cells.

These findings highlight the potential of stem cell technology as a tool to create new human ‘in a dish’ cellular models of disease to learn more about the causes of MND.

The research group included MND Association funded researchers Prof Siddharthan Chandran and Sir Prof Ian Wilmut from University of Edinburgh, Prof Chris Shaw from King’s College London and Prof Tom Maniatis from Columbia University in America.

This important finding was published in the scientific journal PNAS on 11 February 2013. This new finding follows on from previous work published by this research group in 2012 where they demonstrated the proof of principle of creating human motor neurones with MND in a dish.

Why we need an astrocyte model of MND

Astrocytes, so called because of their star-like appearance, normally act as neurone support cells to nourish and protect motor neurones. They act with motor neurones to ensure that they can continue to function.

From previous studies, we know that when these cells begin to dysfunction, they can become toxic to motor neurones to contribute to MND. Finding out why astrocytes can cause motor neurones to degenerate is an issue of ongoing debate – we recently gave an update on this from the International Symposium.

Being able to grow human astrocytes in a laboratory dish is of importance to be able to learn more about the relationship between astrocytes and motor neurones in MND.

Creating human astrocytes in a dish

Using cutting-edge stem cell technology, the research group reprogrammed skin cells into astrocytes in a laboratory dish. The skin cells were donated by people with MND who have a family history of the disease caused by known mistakes in a gene called TDP-43.

Led by Prof Chandran and colleagues, the research group aimed to identify whether these cells would develop the ‘hallmarks’ of MND in a laboratory dish.

By studying the characteristics of these human astrocytes with faults in the TDP-43 gene, the research group identified that they shared the same qualities as cells affected by MND. The astrocytes had increased levels of TDP-43 found in areas where it isn’t usually found – outside of the control centre of the cell. They also found that the astrocytes didn’t survive as long as astrocytes created from skin cells of people that didn’t have MND.

This means that the human astrocytes created by Prof Chandran and colleagues using stem cell technology develop MND-like characteristics. This new model can be used to study how motor neurones develop the disease in a system that is directly relevant to people living with MND.

Answering whether faulty astrocytes affect healthy motor neurones

The next question that this research group wanted to answer was whether these faulty astrocytes had an effect on healthy motor neurones.

By growing faulty TDP-43 astrocytes with healthy motor neurones, the research group identified that the survival of motor neurones was not adversely affected.

This was surprising as other research groups have shown that when astrocytes have faults in the SOD1 gene (which cause one in five cases of MND with a family history) that motor neurones are compromised, even if the motor neurones were originally healthy.

TDP-43 is found within tangled lumps in over 90% of cases of MND (irrespective of whether it was caused by an inherited genetic mistake). However, when MND is caused by SOD1, TDP-43 is not found in these tangled lumps. This important difference could be leading to the key difference in whether astrocytes become toxic to contribute to causing MND.

These findings will of course need to be verified by an independent research group to determine that they are valid, but the results suggests that SOD1 and TDP-43 could be causing havoc in motor neurones in slightly different ways, both avenues leading to MND.

Our Director of Research Development, Dr Brian Dickie comments: “From a therapeutic perspective this is important because it means that specific treatments targeted at astrocytes may only be relevant and effective, in specific subsets of patients who will have to be carefully selected for drug trials.”

References:

Our news release on this finding.

March 2012 finding: Association-funded stem cell study achieves milestone

Serio A et al. Astrocyte pathology and the absence of non-cell autonomy in an induced pluripotent stem cell model of TDP-43 proteinopathy. PNAS 2013

The clinical trials session

A very much ‘must report on’ session of the 23^rd International Symposium on ALS/MND was the clinical trials and trial design session. There are many reasons that make this an interesting session – perhaps the most eagerly anticipated were the presentations on the NP001 study and the results of the stem cell safety trial:

NP001 update

We reported on the blog on 1 November the results of the NP001 study, and these findings were confirmed today by Dr Bob Miller from Forbes Norris Centre in California USA. The trial showed that intra-venous administration of NP001 was found to be generally safe and well tolerated, with a modest clinical benefit seen in the high dose (2mg/kg) group.

As previously reported in their press release, ‘post-hoc analysis’ (meaning literally after the event), showed that some patients in the higher dose group did not have any change of a scale that measures the functional capabilities of people with MND called the ALS-functional rating scale (ALSFRS) over the course of the study. Historical controls were used in the post-hoc analysis – the first time that the US Food and Drugs Administration (FDA) had allowed them to do this.

The room was packed and there were five people queuing to ask questions about this talk. Questions were asked about the use of historical controls; the possibility that patients would identify that they were in the treatment group due to the presence of a ‘burning feeling’ at the injection site; and about other forms or ways of taking NP001. On the last of these points, a question about the chemical structures of NP001 and WF10 went unanswered.

But Dr Miller was categoric about different ways of taking NP001. “Taking NP001 in any other route [than intra-venously] is unsafe and unproductive”.

Results of stem cell safety trial

The first regulatory body (FDA) approved phase I safety trial of a stem cell treatment for MND, conducted in America, is now complete. Dr Johnathan Glass from Emory ALS Center, Georgia USA presented the results of this study.

In the last 5-10 years there has been a huge amount of interest from MND researchers, clinicians and patients alike about the possibility and potential for using stem cells to treat MND. More information about what stem cells are and how they might help is available on the MND Association’s website.

As for any other drug or potentially beneficial intervention, the first part of the assessment should always be to obtain a robust and objective measure on whether such a treatment is safe, and this is what the NeuralStem study was designed to find out.

A team of highly trained specialists, in close consultation with the FDA, designed a study to look at the safety of giving an injection of stem cells directly into the spinal cord of people with MND. Eighteen surgeries were performed on fifteen patients – three of these patients volunteered to have two surgeries (two injections).

The first three people with MND recruited into the study received a single injection of stem cells on one side of the bottom (lumbar) of the spinal cord. The next three received injections on both sides of the lumbar spinal cord. These first six patients were at an advanced stage of MND, where they were unable to walk.

The next six patients, who were able to walk, received injections at one or both sides of the lumbar spinal cord. The last three patients received a single injection higher up the spinal cord (cervical) and finally, the three patients able to walk who received a single lumbar injection underwent a second surgery to receive a single cervical injection.

The results from the first six patients has already been published in a scientific paper:

Stem Cells 2012 30(6) 1144 – 51

Dr Glass concluded that the procedure is well tolerated and safe and that there is no indication that the surgery accelerates the progression of the disease. The next phase of the study, giving injections into the cervical spinal cord at increasing doses (numbers of cells) is funded and is awaiting FDA approval.

Our International Symposium website news stories:

International Symposium closes in Chicago

International Symposium focuses on clinical trials

International Symposium focuses on carer and family support

International Symposium begins in Chicago

Researchers unite at our International Symposium on MND

After you’ve finished reading the symposium articles that interest you, we’d be grateful if you could spare a few minutes to fill in our short online survey on our symposium reporting. Your comments really are useful and allow us to continually improve our symposium reporting. surveymonkey.com/s/alssymp 

Have your say on emerging technologies

The Nuffield Council on Bioethics are currently asking for views on a number of technologies that people affected by MND may have a view on. They are seeking views on both the medical and non-medical applications of neural stem cell therapy, brain computer interfaces, deep brain stimulation and transcranial magnetic stimulation.

 To find out how to take part you can visit their website and download a Word document. This gives you explanations of each technology, followed by a series of questions about your thoughts on how it is and should be used and regulated. You can choose whether to give your name or whether to submit your answers anonymously. Responses must be received by the Nuffield Council by Friday 23 April.

A quick peruse of the posters

Sometimes, presenters’ reactions to hearing that they’ve been given a poster presentation, rather than a talk is that of disappointment. I disagree. I feel it is a great opportunity to have a more in depth two way discussion than is ever possible during the 2-3 minutes allocated to questions after a talk.

There are over 200 posters being presented at this International Symposium. Before heading anywhere near the room where they’re on display I mark off a selection of posters to visit. Sometimes they are topics I know something about, or people that I know – for example MND Association grantees, or I sometimes choose topics that I don’t know anything about – the latter to find just what they are about. In one blog post (and the time available to write it) I can’t do justice to the topics that I did learn more about, but here is a bit of a taster:

Split hand wasting – this definitely fell into the latter category above! Two posters reported on how two quite closely connected muscles in your hand waste at different rates in people with MND. (The muscle groups are the thenar muscles and the abductor digiti minimum in case you want to look them up). Parvathi Menon’s poster established that it may be possible to use the ratio of the two different muscles as a way to diagnose MND and as a possible biomarker. Jocelyn Zwicker’s study investigated the electrophysiological nature of this observation.

Early conclusions from Neuralstem safety clinical trial included: Injections in the lumbar section of the spinal cord are well tolerated by people with MND are various disease stages. Participants experienced significant discomfort from the stomach / GI effects of the immunosuppressant drugs they received. Permission has been given by the FDA to advance the trial to cervical sections of the spinal cord, neuroprotection at this level may help with diaphragm function.

Does riluzole have an affect on Dexpramipexole?: Using the results from the previous, phase II, clinical trial for dexpramipexole, the authors described how the use of riluzole and dexpramipexole neither adds to, nor takes away from the effect of dexpramipexole on survival or progression. They conclude that it would be useful to confirm this in the phase III clinical trial currently underway across multiple sites across the world.

Read our official press release on day two of the symposium.

Prof Siddharthan Chandran talks about the recipe for stem cell success at our Annual Conference

Neural Progenitor cells, courtesy of Prof Chandran lab, University of Edinburgh

We invited Prof Siddharthan Chandran to be our keynote speaker at our Annual Conference and below we’ve provided a brief overview of his presentation which we hope you’ll find useful as either a recap if you attended or as an insight into MND and stem cells if you couldn’t make it on the day.

About Prof Chandran

Prof Chandran is Professor of Neurology at the University of Edinburgh and Director of the Euan MacDonald Centre for MND Research which is based at the university. He is leading the Association’s largest stem cell research programme which pulls together world-class researchers from leading institutes in Edinburgh, London and New York. Working together, the international research teams are manipulating stem cells to provide a unique tool for studying MND and developing new drugs. It’s research programmes like this, that really demonstrate our role as a leader in funding and promoting cutting-edge MND research. Naturally we were only too pleased to introduce Prof Chandran to our conference delegates.

Origins of understanding the power of stem cells

Prof Chandran began his talk on a mythological level with the story of Prometheus, who was punished by the Greek God Zeus by being chained to a rock and having his liver eaten daily by an eagle, only to have it grow back the next day to endure the torture again. Not a very nice story, but Prof Chandran went on to explain that through this myth, the Greeks had stumbled onto the origins of understanding the nature of stem cells. The liver is one of the only solid organs that we have that has the power to regenerate itself when damaged. Although this wasn’t the moral of the myth, it’s still an important historical reference that demonstrates that the potential of stem cells as a regenerative tool is not a new concept.

From science fiction to science fact

If Prof Chandran, while at university, had suggested that in the future it would be possible to create stem cells from a skin sample, he said that he would have been ridiculed and the idea would’ve been seen as pure science fiction. Yet here we are, now living in ‘the future’ and this technology is a reality, the newest finding of which was the discovery of stem cell-like cells called ‘induced pleuripotent stem cells’ (or iPS cells for short) in 2008 by a Japanese research group. By delivering a cocktail of chemicals to skin cells donated by a living person, they were able to turn back the clock of the skin cells to turn them into iPS cells. This finding is now the cornerstone of many new stem cell research projects, which has arguably revolutionised the field.

Future treatment potential, but currently regeneration is impractical

There are many ways that stem cells could be used in the future to treat MND, but using them to regenerate motor neurones is not currently a practical solution. But why isn’t this practical? In his talk, Prof Chandran explained…

Crossing wires

The brain is a very complex organ and can be related to a ball of wiring, with each wire being linked to a specific place within the brain and body. If this were to be wired up inaccurately, then it would cause pandemonium in our bodies, with movement instructions meant for our feet to possibly end in our hands, mouth or elbow for example – something we’d definitely not want to happen!

Prof Chandran went onto explain that each neurone has its own ‘postcode’ in the brain, and depending on where it ‘lives’, he explained that its function will vary.

The function of each motor neurone will also intuitively denote what muscle it’s supposed to connect to. The way that our neurones grow toward a muscle is an extremely well orchestrated affair, with chemical messages throughout the body that either attract, or repulse it. However, as our bodies develop in the womb, this system is switched off – meaning that any new motor neurones trying to grow from scratch in the brain will find it near to impossible to know where it’s supposed to go.

It is therefore a very complicated issue to try and regenerate motor neurones in humans to ensure that the motor neurone firstly starts in the right place, and secondly that the neurone has the right instructions in place to guide it toward its target muscle.  However, these aren’t the only issues that researchers face…

Being sure it’s a motor neurone

In our search for using stem cells as a treatment for MND, there is also an issue of making sure that stem cells turn into the cells you want them to be, and Prof Chandran eloquently explained this by using a video of heart cells, generated using stem cell technology and saying that you definitely wouldn’t want these cells beating away in your brain instead of your motor neurones!

But how do researchers turn stem cells into the ‘right’ sort of cell? Prof Chandran explained that this is done quite simply, by giving them the right recipe of chemical ingredients to tell them what to become when they’re older.

Neurones are slow growers

Even if researchers could somehow ensure that ‘new’ motor neurones could be created and would connect to the right ‘postcode’ of the brain, neurones are very slow growing. As some of our motor neurones would have to grow over a metre to reach its target muscle, the amount of time that it would take to regenerate motor neurones would be implausible in terms of using them as a treatment. There just isn’t a way to speed this up at the moment.

For all of the above reasons, this is why stem cells cannot currently be used to regenerate motor neurones as a treatment for MND. However, this is not to say that they don’t have other uses…

Using stem cells to learn more about MND

Stem cells are great tools for recreating diseases in a dish, as they are able to divide to create large numbers of cells and are able to turn (with the right receipe) into any type of cell, such as a motor neurones.

In his laboratory, Prof Chandran’s research group have created living human motor neurones grown in a dish from skin cells donated by people with an inherited form of MND using iPS cell technology. In his presentation, he showed us that within 100 days, his laboratory is able to create a billion (10¹², referred to as a trillion in USA) cells from a stem cell. He has also shown that these motor neurones generated from stem cells connect to muscle cells and are electrically active – which means that to all intents and purposes, they are real motor neurones.

He then explained that his MND Association funded project is creating these motor neurones and support cells from a skin biopsy of somebody with MND with faults in a gene called TDP-43. They can then use these new cells as a tool to investigate the disease process and hopefully in the future to test the effectiveness of therapies in this model.

Realising the potential of stem cells

As well as using stem cells to create new models in the laboratory, to discover new medicines, stem cells could potentially be used in a different way to treat the disease. These treatments would not aim to regenerate the motor neurones, but instead would attempt to slow down, or even stop the disease.

Realistically, researchers could use neurone support cells to provide a protective environment to lasting motor neurones – in fact, there are plans in place to test such a treatment which is estimated to being enrolling in 2014 (see stem cell conference blog article for more information).

Overall, Prof Chandran’s talk was extremely well received with delegates commenting to us that “Prof Chandran was the best speaker I can recall” and Prof Chandran’s talk was: “clear, hopeful, excellent. He inspired confidence and spoke in language I could understand”

We’re pleased that so many people who attended our AGM and Annual Conference enjoyed Prof Chandran’s talk, with 91.2% of delegates saying that it was “excellent” (from our survey of 57 people who attended).

Find out more about stem cells on our website.

Stay up-to-date with news on our next conferences by following our conference team on Twitter @mndconference

Read all about the New York Stem Cell Conference

 ….or at least, read even more about it!  

Back in January, we reported that sixty of the world’s leading stem cell research experts from 14 countries were brought together for the first time to shape the development of future international MND stem cell research.

The two-day conference in New York – organised by the MND Association in conjunction with the UK National Stem Cell Network; the Canadian Stem Cell Network; the New York Stem Cell Foundation; and the ALS Association of the USA (ALSA) – brought leading stem cell experts together under one roof in order to agree key areas of investigation in this exciting field of MND research.

You can catch up with what our director of research, Dr Brian Dickie said about the conference in seven Stem Cell Workshop blog posts. 

If you felt that Brian’s daily blogs from the beginning of the year weren’t enough, a more comprehensive report has just been published in the journal Amyotrophic Lateral Sclerosis, of which Brian is a co-author. The journal publishers have also kindly given permission for a version of the report to be available online, which can be downloaded from the ALS Association’s website.

The published report on the ALS Association’s website is not written in plain-english as it provides a thorough assessment of the ‘state of affairs’ of MND stem cell research for scientists – you may find it interesting none-the-less!

New unproven stem cell treatment via IV and mannitol causes concern

We have been made aware that there’s a new kid on the block in terms of unproven treatments, which is a new route of administration of stem cells at the X-Cell stem cell clinic based in Germany.

As a brief background of the story to date, last year, a group of international researchers collectively known as ALSUntangled investigated the claims of X-Cell.

ALSUntangled wrote, and published an article (in the journal ALS) on the X-Cell clinic which concluded that until they demonstrate the safety and effectiveness of their stem cell treatment through a rigorous clinical trial that they would not condone X-Cell centre’s protocol for people living with MND. We wrote about this in our ‘X-Cell Stem Cell Centre has been investigated by ALSUntangled’ blog article.

X-Cell has now adapted their strategy to use intravenous (IV) administration for stem cells, meaning that the cells are delivered into a vein in the arm rather than via surgery on the brain or spine. X-Cell claim that they are able to use this new, far less invasive route of administration because they also give patients IV mannitol to help the stem cells gain access to the central nervous system. Mannitol is a drug used to draw water out of the brain in cases of cerebral oedema (swelling of the brain). There has been research into mannitol use to ‘open’ the blood brain barrier for chemotherapy to improve delivery of drugs to tumors in the brain. However, there is a big difference in trying to get a reasonably small chemical through the blood brain barrier – which in real life terms is like a sieve from the blood through to the brain, and trying to get comparatively huge stem cells through the blood-brain barrier. Unless research is published to demonstrate that this is possible, then it is an unproven method.

We are aware that unproven treatments can seem attractive to people affected by MND given the lack of a treatment. However, they often come at a large cost and have not demonstrated their effectiveness in rigorous clinical trials. To find out more about what makes a good clinical trial, visit our website: ‘what makes a good clinical trial’, or ‘unproven treatments’.

If you are considering an unproven treatment and would like to know the facts about the information they provide, please contact us at research@mndassociation.org. We provide the facts so that people affected by MND can make up their own minds about whether it’s an option they would like to consider.

*Updated – the X-Cell centre has now been closed due to the German Government tightening the loophole that allowed the centre to offer unproven stem cell treatments.

Painting the way to new motor neurones from stem cells

A study led by MND Association funded researcher Prof Siddharthan Chandran from the University of Edinburgh has developed a new method to create a diverse group of motor neurones from stem cells. The research, published in the journal Nature Communications could be used to create more accurate and clinically relevant laboratory dish models to learn more about the differences in vulnerability and connectivity of motor neurones in MND.

 Why are the subtypes of motor neurones important to MND research?
When we first start to develop as embryos in the womb, chemical messages are used as cues to tell our cells what to turn in to. At the start of this process our cells can be thought of as blank canvases that have the potential to turn into any type of cell. Mixtures of ‘colourful’ chemicals are then used to create a unique ‘hue’ signal in order for the cell to know what to become.

So, depending on the ‘hue’ of chemicals around them, neuronal precursor cells will turn into different subtypes of motor neurone. In their fully formed state, these motor neurones subtly vary in their chemical makeup (due to acting on the different ‘hue’ signals given), their vulnerability to degenerate in MND, as well as the way they connect and communicate with other cells.

The subtle differences in subtypes of motor neurone have not been replicated in a laboratory dish model of MND to date. However, being able to develop such a model would provide MND researchers with a true spectrum of the way that MND affects the different subtypes of motor neurones. They would then also be able to develop new and better treatments that can target specific types of motor neurones that may be more vulnerable to MND.

What did the researchers do to find this?
The collaborative research group from Universities of Edinburgh, Cardiff and Cambridge tested a new method for creating different types of motor neurones in a dish from human embryonic stem cells.

To do this, they first added a chemical that accelerates the process of turning stem cells into neurone precursor cells – it’s the equivalent of being able to add a ‘quick drying’ additive to a painting. By adding this chemical, which has been given the catchy name of SB431542, the process of changing an embryonic stem cell into motor neurone progenitor cells is sped up from approximately 30 days to just 12 days.

They then tested whether a certain chemical called ‘retinoic acid’ is needed for the process of making different types of motor neurone. By measuring the chemical makeup of the functional motor neurones produced without retinoic acid, they were able to determine that they had produced a different type of motor neurone that is different from those created with the use of retinoic acid.

What’s next?
By defining a new process to create new and better models using stem cell technology, a new multi-motor neurone type model could be created for MND to study the similarities and differences between motor neurones in MND.

By learning more about these differences, we could learn more about how and why some motor neurones remain spared in MND.

To find out more about the future of stem cell research, please read Dr Brian Dickie’s account of the recent stem cell conference. Or, download a copy of our stem cell information sheet.

Journal Reference: Patani, R. et al. Retinoid-independent motor neurogenesis from human embryonic stem cells reveals a medial columnar ground state. Nat. Commun. 2:214 doi: 10.1038/ncomms1216 (2011).

Stem cell conference part seven: Creating new and better models for MND

It was then back to the science. Prof Frank Soldner (Massachusetts Institute of Technology) provided an overview of a new and exciting way in which MND-causing genes can be introduced into human embryonic stem cells in order to study the disease. Traditional gene transfection techniques are rather uncontrolled, resulting in multiple copies of the gene being introduced in random parts of the human genome – both of which can affect normal cellular functioning. A new genome-editing technique allows the existing ‘normal’ gene within the stem cells to be converted directly into a ‘mutant’ gene, which should result in the creation of stem cell-derived motor neurones that are much more representative of those in the patient.

Of course, the other way of getting to this point is not to use embryonic stem cells, but instead to use induced pleuripotent stem (iPS) cells, generated from skin samples taken from inherited ALS patients with a known gene mutation. Prof Jeff Rothstein (Johns Hopkins University) provided an update on the US National ALS Cell Bank which to date has produced 30 iPS cell lines from patients with various known MND gene mutations. He stressed the need for a large number of well characterised  cells to be made available to the research community, as each one will be slightly different, putting it very succinctly with the statement: “You need more than one ‘human’ to test a hypothesis or a compound.”

The National ALS Cell Bank will create both motor neurones and a type of neurone support cell called ‘astrocytes’ from each iPS cell line.

We know very little about the different subtypes of astrocytes that are present in the central nervous system – we know that brain astrocytes are different from those in the spinal cord. Both Prof Rothstein and Prof Su-Chun Zhang (University of Wisconsin) highlighted recent research showing that there are marked ‘regional differences’ within the spinal cord itself.

Using different ‘cues’ Prof Zhang is able to develop subtypes of astrocytes similar to those found in different parts of the spinal cord. This information may be very important in understanding why the disease progresses so differently between one person and the next. As the emerging stem cell trials in MND are based on replacing and improving the astrocyte populations in the spinal cord, it is also likely to be important in maximising the chances of success in altering disease progression, by ensuring the stem cells turn into the right type of astrocyte, best able to support motor neurones around the site of injection.

Stem cell conference part six: unregulated treatments

The room was crowded at 8am for the first presentation of day two, from Dr Doug Sipp (RIKEN Institute, Japan) on ‘Unregulated ALS/MND treatments and public education’.  Dr Sipp provided an insightful and entertaining overview of the plethora of self-styled stem cell ‘clinics’ and the tactics they employ to attract business. During the talk, the song Snake Oil, by the country singer Steve Earle, kept going round my head…. 

“Ladies and gentlemen, attention please
Come in close so everyone can see
I got a tale to tell
A listen don’t cost a dime
And if you believe that, we’re gonna get along just fine….”

Time was given over for a discussion on the issue of unregulated treatments, moderated by Dr Rick Bedlack (Duke University) and involving myself and Steven Byer of the US charity ALS Worldwide. Dr Bedlack is one of the founders of ALSUntangled, a consortium of ALS clinicians that used the Internet and social media to investigate alternative and off-label ALS treatments. Although in its early stages of development, ALSUntangled is fast becoming a very important resource to people with MND, providing the sort of objective information that helps people to come to an informed choice on whether or not to pursue alternative approaches to treating their disease.

There was clear consensus among those in the room that clinicians, scientists and patient associations need to find mechanisms for working more closely together – in separating ‘hope from hype’ and providing a more accurate explanation of the potential uses of stem cells in both basic science and disease treatment. Stephen Byer talked about the two C’s: the need for closer Collaboration and sharing of information; and better methods of Communication. I added a third – Consistency – to the discussion. We don’t necessarily all need to be providing exactly the same message, as different individuals and organisations we may well have differing opinions, but we should be basing those opinions on the same level of information and understanding.