Podcasts about lmna

In this Better Edge podcast episode, Margrit Urbanek, PhD, associate professor of Endocrinology, and doctoral student Rosie Bauer discuss key insights from their recent research on the potential role of a rare genetic variation in the LMNA gene in the development of PCOS.

Francis Collins is a veritable national treasure. He directed the National Institutes of Health from 2009 to 2021. Prior to that he led the National Human Genetics Research Institute (NHGRI) from 1997-2009, during which the human genome was first sequenced. As a physician-scientist, he has made multiple seminal discoveries on the genetic underpinnings of cystic fibrosis, Huntington's disease, neurofibromatosis, progeria, and others. This brief summary is barely scratching the surface oh his vast contributions to life science and medicine.A video clip from our conversation on hepatitis C. Full videos of all Ground Truths podcasts can be seen on YouTube here. The audios are also available on Apple and Spotify.Transcript with external inks and links to audioEric Topol (00:06):Well, I am really delighted to be able to have our conversation with Francis Collins. This is Eric Topol with Ground Truths and I had the chance to first meet Francis when he was on the faculty at the University of Michigan when I was a junior faculty. And he gave, still today, years later, we're talking about 40 years later, the most dazzling Grand Rounds during his discovery of cystic fibrosis. And Francis, welcome, you inspired me and so many others throughout your career.Francis Collins (00:40):Well, Eric, thank you and you've inspired me and a lot of other people as well, so it's nice to have this conversation with you in the Ground Truths format.Eric Topol (00:49):Well, thank you. We're at the occasion of an extraordinary book you put together. It's the fifth book, but it stands out quite different from the prior books as far as I can tell. It's called The Road to Wisdom: On Truth, Science, Faith and Trust, these four essential goods that build upon each other. And it's quite a book, Francis, I have to say, because you have these deep insights about these four critical domains and so we'll get into them. But I guess the first thing I thought I'd do is just say, how at some point along the way you said, “the goal of this book is to turn the focus away from hyperpartisan politics and bring it back to the most important sources of wisdom: truth, science, faith and trust, resting upon a foundation of humility, knowledge, morality, and good judgment.” So there's a lot there. Maybe you want to start off with what was in the background when you were putting this together? What were you really aiming at getting across?Reflections on CovidFrancis Collins (02:06):I'm glad to, and it's really a pleasure to have a chance to chat with you about this. I guess before Covid came along, I was probably a bit of a naive person when it came to how we make decisions. Yeah, I knew there were kind of wacky things that had gone out there from time to time, but I had a sort of Cartesian attitude that we were mostly rational actors and when presented with evidence that's been well defended and validated that most people will say, okay, I know what to do. Things really ran off the rails in the course of Covid. It was this remarkable paradox where, I don't know what you would say, but I would say the development of the vaccines that were safe and highly effective in 11 months using the mRNA platform was one of the most stunning achievements of science in all of history up until now.Francis Collins (03:02):And yet 50 million Americans decided they didn't want any part of it because of information that came to them that suggested this was not safe or there was conspiracies behind it, or maybe the syringes had chips that Bill Gates had put in there or all manner of other things that were being claimed. And good honorable people were distracted by that, lost their trust in other institutions like the CDC, maybe like the government in general like me, because I was out there a lot trying to explain what we knew and what we didn't know about Covid. And as a consequence of that, according to Kaiser Family Foundation, more than 230,000 people died between June of 2021 and April of 2022 because of a decision to reject the opportunity for vaccines that were at that time free and widely available. That is just an incredibly terribly tragic thing to say.Francis Collins (04:03):More than four times the number of people who died, Americans who died in the Vietnam War are in graveyards unnecessarily because we lost our anchor to truth, or at least the ability to discern it or we couldn't figure out who to trust while we decided science was maybe not that reliable. And people of faith for reasons that are equally tragic were among those most vulnerable to the misinformation and the least likely therefore, to take advantage of some of these lifesaving opportunities. It just completely stunned me, Eric, that this kind of thing could happen and that what should have been a shared sense of working against the real enemy, which was the SARS-CoV-2 virus became instead a polarized, divisive, vitriolic separation of people into separate camps that were many times driven more by politics than by any other real evidence. It made me begin to despair for where we're headed as a country if we can't figure out how to turn this around.Francis Collins (05:11):And I hadn't really considered it until Covid how serious this was and then I couldn't look away. And so, I felt if I have a little bit of credibility after having stepped down after 12 years as the NIH Director and maybe a chance to influence a few people. I just have to try to do something to point out the dangers here and then to offer some suggestions about what individuals can do to try to get us back on track. And that's what this book is all about. And yeah, it's called The Road to Wisdom because that's really how I want to think of all this in terms of truth and science and faith and trust. They all kind of give you the opportunities to acquire wisdom. Wisdom is of course knowledge, but it's not just knowledge, it's also understanding it has a moral character to it. It involves sophisticated judgment about difficult situations where there isn't an obvious answer. We need a lot more of that, it seems we're at short supply.Deconvoluting TruthEric Topol (06:13):Well, what I really loved about the book among many things was how you broke things down in just a remarkably thoughtful way. So truth, you have this great diagram like a target with the four different components.in the middle, necessary truth. And then as you go further out, firmly established facts, then uncertainty and then opinion, and truth is not a dichotomous by any means. And you really got that down and you explained each of these different facets of truth with great examples. And so, this among many other things that you broke down, it wasn't just something that you read somewhere, you really had to think this through and perhaps this experience that we all went through, but especially you. But because you bring so much of the book back to the pandemic at times with each of the four domains, so that and the spider web. The spider web of where your core beliefsare and then the ones further out on the web and you might be able to work on somebody out further periphery, but it's pretty hard if you're going to get to them in the middle where their main thing is science is untrustworthy or something like that.Eric Topol (07:36):So how did you synthesize these because the graphics are quite extraordinary?Francis Collins (07:44):Well, I will say the artist for the graphics is a remarkable graphic design student at the University of Michigan who happens to be my granddaughter. So it was nice having that ability to have my scratches turned into something actually looks like artwork. The concepts I got to say, Eric, I was feeling pretty unsure of myself. I never took a course in philosophy. I know there are people who've spent their entire careers going all the way back to Socrates and on up until now about what does truth mean and here's this scientist guy who's trying to say, well, let me tell you what I think about it. I'm glad to hear that you found these circles useful. They have been very useful for me and I hadn't thought about it much until I tried to put it in some sort of framework and a lot of the problems we have right now where somebody says, well, that might be true for you, but it's not true for me, that's fine if you're talking about an opinion, like whether that movie was really good or not.Francis Collins (08:43):But it's not fine if it's about an established fact, like the fact that climate change is real and that human activity is the main contributor to the fact that we've warmed up dramatically since 1950. I'm sorry, that's just true. It doesn't care how you feel about it, it's just true. So that zone of established facts is where I think we have to re-anchor ourselves again when something's in that place. I'm sorry, you can't just decide you don't like it, but in our current climate and maybe postmodernism has crept in all kinds of ways we're not aware of, the idea that there is such a thing as objective truth even seems to be questioned in some people's minds. And that is the path towards a terrible future if we can't actually decide that we have, as Jonathan Rauch calls it, a constitution of knowledge that we can depend on, then where are we?Eric Topol (09:37):Well, and I never heard of the term old facts until the pandemic began and you really dissect that issue and like you, I never had anticipated there would be, I knew there was an anti-science, anti-vaccine sector out there, but the fact that it would become so strong, organized, supported, funded, and vociferous, it's just looking back just amazing. I do agree with the statement you made earlier as we were talking and in the book, “the development of mRNA vaccines for Covid in record time as one of the greatest medical achievements in human history.” And you mentioned besides the Kaiser Family Foundation, but the Commonwealth Fund, a bipartisan entity saved three million lives in the US, eighteen million hospitalizations. I mean it's pretty extraordinary. So besides Covid, which we may come back to, but you bring in everything, you bring in AI. So for example, you quoted the fellow from Google who lost his job and you have a whole conversation with Blake Lemoine and maybe you can give us obviously, where is AI in the truth and science world? Where do you stand there and what were you thinking when you included his very interesting vignette?Perspective on A.I.Francis Collins (11:17):Well, I guess I was trying to talk about where are we actually at the point of AGI (artificial general intelligence) having been achieved? That is the big question. And here's Blake Lemoine who claimed based on this conversation that I quote in the book between him and the Google AI apparatus called LaMDA. Some pretty interesting comments where LaMDA is talking about having a soul and what its soul looks like and it's a portal to all sorts of other dimensions, and I can sort of see why Blake might've been taken in, but I can also see why a lot of people said, oh, come on, this is of course what an AI operation would say just by scanning the internet and picking out what it should say if it's being asked about a soul. So I was just being a little provocative there. My view of AI, Eric, is that it's applications to science and medicine are phenomenal and we should embrace them and figure out ways to speed them up in every way we can.Francis Collins (12:17):I mean here at NIH, we have the BRAIN Initiative that's trying to figure out how your brain works with those 86 billion neurons and all their connections. We're never going to sort that out without having AI tools to help us. It's just too complicated of a problem. And look what AI is doing and things like imaging radiologists are going to be going out of business and the pathologists may not be too far behind because when it comes to image analysis, AI is really good at that, and we should celebrate that. It's going to improve the speed and accuracy of all kinds of medical applications. I think what we have to worry about, and I'm not unique in saying this, is that AI when applied to a lot of things kind of depends on what's known and goes and scrapes through the internet to pull that out. And there's a lot of stuff on the internet that's wrong and a lot of it that's biased and certainly when it comes to things like healthcare, the bias in our healthcare system, health disparities, inadequacies, racial inequities are all in there too, and if we're going to count on AI to fix the system, it's building on a cracked foundation.Francis Collins (13:18):So we have to watch out for that kind of outcome. But for the most part, generative AI it's taking really exciting difficult problems and turning them into solutions, I'm all for it, but let's just be very careful here as we watch how it might be incorporating information that's wrong and we won't realize it and we'll start depending on it more than we should.Breathtaking AdvancesEric Topol (13:42):Yeah, no, that's great. And you have some commentary on all the major fronts that we're seeing these days. Another one that is a particularly apropos is way back when you were at Michigan and the years before that when you were warming up to make some seminal gene discoveries and cystic fibrosis being perhaps the first major one. You circle back in the book to CRISPR genome editing and how the success story to talk about some extraordinary science to be able to have a remedy, a cure potentially for cystic fibrosis. So maybe you could just summarize that. I mean that's in your career to see that has to be quite remarkable.Francis Collins (14:32):It is breathtaking, Eric. I mean I sort of like to think of three major developments just in the last less than 20 years that I never dreamed would happen in my lifetime. One was the ability to make stem cells from people who are walking around from a skin biopsy or a blood sample that are pluripotent. My whole lab studies diabetes, our main approach is to take induced pluripotent stem cells from people whose phenotypes we know really well and differentiate them into beta cells that make insulin and see how we can figure out how the genetics and other aspects of this determine whether something is going to work properly or not. I mean that's just astounding. The second thing is the ability to do single cell biology.Francis Collins (15:16):Which really 15 years ago you just had to have a bunch of cells and studying diabetes, we would take a whole eyelid and grind it up and try to infer what was there, ridiculous. Now we can look at each cell, we even can look at each cell in terms of what's its neighbor, does the beta cell next to an alpha cell behave the same way as a beta cell next to a duct? We can answer those questions, and of course the third thing is CRISPR and gene editing and of course the first version of CRISPR, which is the knockout of a gene was exciting enough, but the ability to go in and edit without doing a double stranded break and actually do a search and replace operation is what I'm truly excited about when it comes to rare genetic diseases including one that we work on progeria, which is this dramatic form of premature aging that is caused almost invariably by a C to T mutation in exon 11 of the LMNA gene and for which we have a viable strategy towards a human clinical trial of in vivo gene editing for kids with this disease in the next two years.Eric Topol (16:24):Yeah, it's just the fact that we were looking at potential cures for hundreds and potentially even thousands of diseases where there was never a treatment. I mean that's astounding in itself, no less, the two other examples. The fact that you can in a single cell, you can not only get the sequence of DNA and RNA and methylation and who would've ever thought, and then as you mentioned, taking white cells from someone's blood and making pluripotent stem cells. I mean all these things are happening now at scale and you capture this in the book. On Humility and Trust Now the other thing that you do that I think is unique to you, I don't know if it's because of your background in growing up in Staunton, Virginia, a very different type of world, but you have a lot of humility in the book. You go over how you got snickered by Bill Maher, how you had a graduate student who was fabricating images and lots of things, how you might not have communicated about Covid perhaps as well as could. A lot of our colleagues are not able to do that. They don't ever have these sorts of things happening to them. And this humility which comes across especially in the chapter on trust where you break down who do you trust, humility is one of the four blocks as you outlined, competence, integrity, and aligned valueSo maybe can you give us a little brief lesson on humility?Eric Topol (18:06):Because it's checkered throughout the book and it makes it this personal story that you're willing to tell about yourself, which so few of us are willing to do.Francis Collins (18:17):Well, I don't want to sound proud about my humility. That would not be a good thing because I'm not, but thanks for raising it. I do think when we consider one of the reasons we decide to trust somebody, that it does have that humility built into it. Somebody who's willing to say, I don't know. Somebody's willing to say I'm an expert on this issue, but that other issue you just asked me about, I don't know any more than anybody else and you should speak to someone else. We don't do that very well. We tend to plunge right in and try to soak it up. I do feel when it comes to Covid, and I talk about this in the book a bit, that I was one of those trying to communicate to the public about what we think are going to be the ways to deal with this worst pandemic in more than a century.Francis Collins (19:06):And I wish Eric, I had said more often what I'm telling you today is the best that the assembled experts can come up with, but the data we have to look at is woefully inadequate. And so, it very well could be that what I'm telling you is wrong, when we get more data, I will come back to you as soon as we have something better and we'll let you know, but don't be surprised if it's different and that will not mean that we are jerking you around or we don't know what we're talking about. It's like this is how science works. You are watching science in real time, even though it's a terrible crisis, it's also an opportunity to see how it works. I didn't say that often enough and neither did a lot of the other folks who were doing the communicating. Of course, the media doesn't like to give you that much time to say those things as you well know, but we could have done a better job of preparing people for uncertainty and maybe there would've been less of a tendency for people to just decide, these jokers don't know what they're talking about.Francis Collins (20:10):I'm going to ignore them from now on. And that was part of what contributed to those 230,000 unnecessary deaths, it was just people losing their confidence in the information they were hearing. That's a source of grief from my part.His Diagnosis And Treatment for Prostate CancerEric Topol (20:24):Well, it's great and a lesson for all of us. And the other thing that along with that is remarkable transparency about your own health, and there's several things in there, but one that coincides. You mentioned in the book, of course, you wrote an op-ed in the Washington Post back in April 2024 about your diagnosis of prostate cancer. So you touched on it in the book and maybe you could just update us about this because again, you're willing to tell your story and trying to help others by the experiences that you've been through.Francis Collins (21:00):Well, I sure didn't want to have that diagnosis happen, but once it did, it certainly felt like an opportunity for some education. We men aren't that good about talking about issues like this, especially when it involves the reproductive system. So going out and being public and saying, yep, I had a five year course of watching to see if something was happening, and then the slow indolent cancer suddenly decided it wasn't slow and indolent anymore. And so, I'm now having my prostate removed and I think I'm a success story, a poster boy for the importance of screening. If I hadn't gone through that process of PSA followed by imaging by MRI followed by targeted biopsies, so you're actually sampling the right place to see if something's going on. I probably would know nothing about it right now, and yet incubating within me would be a Gleason category 9 prostate cancer, which has a very high likelihood if nothing was done to become metastatic.Francis Collins (22:03):So I wanted that story to be out there. I wanted men who were squeamish about this whole topic to say, maybe this is something to look into. And I've heard a bunch of follow-ups from individuals, but I don't know how much of it impact it hit. I'm glad to say I'm doing really well. I'm four months out now from the surgery, it is now the case I'm pretty much back to the same level of schedule and energy that I had beforehand, and I'm very happy to say that the post-op value of PSA, which is the best measure to see whether you in fact are now cancer free was zero, which is a really nice number.Eric Topol (22:45):Wow. Well, the prostate is the curse of men, and I wish we could all have an automated prostatectomy so we don't have to deal with this. It's just horrible.Francis Collins (22:58):It was done by a robot. It wasn't quite automated, I have stab wounds to prove that the robot was actually very actively doing what it needed to do, but they healed quickly.The Promise of Music As Therapy in MedicineEric Topol (23:11):Right. Well, this gets me to something else that you're well known for throughout your career as a musician, a guitarist, a singer, and recently you hooked up with Renée Fleming, the noted opera singer, and you've been into this music is therapy and maybe you can tell us about that. It wasn't necessarily built up much in the book because it's a little different than the main agenda, but I think it's fascinating because who doesn't like music? I mean, you have to be out there if you don't enjoy music, but can you tell us more about that?Francis Collins (23:53):Yeah, I grew up in a family where music was very much what one did after dinner, so I learned to play keyboard and then guitar, and that's always been a source of joy and also a source of comfort sometimes when you were feeling a bit down or going through a painful experience. I think we all know that experience where music can get into your heart and your soul in a way that a lot of other things can't. And the whole field of music therapy is all about that, but it's largely been anecdotal since about World War II when it got started. And music therapists will tell you sometimes you try things that work and sometimes they don't and it's really hard to know ahead of time what's going to succeed. But now we have that BRAIN Initiative, which is pushing us into whole new places as far as the neuroscience of the brain, and it's really clear that music has a special kind of music room in the brain that evolution has put there for an important reason.Francis Collins (24:47):If we understood that we could probably make music therapy even more scientifically successful and maybe even get third parties to pay for it. All of this became opportunity for building a lot more visibility because of making friends withRenée Fleming, who I hadn't really known until a famous dinner party in 2015 where we both ended up singing to a trio of Supreme Court justices trying to cheer them up after a bent week. And she has become such an incredible partner in this. She's trained herself pretty significantly in neuroscience, and she's a convener and an articulate spokesperson. So over the course of that, we built a whole program called Sound Health that now has invested an additional $35 million worth NIH research to try to see how we can bring together music therapy, musician performers and neuroscientists to learn from each other, speak each other's language and see what we could learn about this particularly interesting input to the human brain that has such power on us and maybe could be harnessed to do even more good for people with chronic pain or people with PTSD, people with dementia where music seems to bring people back to life who'd otherwise seem to have disappeared into the shadows.Francis Collins (26:09):It's phenomenal what is starting to happen here, but we're just scratching the surface.The Big Miss vs Hepatitis CEric Topol (26:14):Well, I share your enthusiasm for that. I mean, it's something that you could think of that doesn't have a whole lot of side effects, but could have a lot of good. Yeah. Well, now before I get back to the book, I did want to cover one other relatively recent op-ed late last year that you wrote about Hepatitis C. Hepatitis C, one of the most important medical advances in the 21st century that we're squandering. Can you tell us about that? Because I think a lot of people don't realize this is a big deal.Francis Collins (26:47):It's a really big deal, and I confess I'm a little obsessed about it. So yes, you may regret bringing it up because I'm really going to want to talk about what the opportunity is here, and I am still the lead for the White House in an initiative to try to find the 4 million Americans who are already infected with this virus and get access to them for treatment. The treatment is fantastic, as you just said, one of the most major achievements of medical research, one pill a day for 12 weeks, 95% cure in the real world, essentially no side effects, and yet the cost is quite high and the people who need it many times do not have great healthcare and maybe also in difficult circumstances because you get hepatitis C from infected blood. And the many ways that happens these days are from shared needles from people who are experimenting with intravenous drugs, but they are family too, and many of them now recovering from that, face the irony of getting over their opioid addiction and then looking down the barrel of a really awful final couple of years dying of liver failure. I watched my brother-in-law die of hepatitis C, and it was just absolutely gruesome and heartbreaking.Francis Collins (28:04):So this isn't right. And on top of that, Eric, the cost of all this for all those folks who are going to get into liver failure need a transplant or develop liver cancer, this is the most common cause now of liver cancer it is astronomical in the tens of billions of dollars. So you can make a very compelling case, and this is now in the form of legislation sponsored by Senators Cassidy and Van Hollen that in a five-year program we could find and cure most of those people saving tens of thousands of lives and we would save tens of billions of dollars in just 10 years in terms of healthcare that we will not have to pay for. What's not to love here? There's a lot of things that have to be worked out to make it happen. One thing we've already done is to develop, thanks to NIH and FDA, a point of care viral RNA finger stick test for Hep C. You get an answer in less than an hour.Francis Collins (29:00):FDA approved that the end of June. That was a big crash program so you can do test and treat in one visit, which is phenomenally helpful for marginalized populations. The other thing we need to do is to figure out how to pay for this and this subscription model, which was piloted in Louisiana, looks like it ought to work for the whole nation. Basically, you ask the companies Gilead and AbbVie to accept a lump sum, which is more than what they're currently making for Medicaid patients and people who are uninsured and people in the prison system and Native Americans and then make the pills available to those four groups for free. They do fine. The companies come out on this and the cost per patient plummets and it gives you the greatest motivation you can imagine to go and find the next person who's infected because it's not going to cost you another dime for their medicine, it's already paid for. That's the model, and I would say the path we're on right now waiting for the congressional budget office to give the final score, it's looking pretty promising we're going to get this done by the end of this year.The PledgeEric Topol (30:04):Yeah, that's fantastic. I mean, your work there alone is of monumental importance. Now I want to get back to the book the way you pulled it all together. By the way, if anybody's going to write a book about wisdom, it ought to be you, Francis. You've got a lot of it, but you had to think through how are we going to change because there's a lot of problems as you work through the earlier chapters and then the last chapter you come up with something that was surprising to me and that was a pledge for the Road to Wisdom. A pledge that we could all sign, which is just five paragraphs long and basically get on board about these four critical areas. Can you tell us more about the pledge and how this could be enacted and help the situation? Francis Collins (31:03):Well, I hope it can. The initial version of this book, I wrote a long piece about what governments should do and what institutions should do and what universities should do and what K through 12 education should do. And then I thought they're not reading this book and I'm not sure any of those folks are really that motivated to change the status quo. Certainly, politicians are not going to solve our current woes. It seems that politics is mostly performance these days and it's not really about governance. So if there's going to be a chance of recovering from our current malaise, I think it's got to come from the exhausted middle of the country, which is about two thirds of us. We're not out there in the shrill screaming edges of the left and the right we're maybe tempted to just check out because it just seems so discouraging, but we're the solution.Francis Collins (31:56):So the last chapter is basically a whole series of things that I think an individual could start to do to turn this around. Beginning with doing a little of their own house cleaning of their worldview to be sure that we are re-anchoring to things like objective truths and to loving your neighbor instead of demonizing your neighbor. But yeah, it does go through a number of those things and then it does suggest as a way of making this not just a nice book to read, but something where you actually decide to make a commitment. Look at this pledge. I've tried the pledge out on various audiences so far and I haven't yet really encountered anybody who said, well, those are ridiculous things to ask of people. They're mostly things that make a lot of sense, but do require a commitment. That you are, for instance, you're not going to pass around information on social media in other ways unless you're sure it's true because an awful lot of what's going on right now is this quick tendency for things that are absolutely wrong and maybe anger inducing or fear inducing to go viral where something that's true almost lands with a thud.Francis Collins (33:07):Don't be part of that, that's part of this, but also to make an honest effort to reach out to people who have different views from you. Don't stay in your bubble and try to hear their concerns. Listen, not that you're listening in order to give a snappy response, but listen, so you're really trying to understand. We do far too little of that. So the pledge asks people to think about that, and there is a website now which will be as part of the book up on the Braver Angels website and Braver Angels is a group that has made its mission trying to bring together these divided parties across our country and I'm part of them, and you can then go and sign it there and make a public statement that this is who I am, and it will also give you a whole lot of other resources you could start to explore to get engaged in being part of the solution instead of just shaking your head. I think what we're trying to do is to get people to go beyond the point of saying, this isn't the way it should be to saying, this isn't the way I should be. I'm going to try to change myself as part of fixing our society.Eric Topol (34:14):Well, I'm on board for this and I hope it creates a movement. This is as you tell the stories in the book, like the fellow that you wrangled with about the pandemic and how you listened to him and it changed your views and you changed his views and this is the health of different opinions and perspectives and we got to get back there. It used to be that way more at least it wasn't always perfect, and as you said in the book, we all have some entrenched biases. We're never going to get rid of all of them, but your wisdom about the road, the pledge here is I think masterful. So I just want to pass on along and I hope listeners will go to the Brave for Angels website and sign up because if we got millions of people to help you on this, that would say a lot about a commitment to a renewed commitment to the way it should be, not the way it is right now. Well, I've covered a bunch of things, of course, Francis, but did I miss something that you're passionate about or in the book or anything that you want to touch on?Francis Collins (35:32):Oh my goodness, yeah. You did cover a lot of ground here, including things that I didn't pay much attention to in the book, but I was glad to talk to you about. No, I think we got a pretty good coverage. The one topic in the book that will maybe appeal particularly to believers is a whole chapter about faith because I am concerned that people of faith have been particularly vulnerable to misinformation and disinformation, and yet they stand on a foundation of principles that ought to be the best antidote to most of the meanness that's going on, and just trying to encourage them to recall that and then build upon the strength that they carry as a result of their faith traditions to try to be part of the solution as well.Eric Topol (36:12):I'm so glad you mentioned that. It's an important part of the book, and it is also I think something that you were able to do throughout your long tenure at NIH Director that you were able to connect to people across the aisle. You had senators and the Republicans that were so supportive of your efforts to lead NIH and get the proper funding, and it's a unique thing that you're able to connect with people of such different backgrounds, people of really deep commitment to religion and faith and everything else. And that's one of the other things that we talk about Francis here, and many times I gather is we don't have you at the helm anymore at NIH, and we're worried. We're worried because you're a unique diplomat with all this heavy wisdom and it's pretty hard to simulate your ability to keep the NIH whole and to build on it. Do you worry about it at all?Francis Collins (37:23):Well, I was privileged to have those 12 years, but I think it was time to get a new perspective in there, and I appreciate you saying those nice things about my abilities. Monica Bertagnolli is also a person of great skill, and I think on the hill she rapidly acquired a lot of fans by her approach, by some of her background. She's from Wyoming, she's a cancer surgeon. She's got a lot of stories to tell that are really quite inspiring. I think though it's just a very difficult time. She walked in at a point where the partisan attitudes about medical research, which we always hoped would kind of stay out of the conversation and become so prominent, a lot of it politically driven, nasty rhetoric on the heels of Covid, which spills over into lots of other areas of medical research and is truly unfortunate. So she's got a lot to deal with there, but I'm not sure I would be much better than she is in trying to continue stay on message, tell the stories about how medical research is saving lives and alleviating suffering, and we're just getting started, and she does that pretty well.Francis Collins (38:34):I just hope the people who need to listen are in a listening mood.Eric Topol (38:38):Yeah. Well, that's great to hear your perspective. Well, I can't thank you enough for our conversation and moreover for a friendship that's extended many decades now. We're going to be following not just your progeria research and all the other things that you're up to because juggling a bunch of things still, it isn't like you're slowed down at all. And thanks so much for this book. I think it's a gift. I think it's something that many people will find is a pretty extraordinary, thoughtful and easy read. I mean, it's something that I found that you didn't write it for in technical jargon. You wrote it for the public, you wrote it for non-scientists, non-medical people, and I think hopefully that's what's going to help it get legs in terms of what's needed, which is a sign the darn pledge. Thank you.Francis Collins (39:42):Eric, thank you. It has been a privilege being your friend for all these years, and this was a really nice interview and I appreciate that you already had carefully read the book and asked some great questions that were fun to try to answer. So thanks a lot.*******************************************************Thanks for listening, reading or watching!The Ground Truths newsletters and podcasts are all free, open-access, without ads.Please share this post/podcast with your friends and network if you found it informative!Voluntary paid subscriptions all go to support Scripps Research. Many thanks for that—they greatly helped fund our summer internship programs for 2023 and 2024.Thanks to my producer Jessica Nguyen and Sinjun Balabanoff for audio and video support at Scripps Research.Note: you can select preferences to receive emails about newsletters, podcasts, or all I don't want to bother you with an email for content that you're not interested in. Get full access to Ground Truths at erictopol.substack.com/subscribe

Folk der har den utroligt sjældne genetiske sygdom progeria ældes 8 gange hurtigere end andre mennesker. Hvor tæt er vi på at behandle sygdommen og hvad ved vi egentligt om den?Køb biletterne her: https://videnskabeligtudfordret.dk/liveSupport the showHvis du vil være med til at optage live med os på Discord kan du støtte os på 10er og blive en af vores kernelyttere https://vudfordret.10er.appDu kan også tjekke vores webshop: bit.ly/vushop. Der er en hønsetrøje!Send os vanvittig videnskab eller stil et spørgsmål på facebook, Instagram eller vudfordret@gmail.comTak til Christian Eiming for disclaimer.Tak til Barometer-Bjarke for Gak-O-meteret.Husk at være dumme

Bette Kauffman is president of the Louisiana Master Naturalists Association, a statewide organization that promotes learning and conservation. The conservation message the group gives coincides well with managed forests. Want to find out more, check out the LMNA's website at https://www.louisianamasternaturalist.org/Minding the Forest is a podcast of the Louisiana Forestry Association and his hosted by LFA Media Specialist Jeff Zeringue. Comments can be sent to jzeringue@laforestry.com.If you want to find out more about the Sustainable Forestry Initiative, go to forests.org.Check out our website at laforestry.com.Click this link to join the LFA.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.07.18.549413v1?rss=1 Authors: Sun, Y., Guo, C., Chen, Z., Lin, J., Yang, L., Zhang, Y., Wu, C., Zhao, D., Jardin, B., Pu, W., Zhao, M., Dong, E., Hu, X., Zhang, S., Guo, Y. Abstract: Aims: Recombinant adeno-associated viruses (rAAVs) are federally approved gene delivery vectors for in vivo gene supplementation therapy. Loss-of-function truncating variants of LMNA, the coding gene for Lamin-A/C, are one of the primary causes of inherited dilate cardiomyopathy (DCM). Here we aim to study whether AAV-based LMNA supplementation could treat LMNA deficiency-triggered cardiac defects. Methods and Results: We compared whole-body, cardiomyocyte-specific and genetic-mosaic mouse models that carry Lmna truncating variants at the same genetic loci and uncovered primarily a non-cell autonomous impact of Lmna on cardiomyocyte maturation. Whole-body lamin-A supplementation by rAAVs moderately rescued the cardiac defects in Lmna germline mutants. By contrast, cardiomyocyte-specific lamin-A addback failed to restore the cardiomyocyte growth defects. A Cre-loxP-based AAV vector that expresses lamin-A throughout the body but excluding the heart was able to restore cardiomyocyte growth in Lmna germline mutants. Conclusions: Lmna regulates cardiomyocyte growth non-cell autonomously. Non-myocytes are the key cell targets for a successful gene therapy for LMNA-associated cardiac defects. Translational perspective: LMNA truncating mutations are among the major causes of inherited DCM. AAV gene supplementation therapy is emerging as a promising strategy to treat genetic cardiomyopathy, but whether this strategy is suitable for LMNA cardiomyopathy remained unclear. Our study counterintuitively showed that the cardiomyocytes are not necessarily the correct therapeutic cell targets for AAV-based treatment of LMNA cardiomyopathy. By contrast, careful elucidation of cell-autonomous versus non-cell-autonomous gene functions is essential for the proper design of a gene supplementation therapy for cardiomyopathy. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

A new research paper was published in Aging (listed by MEDLINE/PubMed as "Aging (Albany NY)" and "Aging-US" by Web of Science) Volume 15, Issue 12, entitled, “Hepatic hydrogen sulfide levels are reduced in mouse model of Hutchinson-Gilford progeria syndrome.” Hutchinson-Gilford progeria syndrome (HGPS) is a rare human disease characterized by accelerated biological aging. Current treatments are limited, and most patients die before 15 years of age. Hydrogen sulfide (H2S) is an important gaseous signaling molecule that is central to multiple cellular homeostasis mechanisms. Dysregulation of tissue H2S levels is thought to contribute to an aging phenotype in many tissues across animal models. Whether H2S is altered in HGPS is unknown. In a new study, researchers Stephen E. Wilkie, Diana E. Marcu, Roderick N. Carter, Nicholas M. Morton, Susana Gonzalo, and Colin Selman from the University of Glasgow, University of Edinburgh, Saint Louis University, and Karolinska Institute investigated hepatic H2S production capacity and transcript, protein and enzymatic activity of proteins that regulate hepatic H2S production and disposal in a mouse model of HGPS (G609G mice, mutated Lmna gene equivalent to a causative mutation in HGPS patients). “This study was designed and undertaken due to the lack of understanding in the mechanistic targets of known treatments against HGPS and considering the positive association between H2S and longevity in model organisms.” Here, the researchers employed the HGPS mouse model G609G to test the hypothesis that, in contrast to anti-aging increases in H2S production, the accelerated aging typical of progeroid mice is associated with reduced hepatic H2S production. G609G mice were maintained on either regular chow (RC) or high fat diet (HFD). HFD has been previously shown to significantly extend lifespan of G609G mice, and compared to wild type (WT) mice maintained on RC. RC-fed G609G mice had significantly reduced hepatic H2S production capacity relative to WT mice, with a compensatory elevation in mRNA transcripts associated with several H2S production enzymes, including cystathionine-γ-lyase (CSE). H2S levels and CSE protein were partially rescued in HFD fed G609G mice. The data acquired here confirmed some aspects of the relevance of H2S in HGPS but raises more questions about the specific mechanisms at play. “Regardless, the work presented here addresses an area of research that remains critically understudied and provides new evidence that the accelerated ageing phenotype observed in HGPS may be partially explained by a reduction in hepatic H2S levels.” DOI - https://doi.org/10.18632/aging.204835 Corresponding authors - Colin Selman - colin.selman@glasgow.ac.uk, and Stephen E. Wilkie - stephen.wilkie@ki.se Sign up for free Altmetric alerts about this article - https://aging.altmetric.com/details/email_updates?id=10.18632%2Faging.204835 Subscribe for free publication alerts from Aging - https://www.aging-us.com/subscribe-to-toc-alerts Keywords - aging, progeria, hydrogen sulfide, high-fat diet, ageing, lamin A About Aging-US: Launched in 2009, Aging publishes papers of general interest and biological significance in all fields of aging research and age-related diseases, including cancer—and now, with a special focus on COVID-19 vulnerability as an age-dependent syndrome. Topics in Aging go beyond traditional gerontology, including, but not limited to, cellular and molecular biology, human age-related diseases, pathology in model organisms, signal transduction pathways (e.g., p53, sirtuins, and PI-3K/AKT/mTOR, among others), and approaches to modulating these signaling pathways. Please visit our website at www.Aging-US.com​​ and connect with us on social media. MEDIA@IMPACTJOURNALS.COM

Four-year-old Lukas van der Walt was born with LMNA, an extremely rare form of congenital muscular dystrophy - the only recorded case of its kind in South Africa!

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.04.09.536174v1?rss=1 Authors: Gregory, E. F., Kalra, S., Brock, T., Bonne, G., Luxton, G. G., Hopkins, C., Starr, D. A. Abstract: Striated muscle laminopathies caused by missense mutations in the nuclear lamin gene LMNA are characterized by cardiac dysfunction and often skeletal muscle defects. Attempts to predict which LMNA variants are pathogenic and to understand their physiological effects lags behind variant discovery. We created Caenorhabditis elegans models for striated muscle laminopathies by introducing pathogenic human LMNA variants and variants of unknown significance at conserved residues within the lmn-1 gene. Severe missense variants reduced fertility and/or motility in C. elegans. Nuclear morphology defects were evident in the hypodermal nuclei of many lamin variant strains, indicating a loss of nuclear envelope integrity. Phenotypic severity varied within the two classes of missense mutations involved in striated muscle disease, but overall, variants associated with both skeletal and cardiac muscle defects in humans lead to more severe phenotypes in our model than variants predicted to disrupt cardiac function alone. We also identified a separation of function allele, lmn-1(R204W), that exhibited normal viability and swimming behavior but had a severe nuclear migration defect. Thus, we established C. elegans avatars for striated muscle laminopathies and identified LMNA variants that offer insight into lamin mechanisms during normal development. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.02.14.528563v1?rss=1 Authors: Sikder, K., Phillips, E., Zhong, Z., Wang, N., Saunders, J., Mothy, D., Kossenkov, A., Schneider, T., Nichtova, Z., Csordas, G., Margulies, K. B., Choi, J. C. Abstract: Mutations in the LMNA gene encoding nuclear lamins A/C cause a diverse array of tissue-selective diseases, with the heart being the most commonly affected organ. Despite progress in understanding the molecular perturbations emanating from LMNA mutations, an integrative understanding of the pathogenesis leading to cardiac dysfunction remains elusive. Using a novel cell-type specific Lmna deletion mouse model capable of translatome profiling, we found that cardiomyocyte-specific Lmna deletion in adult mice led to rapid cardiomyopathy with pathological remodeling. Prior to the onset of cardiac dysfunction, lamin A/C-depleted cardiomyocytes displayed nuclear envelope deterioration, golgi dilation/fragmentation, and CREB3-mediated golgi stress activation. Translatome profiling identified upregulation of Med25, a transcriptional co-factor that can selectively dampen UPR axes. Autophagy is disrupted in the hearts of these mice, which can be recapitulated by disrupting the golgi or inducing nuclear damage by increased matrix stiffness. Systemic administration of pharmacological modulators of autophagy or ER stress significantly improved the cardiac function. These studies support a hypothesis wherein stress responses emanating from the perinuclear space contribute to the development of LMNA cardiomyopathy. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.02.04.527139v1?rss=1 Authors: Hasper, J., Welle, K., Swovick, K., Hryhorenko, J., Ghaemmaghami, S., Buchwalter, A. Abstract: Mutations to the LMNA gene cause laminopathies including Hutchinson-Gilford progeria syndrome (HGPS). The origins of tissue specificity in these diseases are unclear, as the A-type Lamins are abundant and broadly expressed proteins. We show that A-type Lamin protein and transcript levels are uncorrelated across tissues. As protein-transcript discordance can be caused by variations in protein lifetime, we applied quantitative proteomics to profile protein turnover rates in healthy and progeroid tissues. We discover that tissue context and disease mutation each influence A-type Lamin protein lifetime. Lamin A/C has a weeks-long lifetime in the aorta, heart, and fat, but a days-long lifetime in tissues spared from disease. Progerin is even more long-lived than Lamin A/C in the cardiovascular system and accumulates there over time. These proteins are insoluble and densely bundled in cardiovascular tissues, which may present an energetic barrier to degradation. We reveal that human disease alleles are significantly over-represented in the long-lived proteome. These findings indicate that gene therapy interventions will have significant latency and limited potency in disrupting long-lived disease-linked proteins such as Progerin. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Meet Hannah. She's a warrior mama to Austin, a two-year-old, who has a fatal, muscle-wasting disease called LMNA-related congenital muscular dystrophy (L-CMD). She founded the L-CMD Research Foundation to save Austin and other children whose lives depend on the development of rare disease treatments like gene therapy. They're 76% of the way to a $2M goal funding this project through GiveButter, and her peer fundraising tips are GOLD. Don't miss this incredible example of “community is everything” in action.  

Join us as we talk to Hannah Lowe, founder of the L-CMD Foundation and mother to Austin, who has LMNA-related congenital muscular dystrophy. Like many rare disease families we've talked to, her son's condition was caused by a random genetic mutation. There is no treatment or cure, and given how rare it is, they are unsure about his prognosis or life expectancy, making the mission even more urgent. The L-CMD Foundation she started inspires hope for a stronger tomorrow by seeking treatments and, ultimately, a cure. We talk about balancing grief with action, and Hannah exemplifies this in her graceful and determined approach to saving her son. 

Commentary by Dr. Valentin Fuster

ONCE UPON A GENE - EPISODE 108 Finding Hope: From Diagnosis to Action - LMNA Related Congenital Muscular Dystrophy - Hannah Lowe Hannah Lowe is the President and Co-Founder of the L-CMD Research Foundation. Her son Austin has a rare form of muscular dystrophy (L-CMD) caused by a genetic mutation and she's urgently working to find a cure for her son and other kids like him.  EPISODE HIGHLIGHTS Can you tell us about your children? I have two sons— Ean who is four and Austin who is two. Last year, Austin was diagnosed with a rare disease resulting from a randomly occurring genetic mutation. He was about 6 months old when he was diagnosed. Austin wasn't gaining weight, so after 6 months he was admitted to the hospital to get a feeding tube to aid in nutrition. He was in the hospital for three weeks while they ran a series of tests to find the underlying cause of his low weight. Every test came back clear until the genetic tests came back. That's when it was discovered that Austin has a single point mutation on the LMNA gene which results in L-CMD, which is a rare form of muscular dystrophy. What did you do after you got Austin's diagnosis? After getting a new routine worked out, we turned our attention to figuring out what we can do. We started making connections, talking to everyone and gathering information. L-CMD has a fair amount of research happening for the gene itself because genetic mutations of the gene cause about 12 other diseases. Through networking, we connected with a group of other rare disease families working on treatments and cures for their own rare diseases. With some helpful connections, we took baby steps to start a nonprofit. What roadblocks have you hit and what would you do differently? The biggest roadblock is expectation versus reality. When we first started, researchers told us the pace of research is slower than the progression of the disease. We didn't accept that, but it has been a big mindset shift to know this is in fact the case. CONNECT WITH THE L-CMD RESEARCH FOUNDATION L-CMD Research Foundation Website https://www.lcmdresearch.org/ L-CMD Research Foundation on Instagram https://www.instagram.com/lcmd.foundation/ L-CMD Research Foundation on Facebook https://www.facebook.com/LCMD.foundation L-CMD Research Foundation on Twitter https://twitter.com/foundationlcmd RESOURCES AND LINKS MENTIONED Discord Chat https://discord.com/invite/7UFUPAFs8K ONCE UPON A GENE - Episode 104 - A Rare Collection- Stories of Courage with Felix Townsin, Erica Jolene Stearns, Mahrynn McLaughlin and Brianna Colquitt https://effieparks.com/podcast/episode-104-rare-collection-courage Givebutter https://givebutter.com/ TUNE INTO THE ONCE UPON A GENE PODCAST Spotify https://open.spotify.com/show/5Htr9lt5vXGG3ac6enxLQ7 Apple Podcasts https://podcasts.apple.com/us/podcast/once-upon-a-gene/id1485249347 Stitcher https://www.stitcher.com/podcast/once-upon-a-gene Overcast https://overcast.fm/itunes1485249347/once-upon-a-gene CONNECT WITH EFFIE PARKS Website https://effieparks.com/ Twitter https://twitter.com/OnceUponAGene Instagram https://www.instagram.com/onceuponagene.podcast/?hl=en Built Ford Tough Facebook Group https://www.facebook.com/groups/1877643259173346/

What does it mean to suddenly identify with a group you never thought you’d become part of - and how to begin turning those challenges into opportunities for greater communal consciousness? Erica and India are joined by Hannah Lowe Corman, co-founder, and president of L-CMD Research Foundation. According to Hannah, 7,000 diseases currently classify as rare, meaning fewer than 200,000 cases recorded in the US. Her son, Austin, is one of those affected. Hannah shares the ways in which Austin’s reality has shaped her allyship both with families navigating rare diseases as well as with fellow members of Pause On The Play The Community. In this discussion: About LMNA-related congenital muscular dystrophy Navigating the logistical aspects of setting up a non-profit Humanizing foundations Exploring the energetic ties that bind communities and inspire action Riding the “bar graph of emotional capacity” Reframing mission statements to purpose statements  Resources for vetting and giving to non-profit organizations *** Visit the website for the full articles at https://www.pauseontheplay.com/show GUEST CONTACT & BIO Website: https://www.lcmdresearch.org IG: https://www.instagram.com/lcmd.foundation Twitter: https://twitter.com/FoundationLcmd Facebook: https://www.facebook.com/LCMD.foundation Hannah Lowe Corman is the co-founder and president of the L-CMD Research Foundation, which she helped establish in order to urgently translate scientific research into treatments and ultimately a cure for this fatal childhood disease. She is also an independent artist and yoga teacher living and working in Houston, Texas with her husband and two sons. In what seems like a prior life, she was a healthcare banker helping nonprofit healthcare institutions obtain financing. KEEP THE DIALOGUE GOING Visit pauseontheplay.com/community for details about our latest workshops and information on how you can join us.  Learn more about LMNA-related congenital muscular dystrophy and give if you can at lcmdresearch.org. Activate Amazon Smile on your Amazon app! Every time you shop, Amazon donates to your favorite organization at no additional cost to you. Be sure to rate + review the podcast!

Progeria is a rare disease that causes premature aging in childhood; the FODMAP diet is explained as a treatment for IBS; J&J vaccine restarted; Question of the month: Fever and Cough.Introduction: Low FODMAP Diet and J&J COVID Vaccine is back.  By P. Eresha Perera, MS3, and Sherika Adams, MS3.Today is May 10, 2021.Irritable Bowel Syndrome. Patients with IBS frequently have other conditions such as anxiety, depression, somatization, fibromyalgia, chronic fatigue syndrome, GERD, dyspepsia, non-cardiac chest pain, chronic pain, and other mental illness. A common triad we see in the clinic is: Anxiety + Fibromyalgia + IBS. Treating these conditions is hard, and even more so when they are combined. Let’s focus for now on IBS treatment. Recently we had a patient with IBS who had a laparoscopic cholecystectomy and of course was complaining of abdominal pain and constipation. We mentioned the low FODMAP diet as part of the treatment. The low FODMAP diet has been proven for the treatment of irritable bowel syndrome (IBS) and or small intestinal bacterial overgrowth (SIBO). It has decreased symptoms in 86% of people. FODMAP is an acronym that stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. This diet attempts to restrict these short-chain carbs that are poorly absorbed by the small intestine, resulting in cramping, constipation, diarrhea, bloating, and gas or flatulence.You can recommend your patients to follow 3 steps: Step 1: Eliminate foods that are high on FODMAP, Step 2. Determine which foods cause symptoms by reintroducing eliminated foods slowly, and Step 3. After identification of the FODMAP foods that cause symptoms, remove them completely from the patient’s diet. Dr. Hazel Galon Veloso, John Hopkins's gastroenterologist, recommends doing step 1 for 2-6 weeks and step 2 reintroducing a high FODMAP food back into diet every 3 days. Example of HIGH FODMAP foods: Dairy-based milk, yogurt, ice cream, wheat products (cereal, bread, and crackers), beans, lentils, vegetables like artichokes, asparagus, onions, and garlic, and fruits such as apples, cherries, pears, and peaches. Example of LOW FODMAP foods: Eggs, meat, cheese such as Brie, cheddar, and feta; almond milk, rice, quinoa, oats, potatoes, tomatoes, cucumbers, zucchini, grapes, oranges, and strawberries.If available, Fodmap should be initiated with the advice of a nutritionist that can help with the transition, prevent over-restriction and nutritional replete diet. Consider this diet as an initial treatment for your patients with IBS.Vaccination with J&J COVID 19 Vaccination has been restarted.On a different note, On April 23, 2021, the CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended to restart vaccination with the Janssen/Jonson & Jonson COVID-19 vaccine after a pause on April 13, 2021[2]. After giving the J&J vaccine to almost 8 million patients, 15 cases of Thrombosis with Thrombocytopenia Syndrome (TTS) were reported and three of them died. The recommendation was given after a risk-benefit analysis that determined that the benefits of the vaccine outweigh the risks. The risk of TTS in women age 18-49 still exists, but it is considered very low when compared to all the risks carried by COVID 19 itself. Under the emergency use authorization, the Jonson & Jonson vaccine is considered highly effective and safe. In comparison, the AstraZeneca vaccine has had several more cases of TTS, Moderna has had only 3 but with normal platelets, and Pfizer has had zero cases of TTS[3].  This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.___________________________Question of the Month: Fever and CoughWritten by Hector Arreaza, MDWhat are your top 3 differential diagnosis and acute management for a 69-year-old man with new onset of fever, cough, leukocytosis and a right lower lobe consolidation? Important: Rapid COVID-19 test is negative.____________________________Progeria. With Salwa Sadiq-Ali, MS3, Veronica Phung, MS3; and Hector Arreaza, MD.   “The Curious Case of Benjamin Button” is an American movie released in 2008, directed by David Fincher, starring Brad Pitt. Let’s see how we can connect this movie to today’s topic.What is Hutchinson Gilford Syndrome better known as Progeria?V. Phung: That’s a great question! Progeria is an extremely rare disease. It’s progressive and causes children to age very quickly within the first few years of their life. The disease is not evident at birth. S. Sadiq-Ali: Exactly! Usually, kids will start developing symptoms within their first year of life with the first symptom being failure to thrive. Other common features include a disproportionately large head for their face, narrow nasal ridge and tip, small mouth, retro and micrognathia, little to no subQ fat with small outpouchings, delayed eruption of primary teeth, progressive joint contractures, and essentially all geriatric conditions like alopecia, osteoarthritis, and hearing loss. One interesting tidbit though is that their motor and mental development is normal! H. Arreaza: A child getting old quickly, that’s so interesting. What’s the pathophysiology of this condition?V. Phung: So, it’s due to a genetic mutation - a single nucleotide polymorphism - in the LMNA gene known as lamin A. This gene codes for the lamin A protein which holds the cell’s nucleus together. A mutation causes your body to make a much smaller protein called progerin. Progerin is not stable so it doesn’t hold the cell’s nucleus together properly. This instability is thought to be the cause of premature aging. S. Sadiq-Ali: That’s right Veronica! There are two common mutations – the classic form and the non-classic form. The difference between the two forms is where in the gene the mutation occurs. H. Arreaza: So, if I suspect my patient has progeria, I should do a genetic test for the LMNA gene mutation. How common is progeria?S. Sadiq-Ali: About 1 in every 4 to 8 million births is affected by progeria. Unlike many other conditions, there aren’t any predisposing factors - such as gender, location, or ethnicity. It’s completely random! Right now, about 179 children across 53 different countries have been diagnosed with progeria. 18 of those cases are here in the US. One family in India, has had 5 children with progeria. Another interesting fact is that there have been only 2 known cases of a completely healthy person carrying the mutated gene!  V. Phung: Since they’re aging so rapidly and prematurely, their life expectancy is about 14.5 years. However, the oldest believed survivor - Tiffany from Ohio – has lived up to the age of 43! H. Arreaza: And she is still alive, as far as I know. What can be done in terms of management to ensure these children and adults can live their best, most comfortable life? S. Sadiq-Ali: There’s no cure so you’d want to manage any symptoms and make sure the child is getting proper nutrition. Generally, the recommendation is to have small frequent meals, maintain good hydration, do routine PT and exercises, use shoe pads since they don’t have much body fat to provide cushioning, use plenty of sunscreen, prescribe anticoagulation as needed for geriatric conditions like CAD/CVD, and manage any fractures or dislocations that may occur. It requires a multidisciplinary care team.H. Arreaza: So, you mentioned Tiffany Wedekind, the person with progeria who has lived the longest. Now, I want to mention Sam Berns, maybe the most famous person with progeria. “Life According to Sam” is an HBO documentary directed by Sean Fine and Andrea Nix Fine. It was presented in January 2013 at the Sundance Film Festival (I love Park City, Utah). The documentary explains the impact of progeria on the lives of Sam Berns and his parents, Dr. Leslie Gordon and Dr. Scott Berns. You can also see or listen to the Ted Talk given by Sam Berns (google it or go to the link in our script).S. Sadiq-Ali: These kids are aging so quickly they have geriatric conditions; do they die from natural causes or from heart disease and stroke? V. Phung: That’s a great question. Unfortunately, yes. Death is commonly due to complications from atherosclerosis, cardiac disease, and cerebrovascular disease - like a heart attack or stroke. S. Sadiq-Ali: “The Curious Case of Benjamin Button” is usually thought to be an example of progeria, but it’s actually the opposite: A child born as an adult who dies as a baby.H. Arreaza: That was really educational. Progeria, a rare disease that you should know about, in case someone asks you. Remember, “family doctors know everything”.  Even without trying every night you go to bed being a little wiser.ConclusionBy Hector Arreaza, MDNow we conclude our episode number 51 “Progeria”, a rare disease that requires care by a multidisciplinary team. You may not encounter a patient with progeria in your life, but if you do, now you know the fundamentals of that syndrome. We started this episode talking about the FODMAP diet. Consider this diet as part of the initial treatment of IBS. Don’t forget to send your answer (one more week to do it). What are your top 3 differential diagnosis and the acute management of a 69-year-old male with new onset of fever, cough, leukocytosis, right lower lobe consolidation and negative rapid COVID 19 test. Remember, even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Sherika Adams, Eresha Perera, Salwa Sadiq-Ali, and Veronica Phung. Audio edition: Suraj Amrutia. See you next week!_____________________References:Veloso, H. G. (n.d.). FODMAP Diet: What You Need to Know. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/fodmap-diet-what-you-need-to-know.  ACIP Updates Recommendations on Johnson & Johnson Vaccine, American Association of Family Physicians, aafp.org. https://www.aafp.org//news/health-of-the-public/20210429acipjjvac.html Meara, Killian, CDC’s ACIP Votes to Reaffirm Recommendation of Johnson & Johnson COVID-19 Vaccine, April 23, 2021, ContagionLive.com. https://www.contagionlive.com/view/cdc-s-acip-votes-to-reaffirm-recommendation-of-johnson-johnson-covid-19-vaccine Progeria, National Center for Advancing Translational Sciences, National Institutes of Health, https://rarediseases.info.nih.gov/diseases/7467/progeria, accessed on May 6, 2021. Sinha JK, Ghosh S, Raghunath M. Progeria: a rare genetic premature ageing disorder. Indian J Med Res. 2014;139(5):667-674. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140030/ Gordon LB, Brown WT, Collins FS. Hutchinson-Gilford Progeria Syndrome. 2003 Dec 12 [Updated 2019 Jan 17]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1121/.  The Progeria Research Foundation, https://www.progeriaresearch.org/, accessed on May 6, 2021. Family battles with rare progeria disease, Deccan Herald, New Delhi, November 9, 2009, https://www.deccanherald.com/content/34971/family-battles-rare-progeria-disease.html Sam Berns, TEDx MidAtlantic 2013, My philosophy for a happy life. Available at: https://www.ted.com/talks/sam_berns_my_philosophy_for_a_happy_life?language=en, accessed on May 6, 2021.

For this week's Feature Discussion, please join authors Michael Ackerman, Christopher Haggerty, editorialist Michael Rosenberg, and Associate Editor Nicholas Mills as they discuss the original research articles “Artificial Intelligence-Enabled Assessment of the Heart Rate Corrected QT Interval Using a Mobile Electrocardiogram Device,” “ Deep Neural Networks Can Predict New-Onset Atrial Fibrillation From the 12-Lead Electrocardiogram and Help Identify Those at Risk of AF-Related Stroke,” and “Trusting Magic: Interpretability of Predictions from Machine Learning Algorithms.”   TRANSCRIPT BELOW: Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your cohosts. I'm doctor Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well Carolyn, this week's feature, it's kind of a new thing for us. It's more than our double feature; it's actually a forum, where we're going to have two papers discussed, we'll have both authors represented from each of those two papers, we'll have an editorialist, and we'll have one of our associate editors. And the topic, Carolyn, just to keep you in suspense, is really on machine learning and actually how that can be applied to 12 lead electrocardiograms. But before we get to that, how about we grab a cup of coffee and start off on some of the other articles in this issue? Would you like to go first? Dr. Carolyn Lam: Yes, I would, but you're really keeping me in suspense. But first, let's focus on health related quality of life. We know that poor quality of life is common in heart failure, but there are few data on heart health related quality of life and its association with mortality outside of the Western countries. Well, until today's paper. And it's from the Global Congestive Heart Failure, or GCHF study, the largest study that has systematically examined health-related quality of life as measured by the Kansas City cardiomyopathy questionnaire 12, or KCCQ, and its association with outcomes in more than 23,000 patients with heart failure across 40 countries, in eight major geographic regions, spanning five continents. Dr. Greg Hundley: Wow, Carolyn. That KCCQ 12, that has been such an interesting tool for us to use in patients with heart failure. So what did they find in this study? Dr. Carolyn Lam: Really important. So the health-related quality of life differs considerably between geographic regions with markedly lower quality of life related to heart failure in Africa than elsewhere. Quality of life was a strong predictor of death and heart failure hospitalization in all regions, irrespective of symptoms class, and in both preserved and reduced ejection fraction. So there are some important clinical implications, namely that health-related quality of life is an inexpensive and simple prognostic marker that may be useful in characterizing symptom severity and prognosis in patients with heart failure. And there is certainly a need to address disparities that impact quality of life in patients with heart failure in different regions of the world. Dr. Greg Hundley: Very nice, Carolyn. Well, I'm going to turn to the world of basic science and bring us a paper from David Merryman from Vanderbilt University. So Carolyn, myocardial infarction induces an intense injury response, which ultimately generates a collagen dominated scar. Cardiac myofibroblasts are the cells tasked with depositing and remodeling collagen and are a prime target to limit the fibrotic process post myocardial infarction. Now Carolyn, serotonin 2B receptor signaling has been shown to be harmful in a variety of cardiopulmonary pathologies, and could play an important role in mediating scar formation after MI. So Carolyn, these investigators employed two pharmacologic antagonists to explore the effect of serotonin 2B receptor inhibition on outcomes post myocardial infarction and characterized the histological and micro structural changes involved in tissue remodeling. Dr. Carolyn Lam: Oh, that's very interesting, Greg. What did they find? Dr. Greg Hundley: So Carolyn, serotonin 2B receptor antagonism preserved cardiac structure and function by facilitating a less fibrotic scar, indicated in their results by decreased scar thickness and decreased border zone area. Serotonin 2B receptor antagonism resulted in collagen fiber redistribution to a thinner collagen fiber. And they were more anisotropic. They enhanced left ventricular contractility and the fibrotic tissue stiffness was decreased, thereby limiting the hypertrophic response of the uninjured cardiomyocytes. Dr. Carolyn Lam: Wow. That is really fascinating, Greg. Summarize it for us. Dr. Greg Hundley: Yeah, sure. So this study, Carolyn, suggests that early inhibition of serotonin 2B receptor signaling after myocardial infarction is sufficient to optimize scar formation, resulting in a functional scar, which is less likely to expand beyond the initial infarct and cause long-term remodeling. The prolonged presence of the antagonist was not required to maintain the benefits observed in the early stages after injury, indicating that acute treatment can alter chronic remodeling. So Carolyn, it's really going to be interesting to see how this research question is pursued in studies of larger animals, including us, or human subjects. Dr. Carolyn Lam: Wow, that is really interesting. And so is this next paper. Well, we know that genetic variation in coding regions of genes are known to cause inherited cardiomyopathies and heart failure. For example, mutations in MYH7 are a common cause of hypertrophic cardiomyopathy, while mutations in LMNA are a common cause of dilated cardiomyopathy with arrhythmias. Now, to define the contribution of non-coding variations, though, today's authors, led by Dr. Elizabeth McNelly from Northwestern University Feinberg School of Medicine in Chicago and colleagues evaluated the regulatory regions for these two commonly mutated cardiomyopathy genes, namely MYH7 and LMNA. Dr. Greg Hundley: Wow, Carolyn. So this is really interesting. So how did they do this and what did they find? Dr. Carolyn Lam: You asked the top questions, because the method is just as interesting as the findings here. They used an integrative analysis that relied on more than 20 heart enhancer function and enhancer target datasets to identify MYH7 and LMNA left ventricular enhancer regions. They confirmed the activity of these regions using reporter assay and CRISPR mediated deletion of human cardiomyocytes derived from induced pluripotent STEM cells. These regulatory regions contained sequence variants within transcription factor binding sites that altered enhancer function. Extending the strategy genome-wide, they identified an enhancer modifying variant upstream of MYH7. One specific genetic variant correlated with cardiomyopathy features derived from biobank and electronic health record information, including a more dilated left ventricle over time. So these findings really link non-coding enhancer variation to cardiomyopathy phenotypes, and provide direct evidence of the importance of genetic background. Beautiful paper. Dr. Greg Hundley: Very nice, Carolyn. Dr. Carolyn Lam: But let me quickly tell you what else is in this issue. We have an ECG Challenge by Dr. Lutz on flash pulmonary edema in a 70-year-old; there's an On My Mind paper by Dr. Halushka, entitled (An) Urgent Need for Studies of the Late Effects of SARS-CoV-2 on the Cardiovascular System. Dr. Greg Hundley: Ah, Carolyn. Well, in the mailbox, there are two Research Letters, one from Dr. Soman entitled (The) Prevalence of Atrial Fibrillation and Thromboembolic Risk in Wild-Type Transthyretin Amyloid Cardiomyopathy, and a second letter from Dr. Berger entitled Multiple Biomarker Approaches to Risk Stratification in COVID-19. Well Carolyn, now let's get on to that forum discussion and hear a little bit more about using machine learning in the interpretation of a 12 lead ECG. Dr. Carolyn Lam: Wow, can't wait. Thanks, Greg. Dr. Greg Hundley: Well listeners, we are here today for a double feature, but this double feature is somewhat unique, in that we are going to discuss together two papers that focus on machine learning applications as they relate to the interpretation of the electrocardiogram. With us today, we have Mike Ackerman from Mayo Clinic, Chris Haggerty from Geisinger, Mike Rosenberg as an editorialist from University of Colorado, and then our own Nick Mills, an associate editor with Circulation. Welcome, gentlemen. Well, Mike Ackerman, we will start with you first. Could you describe for us the hypothesis that you wanted to test, and what was your study population and your study design? Dr. Michael Ackerman: Thanks, Greg. The hypothesis was pretty simple, and that is could an artificial intelligence based approach, machine learning, deep neural network, could that solve the QT problem? Which is one of the big secrets among cardiologists, which, as you know, one of your associate editors, Sammy Biskin, published a sobering paper over a decade ago, showing and revealing the secret that cardiologists are not so hot at measuring the QT interval, and heart rhythm specialists sometimes don't get it right either. And we all know that the 12 lead ECG itself is vexed by its computer algorithms at getting the QTC just right, compared to those of us who would view ourselves as QT aficionados. And so we were hoping that a machine learning approach would solve this and help us glean, one, a very accurate QTC, as accurate as I can make it when I measure it, or core labs that do QT measuring for living. Dr. Michael Ackerman: And two, could we get that QTC from just a couple of leads to be as accurate as what the whole 12 lead ECG would be seeing so that we can move it to a mobile smartphone enabled solution? And so that was our hypothesis going forward, and we studied a lot of patients. And that's something that machine learning and the power of computation does, that in my world, I'm used to studying a hundred or a thousand patients with congenital long QT syndrome and thinking that I've assembled a large cohort, but for this study, we started with over two and a half million ECGs from over 650,000 people. And then ultimately, through training, testing, and validation of about 1.6 million ECGs from over a half a million individuals to sort of teach the computer or have the AI algorithm get the QT interval not too hot, not too cold, but just right. And as we'll discuss, I think we hit the mark. Dr. Greg Hundley: Thanks so much, Mike, what did you find? Dr. Michael Ackerman: Ultimately, we were able to show that with this drill, we could get the deep neural network derived QTC to be give or take two plus minus 20 milliseconds from what would the standard of care, and that being a technician over-read QTC. But then we took, I would say, pretty unique to AI studies, as many AI studies, just do training, testing, and validation for study number one. And then a future paper of a prospective study. But we did that prospective study within this single paper with a subsequent about two year enrollment of nearly 700 patients that I evaluated in our genetic heart rhythm clinic at Mayo Clinic. And half of those patients have congenital long QT syndrome, half did not. And what we showed was that the deep neural network derived QTC from a mobile ECG approximated the subsequent or the just prior 12 lead ECG within one millisecond, +/- 20 millisecond territory. Dr. Michael Ackerman: And it's ability to say is the QTC above or below 500, which we all know is sort of a warning sign, that's a very actionable ECG finding, do something about it, that that 500 millisecond cutoff by the deep neural network gave us an area under the curve of 0.97, which from a screening perspective, that AUC is far higher than a lot of AUCs for a lot of screening tests done in the cancer world and so forth. And so we think we are very close to what I've called a pivot point, where we will soon pivot from the way we've been doing the QTC since Eindhoven over a century ago to a fundamentally new way of deriving a QTC that's precise and accurate and mobile enabled. Dr. Greg Hundley: Very nice, Mike. So using machine learning to accurately assess the QTC from just two leads of an electrocardiogram. Well Chris, you also have a paper in this issue of circulation that pertains to another application of machine learning and looking at the electrocardiogram. Can you describe for us your study population, study design, and then also the question you were trying to address? Dr. Christopher Haggerty: Sure. Yeah, thanks Greg. Great to be here with you all today. Very similar to Mike's study, the motivation for us was we believe very strongly that there's opportunities with using deep learning applied to ECG data to uncover not only new knowledge latent in the ECG itself related to the current patient context, but also to try to predict future outcomes, future events. And that was really our motivation, was to take that paradigm of looking forward, in this case to predict new onset of atrial fibrillation within a year. We used our Geisinger patient cohort, which is a largely rural population in central Pennsylvania. We have very longitudinal data for a lot of our patients, which allows us to have this kind of design going back in our electronic health records, in this case, our ECG database to 30 plus years. Dr. Christopher Haggerty: Similar big numbers that Mike described, and in our case, 1.6 million ECGs over 430,000 patients used to train the model. And we had several different study designs that we employed. One just being a simple proof of concept, asking can we accurately predict new onset atrial fibrillation one year? And then a second study design that was intended to simulate a real world deployment scenario. Obviously the main rationale for trying to predict atrial fibrillation is to then be able to treat and try to prevent stroke. And so we tried to, as best we can in a retrospective fashion, simulate a scenario in which we might use this model to identify patients who went on to have a presumably AFib associated stroke. Dr. Greg Hundley: And what did you find, Chris? Dr. Christopher Haggerty: So I think there are three main findings that we highlighted here. So first, obviously we were building on the great work that Mike and some of his colleagues at the Mayo Clinic have done, showing that looking at AFib using deep neural networks needs to be feasible. We extended it in this case by looking out further than just an acute sense, looking at that one-year outcome. And we had an area under the curve for our proof of concept of 0.85. So area under the curve of 0.85 to identify patients with new onset of atrial fibrillation within one year in our millions of ECGs. Looking at it another way, the second main finding was that that one year prediction was shown to have prognostic significance beyond that one year, which is really interesting and warrants a lot of further study. Looking over 30 years of follow-up, patients predicted to be at high risk at baseline had a hazard ratio of 7.2 for developing atrial fibrillation, compared to those deemed to be low risk. Dr. Christopher Haggerty: And then really the third, and I think perhaps the most exciting finding that we had here, was this simulated stroke experiment that we had, where we identified patients from an internal stroke registry and identified patients who had new diagnosis of AFib at the time or up to a year after the stroke. So we can assume that they were an AFib associated stroke. And subsequently, or I should say previously, had an ECG that we could use to run through the algorithm to predict their atrial fibrillation risk. And we showed that the model performed well in this setting, that of the 375 strokes that we identified, for example, over a five-year period in our registry, we were able to identify 62% of them within three years based on that ECG. So a number needed to screen for an atrial fibrillation associated with stroke about 162, which compares favorably well to other screening techniques that are out there, obviously. So we took that as a great proof of concept that this type of AI technique might have benefits for screening for atrial fibrillation and preventing strokes. Dr. Greg Hundley: Well congratulations, Chris. Well, we're now going to turn to our associate editor, Dr. Nick Mills. And Nick, you have a lot of manuscripts come across your desk. What attracted you to these two papers, and what are the significance of the results as they apply to ECG applications as we move forward? Nick Mills: Thanks, Greg. Yeah, this is a rapidly growing field, where the availability of data scale with digital archiving and lots of really interesting new methodologies are available to our researchers. So we are receiving a lot of content in this area. What I loved about these two papers is not just the quality of the work, but also the really tangible benefits, potentially, for patients. So AI does not need to be complex, but it does need to solve a tangible problem. I guess what we look for in the journal, beyond the kind of innovation and methodology, is quality, and these studies used prospective validation, really reliable end points, ascertainments, transparency, reporting, all the things that we know are important for high quality clinical research. I think the idea that we can bring QT monitoring to the drug store on a portable device for our patients is potentially transformative. I also think that to take a technology, the electrocardiogram that we've been using for over a century, and provide new insights that go way beyond my ability to interpret the ECG, that might help us recommend a different course of action for our patients is also just really exciting. Dr. Greg Hundley: Very nice. Thank you, Nick. Well Mike ... we're going to turn to Mike Rosenberg now, listeners. And Mike wrote a wonderful editorial, and I would invite you to work through this. As you have an opportunity to read the journal and interact with it. Mike, there are two different types of machine learning, I think, that you described were used by the two respective investigative groups. Could you describe those for our cardiology listeners? What were the differences in those two approaches? Dr. Michael Rosenberg: Yeah, sure. And thank you for the opportunity to write the editorial. Two very fascinating papers. I should say that they both use the same approach of what's called supervised learning, where you basically have a set of data inputs, and you're trying to predict a labeled outcome. And what I talk about in the paper is that what we've learned is if you have enough data and enough computing power, you can predict almost anything highly accurately. What's interesting about the two papers, and what I sort of tried to contrast in the editorial, is that the one from the Mayo Group and Dr. Ackerman, was basically predicting what's already a known biomarker for sudden death, which is the QT interval. And essentially, almost trying to automate that process of predicting it accurately and in a way that, in essence, could allow a home monitoring of patients for QT prolongation, which obviously would be a huge benefit for clinicians, all those alerts and things, to be able to have patients taking drugs that are known to prolong the QT interval and feeling comfortable that if they have any prolongation, it could be detected accurately. Dr. Michael Rosenberg: The second one, which is sort of interesting, and in contrast is from the Geisinger Group and Dr. Haggerty, was the approach of ... where actually the prediction itself is actually the biomarker. And we don't actually know exactly what it's using, which I talk about a little bit of what that means and the implications clinically, but in essence, what they showed was that it actually is a very good biomarker and on par with what a lot of us would consider to be very strong predictors of agents. So I think it was two very interesting approaches to, again, applying the same type of machine learning, but really approaching it one from a more discovery side and another from sort of validated or almost automating something that we do on a daily basis. Dr. Greg Hundley: Thank you, Mike. So Mike, just coming back to you again, as we read the literature, and most of us are clinicians or researchers practicing, what should we look for when these new machine learning manuscripts and research studies come out as to gauge, "Ah, this is a really good study," or maybe not so much? Dr. Michael Rosenberg: Yeah. And it's a good question. I think one of the biggest challenges, as I talked about, is interpretability. I think in the clinical world, we're used to understanding the code for the variables that go into our risk prediction model. And so I think first and foremost is can I even understand what this is predicting or am I sort of expected to take the predictions as sort of a black box, it is what it is type of approach? I think that there's other things that I just look at when I'm reviewing these manuscripts. I mean, as I sort of mentioned, what these models are really doing, it's not anything magical. What they're doing is identifying patterns in the data and then using those to make predictions, again, toward whatever label that you've assigned them to. Dr. Michael Rosenberg: It's important that your data sets are split and that you're training at one data set and then testing it in one that's separate. And again, you can't ignore epidemiology. Is the data set that you're training it reflective of the population that you're going to be using those models in? And we know from outside of healthcare, there's issues with models that have been trained in one population where it's potentially biased or it's potentially offering predictions that are using information we may not necessarily want to use. Recidivism is a big example of that. So I think that that's, first and foremost, it's sort of taking a step back as a clinician and saying, "If this was a biomarker that someone was proposing to use to predict some new disease, what would I expect to use to evaluate that?" And that's probably what I would start with. Dr. Greg Hundley: Excellent. Well, I'm going to turn back and go back to our panelists here, listeners. And we're going to ask each of our panelists in about 20 seconds to describe for us what they think is the next most important aspect of research in their respective areas. So first I'll start with Mike Ackerman. Mike, can you tell us what's coming next in this area of assessment of QT prolongation or other aspects of the electrocardiogram? Dr. Michael Ackerman: I think next is implementing this in the real world. We are having our suite of the AI ECG as a  hypertrophic cardiomyopathy detector. We've shown that as an ejection fraction detector, and now as a QT detector in AFib, from our work and Chris's work. And for the QT itself, I think where we are is we're really, really close to now having a mobile enabled digital QT meter. And a digital QT meter, once FDA cleared, then allows the QTC to truly emerge as the next vital sign. And it really deserves to be a vital sign. We use it as a vital sign. We know I want to know my patient's QTC every bit as I want to know his or her weight, blood pressure, saturation. It's an actionable finding, and we're now getting really close. We're just on the cusp of having a true digital QT meter. Dr. Greg Hundley: Excellent. Chris? Dr. Christopher Haggerty: I think for us to, in part address some of the comments that Mike brought up about the reproducibility of these types of models, we're very keen to demonstrate the prospective capabilities of our models to enroll patients in a prospective fashion, run their ECG through our predictor, and then screen them for AFib to determine how well we actually do moving forward, instead of just relying solely on our retrospective data. So we're very excited to do that. We're ramping up for that trial now and hope to be able to demonstrate similarly positive findings from our technique. Dr. Greg Hundley: Great. How about you, Nick? Nick Mills: I'd like to see the same quality and rigor applied to the implementation of these technologies as we have to other important areas in cardiovascular medicine. I think that's a really important step, not just to develop the tools, but to demonstrate their value. But I also think what we've done so far is relatively simplistic. We've taken an ECG and we've ignored almost all the other information that we have in front of us. And as these algorithms are trained and evolved, these and other vital clinical biomarkers and information, and integrating them into these neural networks will really enhance their performance for predicting things that are less tangible, like sudden death in the future or stroke. Dr. Greg Hundley: And then finally, Mike Rosenberg. Dr. Michael Rosenberg: Yeah, I actually see two challenging areas in this field. One is the access to data. And I think one of the things that a lot of companies are realizing is that even if they make hardware, that the data may be more valuable than the technology that they're getting the data from. So I think one is figuring out ways to get access to data so that people can reproduce findings from these studies. And the second is deliverable. A bottle like this is not like the CHADS-VASc score that I can calculate in my head in the clinic. I mean I need a way to actually run these models within an EHR, within a computer system like that. And I think it's going to be a big challenge to take a model like this and to deploy it at scale the way we would with the drug or any other innovation. Dr. Greg Hundley: Fantastic. Well listeners, we want to thank Mike Ackerman from Mayo Clinic, Chris Haggerty from Geisinger, Mike Rosenberg from University of Colorado, and Nick Mills from University of Edinburgh for really providing us with a wonderful discussion regarding the use of machine learning applications in one study to predict the QTC interval from two leads that may be applicable to wearable devices. And in the second study, predicting the future occurrence of atrial fibrillation and even stroke as an adverse event in people at risk. Dr. Greg Hundley: On behalf of both Carolyn and myself, I want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association, 2021.  

An INSPIRATIONAL stroke survivor is using her new-found voice to advocate for disability rights. Courtney Gabrus, 24, from East Norwich, New York was born with a rare defect in the LMNA gene, a form of muscular dystrophy that is thought to affect one in a million people. The uncommon muscle weakening condition meant by the time Courtney had reached 16 years old, she could no longer stand or walk without the use of an aid. On 19 December 2016, at the age of 22, she had a stroke that changed her life forever. It paralysed the whole right side of her body and she lost her ability to speak. But with the help of friends and family Courtney learnt to speak again, and has now launched a start-up promoting advocacy for disability welfare.

Progeria is an extremely rare genetic disease that practically speeds up time. It affects young children who get it due to a mutation from a very specific Gene, the LMNA gene. Tune in for more!ScrubCaps: A Health and Medical Podcast Every Monday!Visit my Website: https://www.brainontheloose.comLeave a Review on Apple Podcasts: https://podcasts.apple.com/us/podcast/scrubcaps-a-health-and-medical-podcast/id1442030058References: https://www.progeriaresearch.org/about-progeria/ https://ghr.nlm.nih.gov/condition/hutchinson-gilford-progeria-syndrome https://www.mayoclinic.org/diseases-conditions/progeria/diagnosis-treatment/drc-20356043 Support the show (http://patreon.com/ Nathanhidajatscrubcaps)

This month on Episode 5 of the Discover CircRes podcast, host Cindy St. Hilaire highlights five featured articles from the September 27 and October 11, 2019 issues of Circulation Research and talks with Sarvesh Chelvanambi and Matthias Clauss  about their article HIV-Nef Protein Transfer to Endothelial Cells Requires Rac1 Activation and Leads to Endothelial Dysfunction: Implications for Statin Treatment in HIV Patients.   Article highlights:   Stamatelopoulos, et al. Reactive Vasodilation in AL Amyloidosis   Cao, et al. Miro2-Mediated Cardiac Mitochondrial Communication   Georgakis, et al. Circulating MCP-1 Levels and Incident Stroke   Sun, et al. Body Mass Index and DNA Methylation   Tan, et al. Yy1 Suppresses DCM Through Bmp7 and Ctgf Transcript Cindy St. H:                       Hi. Welcome to Discover CircRes, the monthly podcast of the American Heart Association's journal, Circulation Research. I'm your host, Dr Cindy St. Hilaire, and I'm an assistant professor at the University of Pittsburgh. My goal as host of this podcast is to share with you highlights from recent articles published in the September 27th and October 11th issues of Circulation Research.                                            We'll also have an in-depth conversation with Drs Matthias Clauss and Sarvesh Chelvanambi, who are the lead authors in one of the exciting discoveries from our October 11th issue.                                            The first article I want to share with you is titled, Reactive Vasodilation Predicts Mortality in Primary Systemic Light Chain Amyloidosis. The first authors are Drs Kimon Stamatelopoulos, Georgios Georgiopoulos, and the corresponding author is Dr Efstathios Kastritis. And the studies were conducted at the National Kapodistrian University of Athens School of Medicine in Athens, Greece.                                            So we hear about amyloids a lot in things like Alzheimer's, but amyloids are really just aggregates of protein that fold into shapes. And the nature of these shapes allows these individual protein molecules to bind and form many copies that form these fibers that are rather sticky. And the fibers then aggregate into larger and larger globules. And light chain amyloidosis is the most common type of amyloidosis. It's a rare but deadly disease, and it's caused by antibody-producing cells that are aberrantly churning out parts of antibodies called light chains. And it's these light chains that will aggregate and form sticky fibers.                                            So these fibers aggregate and form amyloid deposits, and these deposits build up and damage the organs and the tissue in which they're accumulating. And because it's dependent on where the aggregates are accumulating, AL amyloidosis can present with a wide variety of symptoms. However, symptoms of heart dysfunction and low blood pressure correlate with poor prognosis.                                            And because vascular dysfunction can contribute to hypotension or low blood pressure, this group decided to examine the vascular health of patients by conducting a measurement called flow-mediated vasodilation. And so this is a measurement where the diameter of the brachial artery, which is located in your arm, is measured before and then after a brief period of lower arm ischemia. And they formed a cohort of 115 newly diagnosed AL patients and another cohort of 115 matched controls. This study found that in AL patients, flow-mediated vasodilation was higher than in aged, sex, and cardiovascular risk factor-matched controls. The mean follow-up time for this study was 54 months, and in that time, the authors went on to find that high values of FMD in the amyloidosis patients was strongly predictive of mortality. In fact, high FMD values were more predictive of death than some measures of cardiovascular health. These results suggest that flow-mediated vasodilation may be a superior means of identifying AL patients most at risk and for assessing potential benefits of therapeutic interventions.                                            The next article I'd like to highlight is titled, Miro2 Regulates Inter-Mitochondrial Communication in the Heart and Protects Against TAC-Induced Cardiac Dysfunction. The first author is Yangpo Cao, and the corresponding author is Ming Zheng. And the work was conducted at Peking University, Beijing, China, Key Laboratory of Molecular Cardiovascular Science at the Ministry of Education, also in Beijing, China.                                            Beating heart cells have very high energy requirements, and thus they need lots of fully functioning mitochondria. And as we all know from our good old high school biology days, mitochondria are the powerhouse of the cell. Mitochondrial health and performance is directly dependent on the ability of individual mitochondria to be able to communicate with each other. In many cells, this mitochondrial communication occurs via the fusion of mitochondria into a giant network. However, in cardiomyocytes, the mitochondrial movement is much more constrained. In cardiomyocytes, mitochondria communicate by briefly connecting with neighboring mitochondria, which is often called kissing, mitochondrial kissing, or by nanotunneling, which is when the mitochondria create a sustained connection by means of long nanometer-sized tubular protrusions called nanotubes. And it's thought that the proper health of the cell is dependent on proper mitochondrial communication.                                            Miro2 is a Rho GTPase on the outer mitochondrial membrane and it harbors a calcium sensing domain. Miro2 can interact with transport proteins to promote mitochondrial transport along microtubules in a calcium-dependent manner. This group wanted to investigate whether Miro2 regulates cardiac inter- mitochondrial communication. To do this, they used transverse aortic constriction or TAC or they used an Ang II infusion model to induce hypertrophy in murine hearts. Using these two models, they found Miro2 expression was decreased via Parkin-mediated ubiquitination, and they also found that inter-mitochondrial communication was disrupted.                                            By contrast, transgenic mice over-expressing Miro2 were more resistant to hypertrophy, and they were able to do this by maintaining proper cardiac function than their wild type counterparts. Together these results reveal a novel role for Miro2 in mitochondrial communication and show that maintaining such communication may mitigate effects of hypertrophy.                                            The next paper I want to highlight is titled, Circulating Monocyte Chemoattractant Protein-1 or MCP-1 and the Risk of Stroke: A Meta-Analysis of Population-Based Studies Involving 17,180 individuals. That is a huge study. The first author is Marios Georgakis, and the corresponding author is Martin Dichgans. And they are from the University of Munich in Munich, Germany.                                            A major component of atherosclerosis is chronic inflammation and inhibiting the activity of proinflammatory cytokines has been identified as a potential therapeutic strategy to help slow the disease progression. One such cytokine under study is monocyte chemoattractant protein-1 or MCP-1, and animal studies have shown that blocking MCP-1 limits, or boosting MCP-1, accelerates atherosclerosis. However, large scale observational studies of MCP-1 in humans are lacking. To address this gap in knowledge, this group performed a meta-analysis of previously unpublished data from six population cohorts, which totaled over 17,000 individuals.                                            These individuals were followed for an average of 16 years, which when you think about it, this is an absolutely huge study. So in looking at this cohort of patients, the team identified a significant association between high baseline MCP-1 levels and the likelihood of suffering a future ischemic stroke. Interestingly, this effect was not seen with hemorrhagic stroke, which is typically not associated with atherosclerosis. These findings not only support the previous animal studies, but also support a recent study in humans in which a genetic predisposition for high levels of MCP-1 was associated with an increased risk of coronary artery disease and stroke. This study also suggests that future studies should explore the potential of lowering MCP-1 levels as a possible prevention strategy. Perhaps there could be another CANTOS-like trial where we use something to block MCP-1 signaling. Maybe that would have much broader effects. I guess we'll have to wait and see what the data says.                                            The next paper I want to highlight is titled, Body Mass Index Drives Changes in DNA Methylation, a Longitudinal Study. The first authors are Dianjianyi Sun, Tao Zhong and Shaoyong Su, and the corresponding authors are Shengxu Li and Wei Chen. And they're from the Children's Minnesota Research Institute, Children's Hospitals and Clinics of Minnesota in Minneapolis, Minnesota and The Peking University Health Science Center in Beijing, China, respectively.                                            So it's well appreciated that obesity is increasing worldwide. And obesity contributes to a whole host of cardiovascular morbidity, and ultimately contributes to mortality. It's also well known that environmental factors such as the food we eat and the air we breathe, as well as genetic factors, can influence a person's risk of obesity. And recently there have been studies that suggest that perhaps epigenetic factors also contribute to obesity. And just to remind you what epigenetics is, DNA is the genetic code, and mutations can happen on DNA that can alter either gene expression or maybe protein folding or whether a protein is made at all. But epigenetic factors are not as permanent as DNA mutations.                                            Epigenetic factors are alterable modifications that can happen to DNA itself or that can happen to the proteins on which the DNA is wrapped around. And epigenome-wide association studies have shown that DNA methylation at certain loci is linked to an increase in body mass index, or BMI. However, it's unknown whether these methylations are a cause or consequence of obesity.                                            So to get to the bottom of this, this group performed a large-scale longitudinal study. They examined thousands of DNA methylation sites in 995 white individuals and 490 black individuals. And they also determined the subjects' BMIs. They did this at a baseline measurement and then approximately six years later, they collected the same data in the same patient cohort. What they found was that only a handful of methylation sites were shared between the two ethnicities. And in both groups, however, there was a similar unidirectional link between BMI and methylation. Very interestingly, baseline BMI could predict methylation at a number of genetic loci. However, the team found that none of those baseline methylation sites could predict future BMI. From this data, the authors are able to conclude that it's obesity driving the methylation at certain genetic loci as opposed to certain genetic loci driving obesity, which I think is just extremely interesting. Really nice study.                                            The last article I want to highlight for you is a paper titled, Yin Yang 1 Suppresses Dilated Cardiomyopathy and Cardiac Fibrosis Through Regulation of Bmp7 and Ctgf. The first author is Chia Yee Tan, and the corresponding author is Jianming Jiang, and they're from the National University of Singapore.                                            Dilated cardiomyopathy or DCM is characterized by left ventricle enlargement and associated contractile dysfunction and fibrosis. Patients with DCM are at risk of arrhythmia and also of sudden death. And there's actually a huge number of genetic variants that have been linked to DCM, but the most common one or the most well-studied are mutations that affect the nuclear lamin gene or LMNA. So LMNA knockout mice are used to study the role of this gene in DCM, and these animals exhibit not only cardiac defects but also systemic defects. And those systemic defects include things like shorter lifespan, growth retardation, muscular dystrophy, neuropathy, and lipodystrophy.                                            Recently, LMNA-related dilated cardiomyopathy was linked to the deregulation of cardiac cell cycle. Meaning there was issues in how these cardiac cells are proliferating. So in this study, Tan and colleagues showed that boosting expression of a protein involved in cell cycle regulation, this protein is called Yin Yang 1, so boosting this gene's expression actually reversed the dilated cardiomyopathy symptoms in mice with heart-specific LMNA deficiency. Compared with untreated mice, mice receiving Yy1 via an adenoviral vector exhibited improved cardiac function and also reduced fibrosis after four weeks. The team then went on to show that Yy1 treatment prompted suppression of the extracellular matrix factor, Ctgf, and the upregulation of the growth factor, Bmp7.                                            Now, neither of these factors alone could rescue the symptoms of LMNA lacking mice. However, when both of these factors were manipulated together, they mimicked Yy1 treatment. These results highlight that Yin Yang 1 and its downstream targets Bmp7 and Ctgf are key players and potential therapeutic targets that can be harnessed for tackling LMNA-driven dilated cardiomyopathy.                                            Okay, so now we're going to have our interview with Drs Matthias Clauss and Sarvesh Chelvanambi. And they are from Indiana University School of Medicine in Indianapolis, Indiana. And their title of their paper is, HIV-Nef Protein Transfer to Endothelial Cells Requires Rac1 Activation and Leads to Endothelial Dysfunction: Implications for Statin Treatment in HIV Patients. So thank you both very much for joining me. Sarvesh C:                         Thank you so much, Cindy. Matthias C:                       Thanks for having us here. Cindy St. H:                       Could you both introduce yourselves and tell us a little bit about your background? Sarvesh C:                         My name is Sarvesh Chelvanambi. I grew up in Chennai, India. I did my undergraduate degree at Miami University in Oxford, Ohio. I got a Bachelor of Arts in Zoology with a minor in Finance. I then went to the Pennsylvania State University where I got my Masters in Biotechnology before coming over to Indiana University in 2014 to do my PhD work. And then I joined the lab of Dr Matthias Clauss, and in 2016, I got an American Heart Association predoctoral fellowship to study this project specifically. Cindy St. H:                       Wow! Congratulations. That's wonderful. Sarvesh C:                         Thank you so much. Cindy St. H:                       And now you completed the circle by publishing your AHA grant in Circulation Research. Sarvesh C:                         Exactly. Cindy St. H:                       And Matthias, how about you? Matthias C:                       I'm a Research Professor at IU School of Medicine, and my research interests focus in understanding how stressors connected with endothelium in this way contribute to vascular disease. These stressors include cigarette smoke and viral infections. Regarding viral agents, we are studying both acute infections and chronic infections and that is HIV. This HIV interest started actually 12 years ago in collaboration with Dr Samir Gupta who is also of course on this paper. We started off with a simple question, why are there so many cardiovascular events in patients, in HIV patients, with interrupted antiretroviral therapy? Cindy St. H:                       So it's not just the fact that they're HIV positive, it's that they were on therapy and then went off it? Matthias C:                       Yes. And this was part of this SMART study and this study was then actually halted because of the safety issues. Cindy St. H:                       So you're starting with the idea that patients with HIV who go off this antiviral therapy are more prone or get more cardiovascular events. So what did you start with, with this particular study? Matthias C:                       Well, our overarching idea was that the HIV virus could also do damage in the era of the combined antiretroviral therapy. And we started up with two questions, one was, is there an HIV protein which is persistent? And the other question, how is this HIV protein, if there's any one which is persistent, performing this? And this may be then leading over to your specific way to address these questions. Sarvesh C:                         That's kind of where we are starting with this project. Because back in 2016, the START trial came out saying, "We need to change the way we treat HIV patients," because initially the previous regimen of our drugs had a lot of metabolic side effects, but the current regimen of integrase inhibitors is actually really good and has very low metabolic effects. So there was a New England Journal Of Medicine paper that said, "Well, if a patient walks into the clinic, they're diagnosed as being HIV positive, put them on antiretroviral therapy right away."                                            But even in this era when everybody is on ART and there's almost no viral replication, you still see the persistence of a lot of comorbidities. And especially those associated with vascular events, whether it's peripheral arterial disease, coronary arterial disease, and a lot of other vascular diseases in the lung, or the kidney or the brain. So that kind of is what set us up, is there an element in the blood of these patients that is contributing towards vascular dysfunction? Cindy St. H:                       And so the protein that you are talking about in this paper is a protein called Nef, and is that where you come in,  Sarvash? Sarvesh C:                         Yes, because the project before I joined the lab, that's kind of where it led off, saying that Nef can get to the endothelium and it's very good at killing endothelial cells, but the mechanism through which it transfers into endothelial cells and the signaling pathways that Nef hijacks to induce this apoptosis was not clearly elucidated. A lot of work is done in Nef in monocytes and macrophages because as an HIV protein, it was studied in CD40 cells and the whole immune system as a whole, but we were the first to leverage all of those findings within an endothelial context and answer the questions, so what does Nef do and how does it get there? Cindy St. H:                       All right, so tell us a little bit what does it do and how does it get there? Sarvesh C:                         So we started doing some experiments with starting with HIV patient blood. So we took two fragments, we took the PBMC fraction, that Dr Clauss was talking about, which we knew had Nef within many of those cells. We also took the extracellular vesicle fraction, and we chose to look at this because there's a lot of literature out there saying that this fraction could not only disseminate particles throughout the body but also help signal through that. So in both of these fractions we added to the endothelial cells, we found increased apoptosis in HIV patients when compared to HIV negative patients.                                            And we were excited, but then we went and asked which of these patients had HIV Nef positivity in their blood, and then using that information when we stratified our apoptosis results, we made the surprising observation that the HIV positive, Nef positive patients were more prone to endothelial cell apoptosis. And this sparked a lot of conversation, so how do we target this and what is the signaling pathway it gets into? And that is kind of what led to most of the work in this paper, where you're showing that the transfer is mediated by extracellular, because this is such a nice tool, for HIV I guess, to spread itself into literally every cell type. Because while the HIV virus can only infect very few cell types, extracellular vesicles can be taken up by anything.                                            And the second observation we made was within endothelial cells, we found the signaling pathways that Nef was able to hijack to induce cell death. And that became the focus of this paper. Cindy St. H:                       That was one thing I wanted you to clarify, because I think what a really interesting aspect of this study is that it's the immune cells that are infected. The endothelial cells themselves are healthy and really they're getting this damage from the vesicles. That is,…wow! I don't know. It's just a really, really neat study. So can you tell us a little bit about the techniques you used in this paper? Sarvesh C:                         Yes, so we did a lot of assays to evaluate endothelial cell stress. So we started by looking at apoptosis, and a lot of those studies were done by looking at caspase-3 activity, which is a classic marker for cell death. We also did a lot of microscopy work where we took out extracellular vesicles out of those vesicles on the endothelial cells to show the uptake of Nef protein and thereby hammer that extracellular vesicles are indeed a mechanism of transfer for this protein in particular.                                            Now, one of the interesting experiments that we actually ended up doing, which was not a part of this paper really, was we wanted to see if chemotaxis was being affected by this. So we took an endothelial monolayer and separated T-cells that are expressing Nef using a Transwell membrane. And I had this huge problem where I couldn't read for a week because instead of using the 4-micron filters that allow T-cells to transfer, I was using 0.4 micron filters that T-cells cannot transfer through. But I still went about it and did my whole experiment because I didn't make that realization until a week later, because when I looked at the bottom of these chambers, there were no T-cells at all. But when I looked at the endothelial cells, I observed cytoplasmic transfer and Nef transfer, and we had a couple of conversations going, why is this happening? Did the T-cells all die or did they disappear?                                            And that's when we went back and looked in literature and found that Nef is very good at making virion particles. And those are the similar pathways that extracellular vesicle trafficking comes from. And so that was a huge shift in the way this project was designed and where we then started looking into the modes of transfer, the protein and the subsequent apoptosis that that transfer can cause. Cindy St. H:                       I love this story. So essentially your mistaken filter created this paper and this finding of the vesicles affecting the endothelial cells. Matthias C:                       Yeah, that's a typical finding for practitioner Chelvanambi, because he has this gift to turn negative things into positive things. So we have a lot of fun, and this mistake was really the beginning of a great study. Cindy St. H:                       That's wonderful. Really beautiful images, as well. So a little bit digging into, I guess, the next step. So first off, how were the endothelial cells getting damaged? They're getting damaged from these extracellular vesicles, but then what's Nef doing in the endothelial cell? What's happening there? Sarvesh C:                         So that was a very big question because if you look at it, Nef is a very small protein with almost no known enzymatic function. And yet it is able to interact with a lot of host proteins, which I guess makes it a very good viral protein. So when I went back and looked at literature, there were a host of studies in the 90s to show that Nef interacts with this kinase and that small GTPases, and there was a giant list for us to go after. And we were kind of left a bit fuddled, because we were like, which signaling pathway do we start with? Cindy St. H:                       Right. It's almost like there's too many. Sarvesh C:                         Exactly. And so what we ended up doing was we started looking into one of the various mutants of Nef that we had access to. And one of these mutants was a mutant that was incapable of PAK2 activation, and we showed that that doesn't have a lot of these stress damages. So we asked, "What is directly upstream of PAK2?" And that is where Rac1 came into the picture. And the small GTPase Rac1 is a nice candidate because it is also a master of many, many trades. Cindy St. H:                       I love this because it's such an interesting multidisciplinary approach to addressing the question, why are patients with HIV getting more cardiovascular events? What do you think evolutionarily is going on? Why would this be beneficial? Why would damaging the endothelium be beneficial? What are your thoughts on that? Sarvesh C:                         Personally, I think this is a side effect because HIV is never meant to exist in the era of ART. One of the analogies I always like to use is from Harry Potter, where HIV is Voldemort, which is the big bad villain. And what we have done is a really good job of banishing Voldemort. But what we have failed to do as a field is target its Death Eater, Nef. And I think with what we are suggesting, this paper with additional statins and other strategies that focus this, we can get to that point where we not only block HIV expansion but also the expansion of its minions, Nef. Cindy St. H:                       I love this analogy. I think you should redo your graphical abstract in a Harry Potter theme. Matthias C:                       Yeah, but I like your question. But also in this regard, I think it may be an example of a novel mechanism, how viral infections work in a different way than just infecting cells. And there's evidence from lots of viruses that they make toxic proteins, and why they are doing this, we don't know. But we noticed that the systemic effect of Nef may have some advantage for the infectious agent, because it makes T-cells more sticky, it makes them stick and transmigrate through the endothelium, and that is also shown in our paper. Cindy St. H:                       You have evidence that perhaps statins would be beneficial to give to these HIV patients on ART therapy. Can you tell us a little bit about that and how that would work? Sarvesh C:                         So based on what we did on our mouse studies that was a part of this paper, even after there is endothelial dysfunction, treatment with statins was able to restore endothelial function. Currently, there is a study going on called The Reprieve Trial where they're giving a statin called pitavastatin to HIV patients. The interesting part here is that these are HIV patients who don't have dyslipidemia. And the long-term goal is that statin treatment can help prevent the development of cardiovascular events. We're eagerly awaiting the results of this trial. Cindy St. H:                       Well done. Well thank you so much for speaking with me today. It was a pleasure to speak with you, Dr Chelvanambi and Dr Clauss. And congratulations again on this beautiful project, this beautiful story. And really, the implications for helping patients with HIV is really profound. HIV used to always be in the news and now that we have the ART therapy it's not talked about as much, but these patients are still in danger and I think your study is really doing a lot to highlight that and maybe even help them. So thank you very much and congratulations. Matthias C:                       Thank you. Sarvesh C:                         Thank you so much for the opportunity. Cindy St. H:                       So that's it for highlights from the September 27th and October 11th issues of Circulation Research. Thank you so much for listening. This podcast is produced by Rebecca McTavish, edited by Melissa Stoner, and supported by the editorial team of Circulation Research. Some of the copy text for the highlighted articles is provided by Ruth Williams.                                            I'm your host, Dr Sidney St. Hilaire, and this is Discover CircRes, your source for the most up-to-date and exciting discoveries in basic cardiovascular research.  

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Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley:             And I'm Greg Hundley, Associate Editor at the Pauley Heart Center at VCU Health in Richmond, Virginia.                                                 Well Carolyn, did you ever wonder whether cardiovascular drug effects could be investigated through natural variation in the genes for the protein targets? In our feature discussion today, investigators from the British Isles, Germany, and the United States use this approach to explore the potential side effects and repurposing potential of antihypertensive drugs. Sound interesting? Well listeners, we look forward to the results later in our program, but Carolyn, how about we chat about some of the other papers in this issue? Dr Carolyn Lam:                You bet Greg. So, have you ever asked yourself "What is the role of protein glycosylation in regulating LDL metabolism?" Dr Greg Hundley:             That was going through my mind when we were playing basketball just the other night. Dr Carolyn Lam:                Well this is truly a great study from Dr Holleboom at Academic Medical Center Amsterdam and Dr Lefeber from Radboud University Medical Center, both in the Netherlands. And their colleagues will study 29 patients of the two most prevalent types of Type 1 Congenital Disorder of Glycosylation, and these are the ALG6 and PMM2 types. They also study 23 first and second-degree relatives with a heterozygote mutation and measured their plasma cholesterol levels. LDL metabolism was studied in three cell models. They found that patients with type 1 congenital disorder of glycosylation have hypobetalipoproteinemia through increased LDL receptor expression. Carriers of the mutation in glycosylation enzymes affected in this syndrome had decreased LDL cholesterol levels compared to controls, and defects in glycosylation enzymes could play, therefore, an important role in LDL cholesterol metabolism. Dr Greg Hundley:             Boy, this is pretty insightful I think, Carolyn. So, what are the clinical implications? Dr Carolyn Lam:                Well, given that LDL cholesterol was also reduced in a group of clinically unaffected heterozygotes, the authors propose that increasing LDL receptor mediated cholesterol clearance, by targeting N-glycosylation in the LDL pathway, may therefore represent a novel therapeutic strategy to reduce LDL cholesterol, and of course prevent cardiovascular disease. Dr Greg Hundley:             Very interesting work. You know, we just keep learning more and more about LDL. I'm going to switch and jump back with Empagliflozin. And this is a study in diabetic mice that really has an interesting in-vivo imaging component. As an imager, I was really excited about this. The article is from Dr Kengo Kidokoro from Kawasaki Medical School. And we don't often talk about it, but listeners, if you have a chance, there's a very interesting video-enhanced file associated with this article, and if you can download it, it's really just so cool with multiple image clips demonstrating an operative mechanism of SGLT2 inhibition on renal function. And it really gives us an opportunity to revisit renal function.                                                 Quick quiz Carolyn. In diabetic kidney disease, is glomerular hyperfiltration good or bad? Dr Carolyn Lam:                Bad. Dr Greg Hundley:             Yeah, absolutely. So, hyperfiltration is characteristically observed at earlier stages of diabetic kidney disease and involves activation of the renin-angiotensin-aldosterone system at the efferent arteriole and tubuloglomerular feedback mechanisms, especially at the afferent arteriole. So, as they go through this, just picture in your mind that glomerulus and afferent is arriving, and efferent is leaving.                                                 So, SGLT2 upregulation in diabetes is thought to play an important role in TGF signaling by increasing sodium reabsorption at the proximal tubule, thereby decreasing distal delivery to the sodium sensing macula densa at the juxtaglomerular apparatus. This decline in distal sodium delivery is interpreted as a decline in effective circulating volume, leading to inappropriate afferent vasodilation in an effort to preserve intra-glomerular pressure and GFR.                                                 In diabetes, these TGF effects lead to intra-glomerular hypertension and hyperfiltration. You got that quiz right, Carolyn. Which promotes diabetic kidney disease progression and impaired kidney function, ultimately increasing overall cardiovascular risk and mortality. Conversely, blocking SGTL2 pharmacologically reduces renal hyperperfusion and hyperfiltration in animals and humans, which may preserve renal function, thereby reducing risk associated with diabetic kidney disease progression. Dr Carolyn Lam:                You know what, Greg? I kind of had an unfair advantage in this quiz. I work with a lot with the SGLT2 inhibitors, but I just love that you asked us to picture it and look at that video. Anyways, so this article really allows us to review SGLT2 inhibition at the glomerular level, which is truly hot. So, tell us what did they find? Dr Greg Hundley:             So, this is the first report of changes in renal hemodynamic function by SGLT2 inhibition using direct in-vivo visualization techniques in a diabetic animal model. The videos, they're spectacular, and they're excellent so that you can download them for educational purposes. Afferent arteriolar vasoconstriction, and reduced hyperfiltration occurred within a few hours after a single dose of a SGLT2 inhibitor. And Adenosine signaling, through tubuloglomerular feedback, is a key pathway to prevent diabetic hyperfiltration via SGLT2 inhibition.                                                 Clinically, Carolyn, now I know you would ask me about that, so I got ready, this study highlights another potential mechanism for the benefits of SGTL2 inhibition. The SGLT2 inhibitor-related mechanism's responsible for reducing cardiovascular risk in clinical trials may be due to protection against diabetic kidney disease progression, thereby attenuating risk factors for heart failure, such as volume overload and hypertension. Dr Carolyn Lam:                Ah. That is just so cool, and really just so consistent with the clinical data that's emerging too. Thank you, Greg. So, have you ever asked yourself this other question, what role do platelets play in ischemia reperfusion injury? So, I'm not going to quiz you. I'm actually kind and loving and a good person. And so, I will tell you about ischemia reperfusion injury, which is a common complication of cardiovascular disease.                                                 Now, resolution of the detrimental effects of ischemia reperfusion injury generated prothrombotic and proinflammatory responses, is essential to restore homeostasis. Now, although platelets are known to play a crucial role in the integration of thrombosis and inflammation, their role as participants in the resolution of thrombo-inflammation is really under-appreciated. And hence, this other paper that I chose today, and it's from Dr Gavins from Louisiana State University Health Sciences Center Shreveport, and her colleagues, who used pharmacological and genetic approaches, coupled with murine and clinical samples to uncover key concepts underlying this role for platelets. Dr Greg Hundley:             So Carolyn, what did they find? Dr Carolyn Lam:                Well, they found that exacerbation of thrombo-inflammatory responses occurred in ischemia reperfusion injury mouse models of middle cerebral arterial occlusion, as well as lower plasma levels of the anti-inflammatory pro-resolving protein Annexin A1. And this was a lower plasma level of this Annexin A1 among patients with acute ischemic stroke.                                                 Administration of Annexin A1 promoted cerebral protection against thrombo-inflammation and the development of subsequent thrombotic events post-stroke. Annexin A1 was also able to reduce platelet activation and thrombosis, via the suppression of integrins. So, overall, these data reveal a novel multi-faceted role for Annexin A1 to act both as therapeutic and prophylactic drug via its ability to promote endogenous pro-resolving anti-thrombo, anti-inflammatory circuits in the cerebral ischemia reperfusion injury. And collectively, these results further enhance our understanding in the field of platelet and ischemia reperfusion injury biology. Dr Greg Hundley:             Oh wow. So, another important insight from this author group on platelet activation and thrombosis in key clinically relevant syndromes. Well, my last paper is going to be talking about a risk prediction score for life-threatening ventricular tachyarrhythmias. And they're going to study this in laminopathies, and the lead investigator is Dr Karim Wahabi from Cochin Hospital in France.                                                 To estimate the risk of life-threatening ventricular tachyarrhythmia in patients with LMNA mutations, and thus select candidates for implantable cardiac defibrillators, the investigators evaluated 444 patients of about 40 years in age in a derivation sample. And then, 145 patients that are about the same age, 38 years, in a validation sample, for the occurrence of a) sudden cardiac death or b) ICD-treated or hemodynamically unstable ventricular tachyarrhythmias. Dr Carolyn Lam:                Oh. Very important. These laminopathies are really not that uncommon. So what did they find, Greg? Dr Greg Hundley:             Carolyn, predictors of events included male sex, non-missense LMNA mutations, first-degree and higher AV block, non-sustained ventricular tachycardia, and LVEF. The authors developed a new score to estimate the 5-year risk of life-threatening ventricular tachyarrhythmias in patients with LMNA mutations. And compared to the current standard of care, the proposed risk prediction model offered more accurate prediction of life-threatening ventricular tachyarrhythmias, and correctly re-classified almost 30% of the patients in the study.                                                 Nicely, the authors have made this available, and the score can be derived from readily collected clinical and genetic parameters and estimated using an online calculator that's provided in the journal. But, it's https://lmna-risk-vta.fr.                                                 Future prospective studies should focus on the estimation of the clinical benefit conferred by the use of this score in terms of sudden cardiac death prevention. Dr Carolyn Lam:                That is super cool, Greg. But, I am so excited now to move to our feature discussion. Shall we? Dr Greg Hundley:             You bet. Dr Carolyn Lam:                Can we use natural variations in our genes for the protein targets as a way to look at cardiovascular drug effects? Man, this is going to be such an important and exciting discussion, because this is what our feature paper talks about. I am so pleased to have with us our corresponding author, Dr Dipender Gill from Imperial College London, as well as our Associate Editor, Dr Wendy Post from Johns Hopkins.                                                 So, first of all, Dipender, please, could you give us a background on what you did? This is really very novel in approach. Dr Dipender Gill:               It was also a lot of fun to conduct. I think, currently, we're living in an era where there's been a recent explosion in the availability of genetic data, and this really inspired us to think about how we could use that to learn more about commonly prescribed drugs. The implementation of genetics, or genetic variance, to study drug effects isn't entirely novel. It's actually been undertaken for some years now.                                                 Most of the work has been related to lipid lowering drugs, for example, statins, where people can take genetic variance, or versions of genes, corresponding to the drug effect, and study these to investigate what effects these drugs might have, both on the intended target, but also potential side effects. To my knowledge, this hadn't previously been done for anti-hypertensive drugs. But yet, the data for this was available. And therefore, we thought that actually we could very well go ahead and do this, and perhaps find some interesting things. Dr Carolyn Lam:                Oh, that's so interesting thing, Dipender. You know, there was this term in your abstract, and mentioned multiple times, Mendelian randomization. Now, for those of us that don't think about this every day, could you tell us a little bit what that means? Dr Dipender Gill:               Yeah. So, I'll actually give a little bit of background. One of the main limitations of traditional epidemiological research is that any association, it's sometimes difficult to infer causation. They can be confounded by environmental factors, lifestyle factors. In the Mendelian randomization technique, what we do is we use randomly allocated genetic variants to study the effect to an exposure.                                                 So, we select these genetic variants because they are related to the exposure of interest. And because these genes are randomly allocated at conception, they're not subject to confounding from environmental or lifestyle factors. Whether you have a gene or not, is not necessarily related to your lifestyle or your environment. And therefore, the association of these genetic variants with certain outcomes isn't subject to confounding. Dr Carolyn Lam:                That makes so much sense, and I suppose that, not to allow cause and effect to be determined. So please, tell us, in this particular case of the anti-hypertensive drugs, what did you do and what did you find? Dr Dipender Gill:               First, we decided specifically which drugs we wanted to look at, and we thought, actually, let's start off with the most commonly prescribed anti-hypertensive drugs. So, we short-listed these based on recent consensus guidelines, and we looked at ACE inhibitors, beta-blockers, calcium channel blockers, thiazide type diuretics. And then, we went back to various online databases to identify which genes correspond to the target protein of these drugs.                                                 We took these genes, and we then identified genetic variants at their specific genetic loci, their specific region of the genome, and we identified the variants in these regions that were also related to systolic blood pressure. And in this way, we inferred that genetic variants, at the protein coding targets of these genes, that were also related to systolic blood pressure, likely represented the effect of variations in these proteins that also implicated blood pressure, and therefore, could serve as proxies, or instruments, to study the effect of these drug targets.                                                 We then went ahead to validate the selection of these genetic variants by forming Mendelian randomization, and specifically, we checked whether people that have genetic variants that correspond to, say, ACE inhibitor activity, or beta-blocker activity, or calcium channel blocker activity, if they also have correspondingly lower risk of coronary heart disease and stroke, to the same degree that we would observe in randomized control trials against placebo.                                                 And indeed, we found that actually, the results were fairly similar, and this gave us confidence. And studying these genetic variants that mimic the effect of these drugs could be used as a proxy or as a surrogate to study their clinical effect of taking these drugs. So, that was the first phase. Dr Wendy Post:                 Dipender, congratulations to you and our team. This is a really exciting paper, and the editors were especially interested in the novelty, and the potentially impactful findings, especially of the second part of the study, which I think you'll describe briefly next. And that was using an approach that many who are listening may not have heard about too much before called PheWAS, or a phenome wide association study. And maybe you could tell us briefly what you found in that part of the analysis. Dr Dipender Gill:               The first part, it was very cool, because it allowed us to identify versions of genes that corresponded to the effect of these drugs. But in itself, it didn't tell us anything novel. It didn't tell us anything new. So, the real question was, how could we use this new information to make progress towards helping patients? So, we went back and we thought, "So okay." So, we knew that these drugs are used for certain conditions already to prevent heart disease, to prevent stroke.                                                 But, what about their side effects? What about their repurposing potential? How could we use our new approach to study that a little bit more carefully? As you alluded to, when we used this new technique, relatively new technique called phenome wide association study, and we essentially investigated the association of our genetic variants for each respective anti-hypertensive target with all clinically relevant outcomes throughout the phenome, using the UK bio-back cohort, which was the main population used for this PheWAS, this phenome wide association study.                                                 We were actually able to rapidly investigate over 900 disease outcomes, and their association with our genetic risk score for these drugs. And this was very exciting for us, because it allowed us to very rapidly, efficiently, and cost-effectively explore the potential repurposing opportunity and side effects of these very commonly prescribed drugs, which to our mind, offered significant advantage over previous approaches.                                                 We all know that sometimes randomized control trials can be very expensive and time-consuming, and of course, traditional observational research can be limited by reverse causation, assessment-vise confounding. And so, what we were able to do here had several important advantages, and not to mention the efficiency by which it allowed study of these outcomes. Dr Wendy Post:                 Dipender, tell us what you found in your PheWAS study. Dr Dipender Gill:               We identified genetic variants for 3 commonly prescribed anti-hypertensive targets. The first were ACE inhibitors, second, beta blockers, and the third were calcium channel blockers. When performing PheWAS for all of these drug targets, we identified associations with common cardiovascular disease that are related, or implicated in hypertension, specifically hypertension itself, but also circulatory diseases, things like atrial fibrillation, coronary heart disease. They all came up.                                                 And this actually gave us a lot of confidence because that's exactly what we'd expect. We know that these medications prevent or reduce risk of these diseases, and therefore, this served as kind of a positive control that our approach was doing it what it was supposed to do. The novel finding came when we investigated the genetic risk score, or the genetic variants for calcium channel blockers, in this PheWAS approach.                                                 And we actually identified an association which we weren't expecting. We showed that blood pressure reduction through the genetic risk score for calcium channel blockers was an association with an increased risk of diverticulosis, a condition not conventionally thought to be associated with blood pressure. We were very excited and interested by this, and we went on to investigate it further using some other techniques as well. Dr Wendy Post:                 The really impactful part of this, many things, but especially this association with diverticulosis. So, maybe you can briefly summarize what you think the potential clinical implications are, and what the next step should be. Dr Dipender Gill:               The first question we had was whether this was related to blood pressure alone, the effect of calcium channel blockers, or perhaps some other effect of these drugs. We investigated the genetic risk score for systolic blood pressure generally and found that this itself wasn't associated with risk of diverticulosis, which suggested that the effect isn't really mediated by blood pressure alone, but it's some other property of calcium channel blockers.                                                 We know that sometimes calcium channel blockers can be associated with constipation, and it may be through this mechanism that they're having consequent effects on risk of diverticulosis. Other possible mechanisms might be through effects on blood flow, through the vasa recta in the bowel. But, what was very interesting was that we went forward with this finding, and investigated, observed, drug use in the UK bio-bank.                                                 Specifically, we looked at people taking non-dihydropyridine, and dihydropyridine calcium channel blockers at baseline, and found that those taking non-dihydropyridine calcium blockers only were known to have a higher risk of diverticulosis as compared to those taking other anti-hypertensive classes, which further added support for our findings. The interesting point here is that looking at the genetics doesn't allow us to discriminate between these drug classes.                                                 That was only possible with the observed data, and that was because the genes for these drug classes were the same. Dr Carolyn Lam:                Well, congratulations. Wow. I'm just so intrigued listening to all of this. Wendy, I would love if you could help put all of this in context for us. The US, the novel information, and the approach that could potentially go way beyond just anti-hypertensive. Dr Wendy Post:                 So, this is a very exciting new approach to doing genetic studies that can help us to understand potential targets for therapy in the future, and understanding more about causality, which as Dipender explained, can sometimes be confusing, as it may be confounded by environmental factors. So, using these genetic approaches through Mendelian randomization, and what we heard about today, which is PheWAS, or phenome wide association study, we can learn much more about how the potential observational analyses can be related to new discoveries through mechanisms, or potential side effects, as we heard about here of calcium channel blockers.                                                 So, wanted to congratulate Dipender again with his impactful paper here. Dr Carolyn Lam:                Thanks, Wendy. And then if I could, I'm just going to steal minutes here, because this is so interesting. Where do you think the field's going to go next? And Dipender, with these findings of diverticulitis and diverticulosis, what next? How do we apply this? Dr Dipender Gill:               There's 2 main points to cover here. The first is what we do specifically with the findings we got for calcium channel blockers and diverticulosis. I should emphasize that on their own, I don't think that this should currently change practice. But, I think it should inspire and capitalize further research into this association. If we're able to replicate and validate it further, then perhaps there might be some implications for the drugs that we prescribe with patients at risk of diverticulosis.                                                 The second point I wanted to make is more generally, what does this mean for research, and particularly, genetic research. I think we're living in very exciting times, and there's a lot of really great work that's going to come out using these types of approaches. I think 2 areas that we could expand further is what else we can do with our genetic instruments, or our genetic variants that proxied these drugs. How do we look at other targeted refocusing potential? Can we try and explore other side effects? Can we investigate efficacy for other disease outcomes? Specifically, for these anti-hypertensives.                                                 And the other thing is, which other drugs can we identify genetic variants to proxy? We've been thinking about looking at diabetes medicines. There's a variety of other drugs that correspond to specific gene targets, and proteins. And in theory, these could also be studied using genetics. So, there's a lot more work to come out from this. Dr Carolyn Lam:                Thanks so much, both of you, for joining us today. This was just such an exciting discussion.                                                 Thank you for listening to Circulation on the Run. Don't forget to tune in again next week. This program is copyright American Heart Association, 2019.  

Leading into Rare Disease Week on Capitol Hill when a team of more than a dozen CMD community members from around the U.S. will advocate for policies, greater funding, and support for CMD...we thought it would be good to check in with Gustavo Dziewczapolski, PhD, Cure CMD Scientific Director, on the current state of CMD research. Quick find for each subtype: 1. SEPN1 - 05:45 2. LMNA - 15:05 3. Collagen VI - 21:46 4. LAMA 2 - 31:35 5. a-Dystroglycanopathy - 38:09 Funding portfolio online: https://www.curecmd.org/funding-portfolio Dr. Dziewczapolski received his Master's degree from the University of Buenos Aires, followed by a Ph.D. in Neuropharmacology. Before joining Cure CMD in September 2016, he researched neurological diseases for eighteen years at UC San Diego and the Salk Institute. He is the father of two beautiful daughters, Tatiana and Rafaela, who continue to challenge and inspire him. And to balance his addiction to chocolate, he enjoys surfing and soccer. Find Two Rare Mama Bears on Facebook, Instagram & Twitter: 2raremamabears

Jane:                                     Hi, everyone. Welcome to Episode 18 of Getting Personal: Omics of the Heart. I'm Jane Ferguson, and this podcast is brought to you by the Circulation: Genomic and Precision Medicine Journal and the American Heart Association Counsel on Genomic and Precision Medicine. It is July 2018, which means that the best possible place to be listening to this episode is at the beach, but failing that I can also recommend listening on planes, during your commute, while exercising or while drinking a nice cup of tea.                                                 So before I get into the papers we published this month, I want to ask for your help. If you're listening to this right now, hi, that means you, we're a year and a half into podcasting and I would love to know what content you like and where we could improve things. We have a poll up on Twitter this week, and I would really appreciate your input. If you're listening to this a little bit later and miss the active voting part of the poll, you can still leave suggestions.                                                 Okay, so what I would like you to do right now is to go to Twitter. You can find us as Circ_Gen and locate the poll. If you don't already follow us on Twitter, go do that now too. We want you to let us know what content we should focus on and what is most useful to you, so go ahead and pick your favorites from the options and also please reply or tweet at us with other thoughts and suggestions.                                                 Options include giving summaries of the recent articles like I'm about to do later this episode, conducting interviews with authors of recently published papers, interviews with people working in cardiovascular genomics, broader topics. For example, to get their insight on career paths and lessons learned along the way.                                                 And something we have not done yet on the podcast but are considering, would be to record podcasts that focus on particular topics in genomics and precision medicine. These could give some background on an emerging field or technology and we could talk to experts who are leading particular innovations in the field. So, if that sounds good to you, let me know! If you're not on Twitter, I don't want to exclude you, so you can email me at jane.f.ferguson@vanderbilt.edu and give me your thoughts that way. I'm looking forward to hearing from you.                                                 Okay, so on to the July 2018 issue of Circ.: Genomic and Precision Medicine. First up is a PhWAS from Abrahim Rao, Eric Ingelsson, and colleagues from Stanford. The discovery of the PCSK9 gene as a regulator of cholesterol levels has led to a new avenue of LDL lowering therapies through PCSK9 inhibition. However, some studies suggest that long term use of PCSK9 inhibitors could have adverse consequences. Because of the long follow-up time required, it will take many more years to address this question through clinical studies. However, genetic approaches offer a fast and convenient alternative to address the issue.                                                 In this paper, entitled: "Large Scale  Phenome-Wide Association Study of PCSK9 Variants Demonstrates Protection Against Ischemic Stroke," the authors use genetic and phenotype data from over 300,000 individuals in the UK BioBank to address whether genetic loss of function variants in PCSK9 are associated with phenotypes including coronary heart disease, stroke, type II diabetes, cataracts, heart failure, atrial fibrillation, epilepsy, and cognitive function.                                                 The missense variant RS11591147 was associated with protection against coronary heart disease and ischemic stroke. This SNP also associated with type II diabetes after adjustment for lipid medication status. Overall, this study recapitulated the associations between PCSK9 and coronary disease, and revealed an association with stroke.                                                 Previous studies suggested use of LDL lowering therapies may increase risk of cataracts, epilepsy, and cognitive dysfunction, but there was no evidence of association in this study. Overall, this study provides some reassurance that the primary effect of PCSK9 is on lipids and lipid related diseases, and that any effects on other phenotypes appear to be modest at best. While a PhWAS can't recapitulate a clinical trial, what this study indicates is that PCSK9 inhibition is an effective strategy for CVD prevention, which may confer protection against ischemic stroke and does not appear to convey increased risk for cognitive side effects.                                                 Next up we have a manuscript form Jason Cowan, Ray Hershberger, and colleagues from Ohio State University College of Medicine. Their paper, "Multigenic Disease and Bilineal Inheritance in Dilated Cardiomyopathy Is Illustrated in Non-segregating LMNA Pedigrees," explored pedigrees of apparent LMNA related cardiomyopathy identifying family members who manifested disease, despite not carrying the purported causal LMNA variant. Of 19 pedigrees studies, six of them had family members with dilated cardiomyopathy who did not carry the family's LMNA mutation. In five of those six pedigrees, the authors identified at least one additional rare variant in a known DCM gene that was a plausible candidate for disease causation.                                                 Presence of additional variants was associated with more severe disease phenotype in those individuals. Overall, what this study tells us is that in DCM, there is evidence for multi-gene causality and bilineal inheritance may be more common than previously suspected. Future larger studies should consider multi-genic causes and will be required to fully understand the genetic architecture of DCM.                                                 Yukiko Nakano, Yasuki Kihara, and colleagues from Hiroshima University published a manuscript detailing how HCN4 gene polymorphisms are associated with tachycardia inducted cardiomyopathy in patients with atrial fibrillation. Tachycardia induced cardiomyopathy is common in subjects with atrial fibrillation, but the pathophysiology is poorly understood. Recent studies have implicated the cardiac hyperpolarization activated cyclic nucleotide gated channel gene, or HCN4, in atrial fibrillation and ventricular function.                                                 In this paper, the authors enrolled almost 3,000 Japanese subjects with atrial fibrillation, both with and without tachycardia-induced cardiomyopathy, as well as non-AF controls. They compared frequency of variants in HCN4 in AF subjects with or without tachycardia-induced cardiomyopathy, and found a SNP, RS7164883, that may be a novel marker of tachycardia-induced cardiomyopathy in atrial fibrillation.                                                 Xinyu Yang, Fuli Yu, and coauthors from Tianjin University were interested in finding causal genes for intracranial aneurysms, and report their results in a manuscript entitled, "Rho Guanine Nucleotide Exchange Factor ARHGEF17 Is a Risk Gene for Intracranial Aneurysms." They sequenced the genomes of 20 Chinese intracranial aneurysm patients to search for potentially deleterious, rare, and low frequency variants. They found a coding variant in the ARHGEF17 gene which was associated with associated with increased risk in the discovery sample, and which they replicated in a sample of Japanese IA and in a larger Chinese sample.                                                 They expanded this to other published studies, including individuals of European-American and French-Canadian origin and found a significantly increased mutation burden in ARHGEF17 in IA patients across all samples. They were interested in further functional characterization of this gene and found that Zebra fish ARHGEF17 was highly expressed in blood vessels in the brain. They used morpholinos to knock down ARHGEF17 in Zebra fish, and found that ARHGEF17 deficient Zebra fish developed endothelial lesions on cerebral blood vessels, and showed evidence of bleeding consistent with defects in the vessel. This study implicates ARHGEF17 as a cerebro-vascular disease gene which may impact disease risk through effects on endothelial function and blood vessel stability.                                                 Sumeet Khetarpal, Paul Babb, Dan Rader, Ben Voight, and colleagues from the University of Pennsylvania used targeted resequencing to look at determinants of extreme HDL cholesterol in their aptly titled manuscript, "Multiplexed Targeted Resequencing Identifies Coding and Regulatory Variation Underlying Phenotypic Extremes of HDL Cholesterol in Humans." Stay tuned because we're gonna hear more about this paper from the first author Dr. Sumeet Khetarpal later this episode.                                                 Rounding out this issue we have a Perspective article from Chris Haggerty, Cynthia James, and coauthors from Geisinger and Johns Hopkins Medical Center entitled, "Managing Secondary Genomic Findings Associated With Arrhythmogenic Right Ventricular Cardiomyopathy: Case Studies and Proposal for Clinical Surveillance." In this paper the authors discuss the challenges for returning findings from clinical sequencing for arrhythmogenic right ventricular cardiomyopathy, presenting case studies exemplifying these challenges. They also propose a management approach for returning clinical genomic findings, and discuss new innovations in the light of precision medicine.                                                 We also published a review article by Pradeep Natarajan, Siddhartha Jaiswal, and Sekar Kathiresan from MGH on "Clonal Hematopoiesis Somatic Mutations in Blood Cells and Atherosclerosis", which discusses recent advances in our knowledge on the role of somatic mutations in cardiovascular disease risk.                                                 Finally, we have an update on some pharmacogenomics research into CYP2C19 Genotype-Guided Antiplatelet Therapy by Craig Lee and colleagues which we published a few months ago. Dr. Lee was also featured on Podcast episode 15 in April of this year.                                                 Jernice Aw and colleagues from Khoo Teck Puat Hospital, Singapore shared from complimentary data from their sample of 247 Asian subjects which found the risk for major adverse cardiovascular events was over 30-fold greater for poor metabolizers, as defined by CYP2C19 genotype on clopidogrel, as compared to those with no loss of function allele.                                                 You can read that letter and the response from Dr. Lee and colleagues online now. And, as usual, all of the original research articles come with an editorial to help give some more background and perspective to each paper. Go to circgenetics.ahajournals.org to find all the papers and to access video summaries and more.                                                 Our interview is with Dr. Sumeet Khetarpal who recently completed his MD-PhD training at the University of Pennsylvania, and is currently a resident in Internal Medicine at Massachusets General Hospital. Sumeet kindly took some time out from his busy residency schedule to talk to me about his recently published paper, and to explain how molecular inversion probe target capture actually works.                                                 So I am here with Dr. Sumeet Khetarpal who is co-first author on a manuscript entitled, "Multiplexed Targeted Resequencing Identifies Coding and Regulatory Variation Underlying Phenotypic Extremes of High-Density Lipoprotein Cholesterol in Humans."                                                 Welcome Sumeet, thanks for taking the time to talk to me. Dr. Khetarpal:                    Thank you so much Dr. Ferguson, it's really a pleasure to talk to you today. Jane:                                     Before we get started, maybe you could give a brief introduction on yourself and then how you started working on this paper. Dr. Khetarpal:                    Sure, so this work actually was a collaboration that came out at the University of Pennsylvania that I was involved with through my PhD thesis lab, my mentor was Dan Rader, and also a lab that is a somewhat newer lab at Penn, Benjamin Voight's lab which is a strong sort of computational genomic lab.                                                 This work actually highlights the fun of collaborating within your institution. We had, for some time, been interested in developing a way to sequence candidate genes. Both known genes and also new genes that have come out of genome-wide association studies that underlie the extremes of HDL cholesterol, namely very high cholesterol versus low HDL cholesterol. We've been looking for a cost-effective and scalable way to do this.                                                 Independently, Ben, who is very interested in capturing the non-coding genome, was interested in developing a method to better understand the non-coding variation, both common and rare variation that may be present at all of these new loci that have come out for complex traits such as HDL.                                                 We, at some Penn event several years ago, were talking about our common interest and Ben had actually identified this work that had come out of J. Shendure's lab at the University of Washington. A paper by the first author, Brian O'Rouke, in Science in 2012 in which they had developed an approach that involved molecular inversion probes, or MIPs, to capture regions of the genome related to target the gene that they were interested in studying for autism-spectrum disorders.                                                 They had applied this largely to coding regions of, I think, almost 50 genes and almost 2,500 patients with the feedback to do deep, targeted sequencing. So our thought was, well, we could try to apply this approach and adapt it to capture non-coding regions, and also see if we can expand the utility of this approach to study the phenotypic extremes of a complex trait such as HDL cholesterol. Jane:                                     Yeah, that's really cool. I love how you saw this method in a totally different application and then realized that there was expertise at Penn that you could bring together to apply this in a different way.                                                 I'd love to hear more about this MIP, the molecular inversion probe. How does it work? How difficult is it to actually do? Is it very different from normal library preparation for sequencing or is it something that's actually relatively easy to apply? Dr. Khetarpal:                    These MIP probes are oligonucleotide probes that capture your region of interest by flanking them and capturing by gap filling. There's a method to capture parts of the genome in a library-free way. They do ultimately involve barcoding the way traditional library-based target capture does and then deep sequencing.                                                 But the most impressive feature about them is just that they're very scalable. I think in the original paper by O'Rouke and colleagues they were able to sequence their set of genes and their set of samples at about a sample preparation cost of $1 per sample, and we were actually able to do about the same for our study.                                                 The main utility of the approach is just the economic scalability, and the ability to customize your panel to capture several regions of the genome that are adjacent to each other. Jane:                                     Right, so how many genes or regions can you multiplex at the same time? Is it just one prep, like you just design all of your oligos, you put them all together in one reaction, or are you doing separate reactions for each region? Dr. Khetarpal:                    We're actually doing all of our oligos together. In our case, I think it ended up being around the order of almost 600 oligos together to capture our ultimately 50kB of genomic territory that we wanted to capture. Really, our study was kind of a pilot experiment where we picked a few genes or regions of high interest to us, both known genes that effect HDL and also those that have been implicated in genome-wide association studies that were of high interest to our labs.                                                 I think that this approach could actually be expanded to capture much more genomic territory in a single capture reaction. We sort of touched the surface probably of what we could do. Jane:                                     Wow, that's cool! And then for sequencing it, I guess it's really just a function of how many samples you wanna multiplex and how much you want to sequence from each region. So I suppose the way you did it, you had about 50kB and then you had over 1,500 participants and you were able to do those on a single HiSeq run, right? Dr. Khetarpal:                    Right. Jane:                                     So I suppose if you'd done more genetic regions, you would've had fewer people and vice versa so you can balance that out depending on if you're having more samples or more genomic regions to sequence. Dr. Khetarpal:                    Exactly, in certain ways the design of our experiment we had a limited sample size that did afford us some luxury in terms of knowing that we would have deep coverage of the region that we were targeting. I think that's always a critical question in sort of targeted or just sequencing in general. The balance between the number of regions that you want to sequence and the number of samples you want to sequence is going to dictate what your sequencing depth with be. Jane:                                     Right, okay so I guess if we go on to what you actually found, how'd you pick this? You picked seven regions which encompasses eight candidate genes for HDL, so how did you select those? Dr. Khetarpal:                    The population that we were studying, the samples we were looking to sequence were largely individuals which fall into two bins if you will. One was extremely high HDL cholesterol which we're defining as the greater than the 95th percentile, but really there was a range within that population that spanned individuals with probably greater than the 99th percentile of HDL.                                                 We were hoping as a proof of principle effort to identify variation in genes that were known causes of high HDL cholesterol in prior studies of Mendelian genes for HDL. So genes such as LIP gene which encodes endothelial lipase or CETP or SCARB1, these 3 genes are, at this point, well-known genes that loss of function mutations are associated with extremely high HDL. We thought that capturing some of those genes would potentially both provide a level of validation for the approach, hypothesizing that individuals with high HDL would be enriched with these genes, but also may allow us to find new variants in these genes or also non-coding variants which has not previously been studied before.                                                 Some of the genes came out from that line of thinking, then some of the other genes happened to be genes that in the Rader laboratory we had a vested interest in understanding the genetic variation that might link the genes to HDL, which may not have necessarily come out before.                                                 For example, the gene GALNT2 is one of the first g-loss implicated novel genes for HDL, novel as in the earliest g-loss study for plasma lipids had identified that gene as associated with HDL but it never had come out before as being so. Our laboratory was very interested in better understanding the genetic relationship between genes such as GALNT2 and several of the others such as CCDC92 and ZNF664 with HDL.                                                 It ended up being a hodge-podge or a sampling of genes that had at some level been implicated with HDL, but really it's just a proof of principle that this method could work for both identifying variation in known genes and also less studied ones. Jane:                                     You validated the MIP genotyping by exome genotyping, and then saw concordance of over 90%, is that lower than you were expecting? Was it about what you were expecting based on these two different methods of genotyping? Dr. Khetarpal:                    Yes, I think we were expecting somewhere on the order of 90 plus percent. It's hard to know why we just hit that, we likely would've benefited from being able to genotype all of the individuals by the exome chip that we had sequenced as well, where we were able to validate in about two-thirds of those individuals.                                                 It's hard to know exactly what the cause of the about 10% discordance rate might be, whether it's just in certain samples the genotyping quality was perhaps on the border of being valid or the sequencing quality. Jane:                                     Right, I'm wondering sort of with the MIP, what's the gold standard? Is the XM chip genotyping still the gold standard and the MIP maybe is more error-prone, or perhaps the other way around? Or is it you can't tell at this point which is the true genotype and which is an error potentially for those discordant ones? Dr. Khetarpal:                    Certainly whenever there's a new sequencing methodology that is proposed I think it's critical to have some sort of validation. We happened to cover regions that would span the genome enough that we had XM chip genotyping in a large subset, that that might be the best approach. But if you had a limited number of regions or variance that you were interested in one could imagine also doing Sanger sequencing as the tried and tested validation approach. Of course it becomes not so scalable at a certain point.                                                 Certainly we would say that the MIPs, while the method has been developed and expanded by the Shendure lab, our hope is that through our studies maybe it will be applied further. It's still very much a new approach and so validation is key. Jane:                                     Very important. What do you think was the most exciting finding that came out of this, after you analyzed the data, what were you most excited about seeing? Dr. Khetarpal:                    The critical finding for us, which I think implies the utility of the approach, was just the validation of four of the loci that we had studied. Validation in our cohort of known genome-wide significant associations for HDL that had been published previously in almost 200,000 individuals in terms of sample size, in our experiment involving just about 1,500 people we were able to find consistent associations of those same variants that segregated with low versus high HDL. Directionally consistent with the large genome-wide association studies.                                                 I think the value of this finding is really just to emphasize the utility of the case control design in these phenotypic extremes, in addition to the overarching goal of our study, which was in a way that perhaps provides the most validation of the approach in terms of concordance with prior known studies. Jane:                                     So if somebody was listening to this and was trying to decide should they use MIP for a study they have in mind, should they use another technique? Based on your experience, what would you recommend? Dr. Khetarpal:                    I think in our current stage it's a very exciting time because we're just seeing whole genome sequencing really take off and being used at scale to ask critical questions about non-coding variation as it relates to both disease and complex traits. I don't think we're quite there yet with being able to apply that approach in a cost effective manner. The ability to annotate and analyze that data is still at it's infancy. The utility of the MIPs is that it provides a very cheap alternative.                                                 I can say from my experiences actually doing the capture and preparation from sample to sequencer stage that it's a very easy to use methodology that is very fast and cheap. That if one is really interested in a handful, or more than a handful, of candidate genes and their non-coding regions as it relates to a trait or disease of interest, it may not be the era for going full on with whole genome sequencing, especially at the current cost. That's where I think the MIPs really come in to be very useful. Jane:                                     It sounds great, is there anything else that you'd like to mention? Dr. Khetarpal:                    Just to say that we recognize it's a relatively small study as our pioneer approach with this method but that the Rader lab and Voight labs are actively pursuing larger applications of this to study, not only HDL, but other complex traits, such as diabetes, in much larger populations. I can't overemphasize how easy of a method it is to apply, but also that I think a bigger take home of this study for me as a very recent graduate student working in a very collaborative institution the ability of two laboratories to come together with different sets of expertise to try to tackle a problem that I think goes beyond the individual science. For any human geneticist how to find the variation you're interested in and not break the bank is kind of at the core of what we do, and so I think it was very fun to be part of this collaboration and our hope is that the outcome of it is a method that can be useful for many people, both in our field and beyond. Jane:                                     I think it's great and I'm hoping this will inspire a lot of other people to try this method and see if it can work for them. So, congratulations on the study, it's really nice work. Dr. Khetarpal:    Thank you so much!                                                                                                                                       Jane:                                     That's all I have for you for July, thanks for listening. Send me your thoughts on the podcast via Twitter or email, or leave us a review in Itunes. I look forward to talking to you next month.  

Imagine being told your child has an ultra-rare disease that is life-limiting, muscle-wasting, and due to a spontaneous genetic mutation...simply put, this child’s muscles will get weaker faster than they can get stronger. This is the life Kyle Gagner and his wife, Melissa, leads and through the chaos of it all has founded Levi’s Hope, an organization to help families adjust and cope with the life-changing diagnosis of Congenital Muscular Dystrophy (CMD), including the subtype their son, Levi, is affected by - LMNA-related CMD. In this episode Kyle describes Levi’s Hope for us, as well as shares how his community finds joy within challenges, how his family has integrated disability into a fully lived life, and the hope they have for their son.

The development of relevant cellular model systems for colorectal cancer is of utmost importance for an improved in vitro assessment of therapeutic strategies against colorectal cancer. Recently published low passage colon cancer cell lines that closely reflect the characteristics of the respective parental in vivo tumor cells represent very promising cell culture models and were therefore used for the investigations in the present thesis. To provide an in vitro model system that also recapitulates the three-dimensional structure of in vivo tumors, these low passage cell lines were cultivated as multicellular spheroids. Compared to monolayer cultures the multicellular spheroids exhibited a wide variety of changes in their expression patterns. The differential expression includes proteins that are involved in growth signaling (15-hydroxyprostaglandin dehydrogenase), protein biosynthesis (acidic ribosomal protein P0), and regulation of the cyto- or nucleoskeleton (acidic calponin and LMNA protein). These proteins were identified by 2D electrophoresis and subsequent MALDI-TOF mass spectrometry. Both methods were established in the lab in the context of this work. Chemotherapy with 5-fluorouracil (5-FU) represents the traditional treatment of colorectal cancer. However, in many patients the efficiency of this therapeutic strategy is often limited by the development of chemoresistance against 5-FU. Therefore, it was an aim of this thesis to detect novel proteins involved in 5-FU chemoresistance that were previously not ascribed to resistance against this chemotherapeutic drug. A chemoresistant subline of a colon cancer cell line was generated by long-term treatment with 5-FU and served as a model for the investigation of 5-FU chemoresistance. This subline exhibited resistance against both 5-FU-induced inhibition of proliferation and apoptosis. Differences in the expression of cytokeratin 18, heat shock protein 27 and aldehyde dehydrogenase 1B1 between the chemoresistant subline and parental cells were detected by 2D electrophoresis. These findings imply that the cytoskeleton plays a role in the development of chemoresistance against 5-FU. Furthermore, processes located to the mitochondria seem to be involved in this resistance, since heat shock protein 27 and aldehyde dehydrogenase 1B1 are associated with this subcellular organelle. The biological relevance of the findings made in the present PhD thesis has to be determined in further studies. Gene therapy represents a promising alternative strategy for the treatment of colorectal cancer. A novel nonviral gene transfer system was developed by combination of DNA with the polycation PEI25br and the cationic lipids DOCSPER or DOSPER to form lipopolyplexes. These lipopolyplexes enabled enhanced gene transfer in vitro and are promising for in vivo applications, since the established lipopolyplexes preserved their small size at physiological conditions; a property essential for a successful in vivo application. Furthermore, the lipopolyplexes exhibited the capability to efficiently transfect three-dimensional multicellular spheroids. The potential of lipopolyplexes for therapeutic applications was further increased by the utilization of the artificial promoter CTP4 which enables highly specific gene expression in cancer cells with mutations in the Wnt signaling pathway by transcriptional targeting. In addition to its high specificity, this promoter enabled high gene expression levels that were comparable to expression levels obtained by the strong, but unspecific CMV promoter. The efficiency of the CTP4 promoter was demonstrated in seven low passage colon cancer cell lines and also in multicellular spheroids. The transcriptional targeted lipopolyplexes not only enabled high tumor specific expression of reporter genes like luciferase or EGFP but also the expression of a therapeutic gene, interleukin-2 (IL-2). Furthermore, tumor specific expression of cytotoxic protease 2A in combination with IL-2 was possible by using a novel bicistronic construct. The expression of the rhinoviral protease 2A led to efficient reduction of overall cap-dependent gene expression levels and therefore also the proliferation of the transfected cells, while continued IL-2 expression was guaranteed by an IRES element enabling cap-independent gene expression in the presence of protease 2A. In summary, the present results provide a promising basis for the development of novel potent strategies in the treatment of colorectal cancer.