Podcasts about university medical center utrecht

Dr. Ruben van Eijk is an associate professor in the Department of Neurology at the University Medical Center Utrecht in the Netherlands as well as a statistical consultant and medical statistician for the clinical trial methodology group at the Julius Center also in Utrecht.  Dr. Michael Benatar is a Professor of Neurology and Chief of the Neuromuscular Division and Executive Director of the ALS Center at the University of Miami.  They will be discussing their recent publication “Rethinking phase 2 trials in amyotrophic lateral sclerosis”.

In this episode of Going anti-Viral, Dr Michael Saag speaks with Dr Annemarie M. Wensing, a Clinical Virologist at the University Medical Center Utrecht and an Honorary Professor at the University of the Witwatersrand in Johannesburg. Dr Wensing joins Dr Saag to discuss the recently released IAS–USA 2025 Update of the Drug Resistance Mutations in HIV-1. Dr Wensing discusses the influence of Dr Charles Boucher in developing her interest in the topic of HIV drug resistance and Dr Wensing and Dr Saag provide an overview of HIV drug resistance and testing. Dr Wensing also provides advice to clinicians on how to manage patients who experience drug resistance. Dr Wensing and Dr Saag then discuss an upcoming report soon to be published that addresses the potential role and the important limitations of HIV DNA resistance testing. Finally, they address the topic of drug resistance in the absence of resistance mutations and look ahead to what the future holds for the field of HIV resistance. 0:00 – Introduction 1:30 – Dr Wensing reviews the influence that Dr Charles Boucher played in her development as an investigator and her interest in HIV resistance 2:46 – Discussion of why there is HIV drug resistance 4:48 – Overview of drug resistance testing, genotypes and phenotypes 7:25 – New recommendations from the IAS-USA resistance mutation panel 9:50 – Advice to clinicians on managing drug resistance 16:16 – Discussion of HIV DNA resistance testing 21:26 – Understanding drug failure in the absence of resistance mutations  24:49 – Predictions about the future Resources:  IAS–USA Drug Resistance Mutations Chart: https://www.iasusa.org/hiv-drug-resistance/hiv-drug-resistance-mutations/ __________________________________________________Produced by IAS-USA, Going anti–Viral is a podcast for clinicians involved in research and care in HIV, its complications, and other viral infections. This podcast is intended as a technical source of information for specialists in this field, but anyone listening will enjoy learning more about the state of modern medicine around viral infections. Going anti-Viral's host is Dr Michael Saag, a physician, prominent HIV researcher at the University of Alabama at Birmingham, and volunteer IAS–USA board member. In most episodes, Dr Saag interviews an expert in infectious diseases or emerging pandemics about their area of specialty and current developments in the field. Other episodes are drawn from the IAS–USA vast catalogue of panel discussions, Dialogues, and other audio from various meetings and conferences. Email podcast@iasusa.org to send feedback, show suggestions, or questions to be answered on a later episode.Follow Going anti-Viral on: Apple Podcasts YouTubeXFacebookInstagram...

Part 3 of the four episode series produced for the course Open Science for Physicists (OS4P). We discuss with our guest, Dr. Inge Stegeman, who is a neuro-otologist at the University Medical Center Utrecht, about the advantages and pitfalls of open science practices, and how to investigate if these practices have the positive effects that are claimed by their advocates. You can find more about the course at github.com/SanliFaez/OS4Physicists

This week's episode spotlights epilepsy, exploring research in the field, and global perspectives on this condition. Jonathan is joined by Maeike Zijlmans, who discusses the electrical activity in the brain which is causative for this disorder; seizures and loss of consciousness; and the more unknown aetiologies of epilepsy. Maeike Zijlmans, Neurologist and Professor, University Medical Center Utrecht, and Stichting Epilepsie Instellingen Nederland, Heemstede, both in the Netherlands, shares valuable insights into her work studying both generalised and focal epilepsy, the longevity of this disease, and exciting treatment options. Use the following timestamps to navigate the content in this episode (00:00)-Introduction (02:38)-Why neurology and later epilepsy research? (03:26)-Global perspectives on epilepsy research and clinical practice (06:30)-Aetiologies and treatment journeys associated with epilepsy (10:29)-Raising awareness (15:58)-Spotlighting electroencephalogram in the context of epilepsy (18:26)-High-frequency oscillations (21:23)-Signal analysis and phase amplitude coupling to generate an individual epileptic ‘signature' (24:38)-Intraoperative electrocorticography in people with brain tumours (26:40)-Surgical approaches to treating epilepsy (29:20)-Next-generation taskforce for the International League Against Epilepsy (31:14)-Machine learning and artificial intelligence (34:05)-Three wishes for the future of healthcare

There are several Cochrane Reviews of the effects of a class of drugs called antioxidants, covering a wide range of health conditions. One of these, focused on adults with chronic kidney disease, was updated in November 2023. In this podcast, Julia Colombijn, talks with fellow author, Robin Vernooij, both from the University Medical Center Utrecht in the Netherlands, about the topic and the findings of the review.

There are several Cochrane Reviews of the effects of a class of drugs called antioxidants, covering a wide range of health conditions. One of these, focused on adults with chronic kidney disease, was updated in November 2023. In this podcast, Julia Colombijn, talks with fellow author, Robin Vernooij, both from the University Medical Center Utrecht in the Netherlands, about the topic and the findings of the review.

Dupixent has transformed the lives of people with moderate to severe eczema, but will patients need to use it indefinitely? In this episode we explore tapering Dupixent (also known as dupilumab) with two researchers from University Medical Center Utrecht in the Netherlands that have created a patient-led roadmap for successful tapering. They are: Pediatric Dermatologist Dr. Marlies de Graaf, Head of the National Expertise Center of Atopic Dermatitis in Children; and Dr. Celeste Boesjes, who is a PhD candidate and Medical Doctor.Research Discussed in this PodcastSuccessful tapering of dupilumab in atopic dermatitis patients with low disease activity: a large pragmatic daily practice study from the BioDay registryAssociation of serum dupilumab levels at 16 weeks with treatment response and adverse effects in patients with atopic dermatitis: a prospective clinical cohort study from the BioDay registryPatient‐centered dupilumab dosing regimen leads to successful dose reduction in persistently controlled atopic dermatitisDupilumab in daily practice for the treatment of pediatric atopic dermatitis: 28‐week clinical and biomarker results from the BioDay registryDupilumab dose spacing after initial successful treatment or adverse events in adult patients with atopic dermatitis: a retrospective analysis

In this episode Teun Teunis, MD, PhD discusses the concept of Bayesian statistical framework and the future of trial design as well as the implications for Hand Surgery. Teun Teunis currently works as an assistant professor of plastic surgery at the University of Pittsburgh Medical Center. He specialises in hand and upper extremity surgery, peripheral nerve surgery, including brachial plexus surgery and complex reconstructive and microsurgery. His research interests are related to his clinical practice, with an emphasis on mental and social health and their effects on patient reported outcomes. He received his medical degree with honours from Utrecht University in the Netherlands. He performed his PhD research at the Massachusetts General Hospital and the Harvard Medical School. He returned to the Netherlands to complete his plastic surgery residency at the University Medical Center Utrecht. After which he completed a Hand and Upper Extremity fellowship at the University of Pittsburgh Medical Center.

Peter de Keizer (Associate Professor, University Medical Center Utrecht, Netherlands) and founder and managing director of Cleara Biotech B.V. discusses his drive to understand how cells that stop dividing and enter a “holding pattern,” known to cell biologists as senescence, drive disease and aging. We talk about how the peptides he has developed, called FOXO4 peptides, will enter clinical trials next year in patients with liver metastases. They work by selectively killing senescent cells, which in turn might unlock localized tissue regeneration programs. This is really cool stuff, and I bet most of you have never heard of this sort of approach!Also, our recurring guest, a board-certified radiologist and medical malpractice lawyer who goes by the pseudonym Dr. MedLaw, answers all our questions about liability associated with referrals, something we all do and probably haven't considered to the depth she covers.Let us know what you thought of this week's episode on Twitter: @physicianswkly Want to share your medical expertise, research, or unique experience in medicine on the PW podcast? Email us at editorial@physweekly.com! Thanks for listening!

Today, it's all about the eyes, which are somewhat the extension of our brain, so treating ANY condition with them can be scary. I've gotten a lot of questions from listeners about dupilumab (Dupixent) and the side effects specifically when it comes to the eyes. So to dive in on this topic, I brought in today's guest, Dr. Roselie Achten, since her PhD focuses on ocular surface disease in atopic dermatitis patients before and during dupilumab treatment. Dr. Roselie Achten is a medical doctor and PhD student at the Department of Dermatology at the University Medical Center Utrecht in the Netherlands, and I am so excited to have her on the show! You can find some of her research findings in the links section below. Have you ever experienced any side effects with your eyes after starting dupilumab? I'd love to hear about it in the comments! In this episode: Stats on how many patients develop Dupixent eye side effects (aka. dupilumab-associated ocular surface disease) Eye symptoms of patients commonly complain about How long does it typically take to develop eye problems from Dupixent? What puts you more at risk for developing Dupixent eye side effects? What are your options if you develop Dupixent eye side effects? Can reducing the use of Dupixent help? Quotes “We were also quite surprised by the fact that the majority of the patients with moderate to severe atopic dermatitis already had characteristics of the ocular surface disease. So of the 70 patients that were analyzed, 90% of them already had characteristics of ocular surface disease before the start of Dupilumab treatment." [11:09] "If patients have these signs and symptoms of dupilumab associated ocular surface disease, we first start with tacrolimus skin ointment for the external eyelids. We also start with ketotifen, which is an antihistamine eye drop... also the artificial tears, it's more for if you experience a dry eye sensation, it could lead to improvement of that symptom for a little time." [17:12] Links Find Dr. Roselie Achten online here Healthy Skin Show ep. 244: How Do Biologic Drugs For Chronic Skin Conditions Work? w/ Heather Zwickey, PhD Long-term follow-up and treatment outcomes of conjunctivitis during dupilumab treatment in patients with moderate-to-severe atopic dermatitis - ScienceDirect Identification of Risk Factors for Dupilumab-associated Ocular Surface Disease in Patients with Atopic Dermatitis - PMC (nih.gov) Ocular surface disease is common in moderate to severe atopic dermatitis patients - Achten - 2022 - Clinical & Experimental Allergy

With Luis Eduardo Juarez-Orozco, University Medical Center Utrecht, Utrecht - Netherlands & Bram Ruijsink from Kings College Hospital, London - UK. Link to paper Link to editorial

Call it serendipity, ‘luck', or being at the right place at the right time, but Miriam Sturkenboom led the IMI's project Advance, which built a pan-European safety monitoring network for vaccines. You can't make it up, but the project ended in March of 2019. Six months later, the world was thrown into chaos with the Wuhan virus, and ADVANCE, rebranded VAC4EU, now finds itself at the centre of a tsunami of vaccine roll-outs and safety studies in Europe. In this podcast we discuss how VAC4EU is currently active in the study and development of vaccines in the fight against COVID-19. We look back of the history of the project's development out of the IMI, and the role it's currently playing in the EU evaluating the performance, safety, and efficacy of the vaccines currently in use or being developed in Europe and internationally. Miriam is the head of the Department of Data Science and Biostatistics at the University Medical Center Utrecht in the Netherlands. She's a PhD of Mathematics and Physics, and the past president of the International Society for Pharmacoepidemiology, serving as an expert to the EMA, FDA, WHO and many other organizations.

The Journal of Rheumatology's Editor-in-Chief Earl Silverman discusses this month's selection of articles that are most relevant to the clinical rheumatologist. Included are excerpts from this month's Editor's Picks spotlight interview with authors Mary Safy-Khan, Paco Welsing and Johannes Jacobs from Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands about their and their co-authors' article "Current Smoking Negatively Affects the Response to Methotrexate in Rheumatoid Arthritis in a Dose-responsive Way, Independently of Concomitant Prednisone Use". - https://doi.org/10.3899/jrheum.200213 This month's selections also include: Mease, et al: Comparison of Men and Women With Axial Spondyloarthritis in the US-based Corrona Psoriatic Arthritis/Spondyloarthritis Registry - https://doi.org/10.3899/jrheum.201549 Feher, et al: Impaired Myocardial Flow Reserve on 82Rubidium Positron Emission Tomography/Computed Tomography in Patients With Systemic Sclerosis - https://doi.org/10.3899/jrheum.210040 Mohajer, et al: Metabolic Syndrome and Osteoarthritis Distribution in the Hand Joints: A Propensity Score Matching Analysis From the Osteoarthritis Initiative - https://doi.org/10.3899/jrheum.210189 Fernández-Ávila, et al: Impact of COVID-19 Pandemic on Rheumatology Practice in Latin America - https://doi.org/10.3899/jrheum.201623 Gilvaz et al: A Case of Disseminated Cutaneous Mycobacterium chelonae Infection During Treatment With Tofacitinib - https://doi.org/10.3899/jrheum.200730 Jansen, et al: Smoking and Methotrexate Inefficacy in Rheumatoid Arthritis: What About Underlying Molecular Mechanisms? - https://doi.org/10.3899/jrheum.210217 Leung: Gender Differences in Disease Activity and Impact in Axial Spondyloarthritis - https://doi.org/10.3899/jrheum.210564 To read these, and other full articles visit www.jrheum.org. Music by David Hilowitz

INTERVIEWS IN THIS EDITION: Lindsay Pietruszewski PT DPT, Research Physical Therapist Center for Perinatal Research, Nationwide Children’s Hospital, Columbus, OHTITLE: Hammersmith Infant Neurological Examination Clinical Use to Recommend Therapist Assessment of Functional Hand AsymmetriesDESCRIPTION: To determine whether in clinical settings, asymmetry scores derived from the Hammersmith Infant Neurological Examination can provide cut-off scores for recommending in-depth assessment of upper extremity functional deficits by therapists using the Hand Assessment for Infants, a high-resource tool with excellent psychometric properties.  Sonia Khurana PhD, Motor Development Laboratory, Physical Therapy Department, Virginia Commonwealth University, Richmond VATITLE: Neonatal PT Improves Neurobehavior and General Movements in Moderate to Late Preterm Infants Born in India: An RCTDESCRIPTION: To examine whether a structured neonatal physical therapy program improves neurobehavior and general movements in moderate to late preterm infants. Kristel Lankhorst PT PhD, Research Group Lifestyle and Health, HU University of Applied Sciences, Utrecht, NetherlandsTITLE: The Preliminary Criterion Validity of the Activ8 Activity Monitor to Measure Physical Activity in Youth Using a WheelchairDESCRIPTION: The primary aim of this study was to assess the absolute and relative time difference, agreement, sensitivity and positive predictive value of the adapted algorithm of the Activ8 to detect ‘active wheelchair use’ compared to observations through video recording. Maaike Bolland-Sprong MSc, Center for Child Development, Exercise and Physical Literacy, University Medical Center Utrecht TITLE: Motor Developmental Delay After Cardiac Surgery in Children With a Critical Congenital Heart Defect: A Systematic Literature Review and Meta-analysisDESCRIPTION: To systematically review evidence regarding the severity and prevalence of motor development in children with a critical congenital heart defect without underlying genetic anomalies. Marilyn Wright PT MSc, CanChild Centre for Childhood Disability Research, McMaster University, School of Rehabilitation Science, Hamilton, CanadaTITLE: Scootering for Children and Youth Is More Than Fun: Exploration of a Feasible Approach to Improve Function and FitnessDESCRIPTION: Describe scootering as a physical therapy intervention for children/adolescents with mobility limitations within the “F-Words in Childhood Disability” (fitness, function, family, friends, fun, and future) and through motion analysis. Bilinc Dogruoz  Karatekin MD, Physical Medicine and Rehabilitation Clinic, Istanbul Medeniyet University, Istanbul, Turkey TITLE: How Did the Lockdown Imposed Due to COVID-19 Affect Patients With Cerebral Palsy?DESCRIPTION: This study investigated the change in mobility, pain, functional status and spasticity in a pediatric rehabilitation unit after the lockdown. Eleonora Montagnani MSc, School of Health Sciences, University of Brighton, Eastbourne, United Kingdom TITLE: Dynamic Characteristics of Foot Development: A Narrative Synthesis of Plantar Pressure Data During Infancy and ChildhoodDESCRIPTION: This narrative review aims to describe existing research reporting plantar pressure analysis in typically developing infants and children, to advance understanding of foot development.

The COVID-19 pandemic has prompted scientists to use adaptive research designs to evaluate potential treatments simultaneously and efficiently, increasing the likelihood that patients will receive treatments most likely to be effective for them. Lennie Derde, MD, of University Medical Center Utrecht in the Netherlands and JAMA Associate Editor Christopher W. Seymour, MD, of University of Pittsburgh Medical Center join JAMA's Q&A series to discuss the latest in critical care management of COVID-19 patients and emerging treatment strategies and therapies. Recorded January 13, 2021. Related Article(s): Sensible Medicine-Optimizing the Trade-off Between Learning and Doing in a Pandemic

The COVID-19 pandemic has prompted scientists to use adaptive research designs to evaluate potential treatments simultaneously and efficiently, increasing the likelihood that patients will receive treatments most likely to be effective for them. Lennie Derde, MD, of University Medical Center Utrecht in the Netherlands and JAMA Associate Editor Christopher W. Seymour, MD, of University of Pittsburgh Medical Center join JAMA's Q&A series to discuss the latest in critical care management of COVID-19 patients and emerging treatment strategies and therapies. Recorded January 13, 2021. Related Article(s): Sensible Medicine-Optimizing the Trade-off Between Learning and Doing in a Pandemic

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Dr Greg Hundley, associate editor, director of the Pauley Heart Center, VCU Health in Richmond, Virginia. Dr Carolyn Lam: Greg, guess what we're discussing for the feature discussion? We're talking about sugar sweetened beverage tax. Isn't that interesting? We talk about sugar sweetened beverages and their health impacts, but don't actually look at how tax policies may impact cardiovascular outcomes. So this paper is super interesting, can't wait to get to it, but I really want to get my cup of coffee and discuss a couple of other really cool stuff in today's issue. I'm going to start. Do you think about factor V Leiden much? Dr Greg Hundley: Carolyn, we are early in August and we have all new house officers rotating, and actually we do discuss factor V Leiden, and we think about Protein C and Protein S deficiencies, et cetera. But how about if you tell us about your paper and educate us a little bit more on the topic? Dr Carolyn Lam: Okay. So first of all, it's Leiden or Leiden, I'm not sure. So I'm going to go with your pronunciation. Factor V Leiden is a genetic variant leading to alteration of the inactivation site of factor V, which in turn leads to activate a Protein C resistance and a prothrombotic state, just like you said, Greg. Affecting almost 5% of the Caucasian population, carriers of a factor V Leiden mutation have a fourfold higher risk of venous thromboembolism. However, the risk of arterial atherothrombotic events, such as myocardial infarction or stroke, conferred by the presence of this variant is less certain. So Dr Patel from University College London, and Dr Asselbergs from University Medical Center Utrecht and colleagues assess the association of the factor V Leiden polymorphism with subsequent atherothrombotic events, including mortality in individuals with established coronary heart disease using an individual level data meta-analysis of 25 prospective studies from the genetics of subsequent or GENIUS coronary heart disease consortium. Dr Greg Hundley: Well Carolyn, what did they find? Dr Carolyn Lam: In nearly 70,000 patients with established coronary heart disease, factor V Leiden was not associated with an increased risk of further atherothrombotic events or death compared to non-carriers. A post hoc analysis, however, suggested that factor V Leiden carriers with established coronary heart disease may gain greater protection from subsequent coronary heart disease, death, or myocardial infarction from dual antiplatelet therapy compared to non-carriers. The routine assessment of factor V Leiden genotype to improve risk stratification in secondary prevention settings is therefore unlikely to be of value and is not recommended. However, further work is required to understand if there may instead be a pharmacogenomic role for factor V Leiden status to help personalize treatment with intensive antiplatelet therapy. Dr Greg Hundley: Very nice, Carolyn. Well, my next paper is from Dr Michelle O'Donoghue from Brigham and Women's Hospital, and creates an interesting question for you, Carolyn. Would you be comfortable discontinuing aspirin three months after PCI in lieu of continuing a P2Y12 inhibitor? Dr Carolyn Lam: Ah, big, big question. Not until guidelines change, but tell me, tell me, tell me, Greg, what this paper said. Dr Greg Hundley: Well, before we get some of these more randomized trial, this study included a meta-analysis of 32,145 patients, 14,095, or 43%, with stable coronary artery disease and 18,000, nearly 56%, with ACS from randomized trials during the time period of 2001 to 2020. And they had to study discontinuing aspirin one to three months after PCI with continued P2Y12 inhibitor monotherapy compared to traditional dual antiplatelet therapy. Five trials were included, and the follow-up duration range from 12 to 15 months after PCI. The primary bleeding and MACE outcomes were the pre-specified definitions in each trial. Dr Carolyn Lam: An important study. So what did they find, Greg? Dr Greg Hundley: Well in the experimental arm, background use of a P2Y12 inhibitor with Clopidogrel in 16.5% of cases, and prasugrel or ticagrelor in 84% of patients. In total, 820 patients experienced a primary bleeding outcome and 937 experienced MACE. So the results, discontinuation of aspirin therapy one to three months post PCI significantly reduced the risk of major bleeding by 40% compared to dual antiplatelet therapy with no observed increase in the risk of MACE, myocardial infarction, or death. The findings were consistent among patients who underwent PCI for an ACS in whom discontinuation of aspirin after one to three months reduced bleeding by 50%, to 1.78% versus 3.58%, and did not appear to increase the risk of MACE where both were 2.5% and 2.98%. Dr Carolyn Lam: Nice, Greg. Could you summarize the take home message for us? Dr Greg Hundley: Sure, Carolyn. So in summary, discontinuation of aspirin with continued P2Y12 inhibitor monotherapy reduced the risk of bleeding when stopped one to three months after PCI. An increased risk of MACE was not observed following discontinuation of aspirin, including patients that had previously sustained ACS. Dr Carolyn Lam: Thanks Greg. Well, my next paper is a preclinical one showing that circular RNAs delivered via extracellular vesicles may be a new treatment for ischemic stroke. Dr Greg Hundley: Oh my goodness. Carolyn, can you orient us to circular RNAs and these extracellular vesicles? Dr Carolyn Lam: Sure, Greg. I decided not to quiz you on them. Circular RNAs are a type of endogenous non-coding RNA molecule characterized by back splicing and covalently closed continuous loops, hence circular. Previous studies have demonstrated that multiple circular RNAs have functional roles relating to ischemic brain injury. Although administering circulating RNAs using lentiviruses is efficient for experimental examination, this route is limited for clinical translation due, of course, to disadvantages in onset time and safety issues. So this is where the extracellular vesicles come in as a potential cargo delivering system, if you may, for brain remodeling after stroke. These extracellular vesicles are lipid membrane vesicles of 30 to 150 nanometers in diameter that are released by cells and can cross the blood brain barrier and have been shown capable of carrying proteins, lipids, and nucleotides as their cargo. So today's co-corresponding authors, Dr Yao from Medical School of Southeast University in Nanjing, and Dr Wang from Chinese Academy of Sciences Kunming, Yunnan in China envisioned the potential of delivering candidate circular RNAs to the brain in vivo by constructing engineered extracellular vesicles bearing circular RNAs. They initially explored this circular RNA delivery strategy idea in the context of their ongoing work regarding the functional roles of circulating RNAs in ischemic brain injury. Their microarray based profiling of acute ischemic stroke patients reveal that a circular RNA generated from the SCM-polycomb group protein homolog 1, or SCMH1 gene, is decreased in plasma of acute ischemic stroke patients and confirmed that a similar decrease occurs in stroke model mice. So they successfully engineered extracellular vesicles with circular SCMH1 over-expression and were thus able to experimentally characterize the ischemia related functional benefits of this circular RNA administration in stroke models in both mice and macaque monkeys. Cool, huh? Dr Greg Hundley: Yeah. Very nice, Carolyn. That was a great explanation. My study comes from Dr Juyong Kim from Stanford University School of Medicine, and Carolyn, this study combined RNA sequencing, chip sequencing, ATEC sequencing, and in vitro assays in human coronary artery smooth muscle cells with single cell RNA sequencing, histology, and RNA scope in a smooth muscle cell specific lineage tracing aryl hydrocarbon receptor knockout mouse model of atherosclerosis to better understand the role of the aryl hydrocarbon receptor in vascular disease. This aryl hydrocarbon receptor, heretofore AHR, is an environment sensing transcription factor that contributes to vascular development. Dr Carolyn Lam: Wow, what a comprehensive study. So what do they find? Dr Greg Hundley: The authors identified a novel population of cells derived from smooth muscle cells, termed condramyocytes, which have gene expression features of cartilage and bone formation within an atherosclerotic lesion. In addition, the environment sensing transcription factor aryl hydrocarbon receptor plays an important role in smooth muscle cell differentiation, ossification, and maintains the smooth muscle cell derived fibrous cap structure. Dr Carolyn Lam: Interesting. Okay, you know what I'm going to ask. What are the clinical implications? Dr Greg Hundley: Yeah, I knew you'd ask me that, Carolyn. So human genetics suggests a protective role of the aryl hydrocarbon receptor in the smooth muscle cell during atherosclerosis, and therapies targeted to increase the aryl hydrocarbon receptor activity in smooth muscle cells may confer protection against adverse calcific remodeling of the atherosclerotic plaque. This study also highlights a methodological advance, and further characterization of the pathways that direct the modulation of smooth muscle cells during atherosclerosis at the single cell level may be able to identify potential therapeutic targets to mitigate the risk of atherosclerosis. Dr Carolyn Lam: Oh, I like that summary, Greg. Thanks. Now, let's move on to other things in today's issue. There's a perspective by Dr Al-Lamee on the ISCHEMIA trial asking was it worth the wait? There's also a perspective by Dr Levine on the ISCHEMIA-CKD trial, providing contemporary randomized clinical data at last in this important population. There's a white paper by Dr Emmaullee on Fontan-Associated Liver Disease, screening, management, and transplant consideration. And finally, there are letters to the editor from Dr Helgestad, Chieffo, and Waksman, with replies from Dr Amin on the article The Evolving Landscape of Impella Use in the United States Among Patients Undergoing PCI With Mechanical Circulatory Support. Dr Greg Hundley: Very good, Carolyn. Well, I have a few other items in the mail bag. Xiang Cheng has a research letter entitled Cardiac Troponin I is an Independent Predictor for Mortality in Hospitalized Patients with Coronavirus Disease 2019. Also, Corinne Frere has a research letter regarding the Systemic Inflammatory Response Syndrome is a Major Contributor to COVID-19-Associated Coagulopathy, and they provide insights from a perspective single center cohort study. And finally, Dr Jeffrey Wagner has an ECG challenge regarding the infamous is it VT or not VT? Well, Carolyn, how about we get on to that feature discussion. Dr Carolyn Lam: Let's go, Greg. Beverage Texas are a promising policy approach to reduce consumption of sugar sweetened beverages. And as we know, these are linked to adverse health outcomes, such as Type 2 diabetes and obesity. Now these taxes have been adopted by seven localities in the United States, and in more than 40 countries around the world using different tax designs, but until now a critical answered question where we lack empirical data is the health impact of these beverage taxes. That is until today's feature paper, and I'm so pleased to have with us, Dr Yujin Lee from Friedman School of Nutrition Science and Policy, Tufts University, as well as our associate editor, Dr Naveed Sattar from University of Glasgow. Welcome both, and Yujin, could I start with you please? What an interesting and important idea to look at this. Could you start by perhaps first explaining to us what are the different types of tax designs? Dr Yujin Lee: There are three types of tax design. First, the volume tax is taxing sugar sweetened beverages based on the volume. For example, a penny per owns for volume tax. So the tax rate is same whether a beverage contains 5 or 20 grams of added sugar for 8 ounces. The second design is the absolute sugar content tax, which is taxing beverages based on the sugar content regardless of the volume. So for example, one cent per one teaspoon of sugar, or one cent per one gram of sugar. Lastly, tier tax is hybrid of volume and absolute sugar content tax. For example, creating different tiers products based on the sugar content and taxing based on the volume at different rates. So for example, the American Heart Association suggested three tiers. First, no tax on beverages with less than five grams of added sugar per eight ounces. And second, 1 cent per ounce on beverages with 5 to 20 grams of added sugar per 8 ounces. And lastly, 2 cents per ounce on beverages with more than 20 grams of added sugar per 8 ounces. Dr Carolyn Lam: Great. So thank you for explaining that. I mean, to be honest, I didn't even realize there were so many different tax designs. Now, could I understand a bit better? So in the US, are they mostly volume-based? And then perhaps you could tell us how did you go about your study of comparing these things, and looking on their impact on outcomes. Dr Yujin Lee: Sure. So as you mentioned, all seven US locality have been implementing the volume tax, and in this study, this is the modeling study, so we're using the nationally representative data and using a microsimulation model, and we wanted to compare and estimate the health and economic impact of the volume, absolute sugar content. And the tier tax designs in the United States. Dr Carolyn Lam: Great. And tell us what you found. Dr Yujin Lee: What we found is we found that implementing a volume-based sugar sweetened beverage tax could prevent 850,000 cardiovascular events and 270,000 diabetes over a lifetime of current US adults aged 35 years or older. And this tax design could save tens of billions of dollars in healthcare costs. In addition, taxing sugar sweetened beverage based on their sugar content, for example, the tier or absolute sugar content based tax design, could generate about double the health and economic benefits compared to the volume tax. Dr Carolyn Lam: Wow, that is so intriguing. Naveed, I have to bring you in here. So in the UK they use a tier tax. Do you? And what are your thoughts? Dr Naveed Sattar: Oh, well clearly, Carolyn, I mean, I think taxation of sugar sweetened beverages is something that all of us can agree on is beneficial. I think it's really important that many other countries and states consider this. I'm surprised that only seven states in the US are currently doing this. And in some respects, this papers is very timely. It's based on modeling. I mean maybe you can come back to Yujin about how good the modeling is, but if you think about the issue we have now in terms of health inequalities and COVID related deaths, going forward we need mechanisms to help reduce health inequalities. And this particular paper will flag up that places need to think about sugar sweetened beverage taxes and how best to do them. And I completely agree, they should be based on sugar content. I don't see why they should be more convoluted than that. And although Yujin explained it, it still seems a bit complex to me, the different mechanisms, but I think your paper is very timely and very important. And for me, the key question for Yujin is people looking at this may say well, how robust is that model? How do we know how accurate you've been in terms of the money saved, because that's going to be really important going forward, and in particular, the number of lives or cardiovascular and diabetes cases prevented? Dr Yujin Lee: Sure. So let me explain how we estimated how many cases of cardiovascular disease and Type 2 diabetes were prevented. So we use a microsimulation model, which is a computer simulation model, which is developed by the research team, led by Dr Thomas Casiano and Harvard School of Public Health. So this model predicts the probability of an individual experiencing cardiovascular disease or diabetes based on each person's risk factor, such as sex, age, total cholesterol, or smoking or diabetes, and also their SSB-consumption also be part of this input. So it estimate the probability of one person, individual, developing the future cardiovascular disease, or Type 2 diabetes, and it estimate how this prevention can save healthcare costs associated with these diseases. So in this study, this model simulates the status quo, so the way things now stand, and also it assimilate the three different tax design. After that, we compute the health outcome and costs associated with this policy options and, by comparing this model, outputs for these three tax design with the status quo. Dr Naveed Sattar: Has any country got long enough perspective data that have implemented such taxes to validate the model, or is that still to come? I mean it would be nice to get it validated in real life, but I think most people would accept that reducing sugar in beverages is a really good thing, and presumably the part of the mechanisms by reducing weight, and reducing all of the implications of excess calorie intake, particularly refined sugar, on a variety of different diseases. Is that fair? Dr Yujin Lee: Yeah, and I wanted to make a point that, since this is a modeling study, so our study cannot prove the health and economic impacts of this tax design in the United States, so rather our estimates provide evidence that can be considered and incorporate into the design, and implementation, and evaluation of future SSB taxes. Dr Carolyn Lam: That's a really good point. And maybe just to round up, Yujin, could I just ask you to were any particular individuals in the population simulated to experience larger gains? We know that it's exactly like Naveed said, it's the minorities, it's perhaps lower income region individuals who might need this more. I mean did your simulation show anything to that effect? Dr Yujin Lee: We also investigate this tax design and how this influence in sub population. Particularly we found that the SSB taxes have a larger benefit among younger adults, minorities, and adults with the lower income. Given that these population, their SSB consumption is higher than the other group, so this SSB tax implementation gives them a greater health and economic benefit to these subpopulations. Dr Carolyn Lam: Thank you so much, Yujin, for this really, really, I think, novel and very important data. Naveed, could I give you the last say as the associate editor who is managing this, and you even invited an editorial, which I liked very much, the title, Simple is Better for Local Beverage Tax Policy Diffusion. It's kind of in line with what you've been saying, but maybe some take home messages? Dr Naveed Sattar: Obviously in Circulation, we get lots of beautiful papers that very molecular depth and various other factors, but actually this paper brings us back to the reality that for many of the diseases that we treat, diet and drink intake is really relevant to our diseases and the likelihood of diseases, and there are simple mechanisms whereby we can help people in the community to actually lead better lifestyles that also are actually economically beneficial. And I think that in this paper, if it was to be implemented and looked at seriously by many states in the US, by many other countries to go along this route would have huge potential benefits on health, And it's really important at this time, given what's happened with the pandemic, and as we move forward over the next 5 to 10 years. So I think it's really timely and I congratulate the authors on it. Dr Carolyn Lam: Well, listeners, you heard it right here, novel, impactful data. That's what Circulation is about. Thank you for listening to Circulation on the Run. Don't forget to tune in again. Next week. Dr Greg Hundley: This program is copyright the American Heart Association, 2020.  

Ali Mobasheri is Professor of Musculoskeletal Biology in the Research Unit of Medical Imaging, Physics and Technology within the Faculty of Medicine at the University of Oulu in Finland. He is also Professor and Chief Researcher in the Department of Regenerative Medicine at the State Research Institute Centre for Innovative Medicine in Vilnius, Lithuania and Associate Professor in the departments of Orthopaedics, Rheumatology and Clinical Immunology at University Medical Center Utrecht, the Netherlands. Since May 2019 he has served as President of the Osteoarthritis Research Society International (OARSI).On this episode we discuss: the mission, vision and promise of the Osteoarthritis Research Society International, goals for the future and much moreConnect with Ali on LinkedInLike what you hear? Donate to our research here. See acast.com/privacy for privacy and opt-out information.

In this episode Danni chats with Dr. Renske de Kleijn from University Medical Center Utrecht. Renske talks about her research on supervisor feedback, her very supportive and useful "Happy PhD Supervisor" twitter account (@HaPhDs) and the importance of music in her life. Renske also talks about the Covid-19 related children book that she has manged to publish recently, and the Dutch imposter syndrome song that she translated to English. During the episode Renske drank a local 0.0 Heineken beer and Danni drank Amaretto.Visit our twitter account (@what2dowiththat) and Instagram account (@what2dowiththat)Enjoy the episode. See acast.com/privacy for privacy and opt-out information.

Professor Richard van Hillegersberg shares his experience with robotic esophagectomy over the years. Professor Richard van Hillegersberg is an Upper GI surgeon from the University Medical Center Utrecht in the Netherlands.

Professor Richard van Hillegersberg shares his experience with robotic esophagectomy over the years. Professor Richard van Hillegersberg is an Upper GI surgeon from the University Medical Center Utrecht in the Netherlands.

Jane Ferguson:                Hello, and welcome to Getting Personal, Omics of the Heart, your monthly podcast from Circulation: Genomic and Precision Medicine. I'm Jane Ferguson. It is August, 2019, and this is episode 31. Let's get started.                                            Our first paper comes from Freyja van Lint and Cynthia James, from University Medical Center Utrecht, and is entitled Arrhythmogenic Right Ventricular Cardiomyopathy-Associated Desmosomal Variants Are Rarely De Novo, Segregation and Haplotype Analysis of a Multinational Cohort. In this study, the team was interested in exploring variants that are associated with arrhythmogenic right ventricular cardiomyopathy or ARVC. ARVC is often attributable to pathogenic variants in genes encoding cardiac desmosomal proteins, but the origin of these variants had not been comprehensively studied.                                            The investigators identified ARVC probands meeting 2010 task force criteria from three ARVC registries in the United States and Europe and who had undergone sequencing of desmosomal genes. All 501 probands, 322 of them, or over 64%, carried a pathogenic or likely pathogenic variant in the desmosomal genes PKP2, DSP DSG2, DSC2, and JUP. The majority of these, over 75%, we're not unique with these variants occurring in more than one proband.                                            The team performed cascade screening and were able to identify the parental origin of almost all of the variants. However, they identified three de novo variants, including two whole gene deletions. They conducted haplotype analysis for 24 PKP2 variants across 183 seemingly unrelated families and concluded that all of these variants originated from common founders.                                            This analysis sheds light on the origin of variants in desmosomal genes and suggests that the vast majority of these ARVC variants originate from ancient founders with only a very small proportion of de novo variants. These data can inform clinical care particularly concerning genetic counseling and cascade screening of relatives.                                            The next paper continues a theme of cardiomyopathy and comes from Derk Frank, Ashraf Yusuf Rangrez, Corinna Friedrich, Sven Dittmann, Norbert Frey, Eric Schulze-Bahr and colleagues from University Medical Center Schleswig-Holstein. In this paper, Cardiac α-Actin Gene Mutation Causes Atrial-Septal Defects Associated with Late-Onset Dilated Cardiomyopathy, the team was interested in understanding the genetics of familial atrial-septal defect. They studied large multi-generational family with 78 family members and mapped a causal variant on chromosome 15q14, which caused nonsynonymous change in exon 5 of the ACTC1 gene.                                            In silico tools predicted this variant to be deleterious. Analysis of myocardial tissue from an affected individual revealed sarcomeric disarray, myofibrillar degeneration, and increased apoptosis. Proteomic analysis highlighted extracellular matrix proteins as being affected. The team over-expressed the mutation in rats and found structural defects and increased apoptosis in neonatal rat ventricular cardiomyocytes and confirmed defects in actin polymerization and turnover which affected contractility. These data implicate the variant in ACTC1 as causing atrial-septal defects and late-onset cardiomyopathy in this family and revealed the underlying molecular mechanisms affecting development and contractility.                                            The next paper is entitled Characterization of the CACNA1C-R518C Missense Mutation in the Pathobiology of Long-QT Syndrome Using Human Induced Pluripotent Stem Cell Cardiomyocytes Shows Action Potential Prolongation and L-Type Calcium Channel Perturbation, and it comes from Steven Estes, Michael Ackerman and colleagues at the Mayo Clinic. They set out to use patient-derived human induced pluripotent stem cells to understand the pathogenicity of a variant in the CACNA1C gene in Long-QT Syndrome.                                            They obtained cells from dermal punch biopsy from an individual with long-QT and a family history of sudden cardiac death who carried an R518C missense mutation in CACNA1C. Starting with fibroblasts, they reprogrammed the cells into iPSCs and then differentiated these into cardiomyocytes. They corrected the mutation back to wild type using CRISPR/Cas9 and then compared the cardiomyocytes carrying the original patient mutation with isogenic corrected cardiomyocyte controls. They found significant differences in action, potential duration, and in calcium handling.                                            Patch clamp analysis revealed increased L-type calcium channel window current in the original mutation-carrying cells in addition to slow decay time and increased late calcium current compared with the isogenic corrected control human iPSC cardiomyocytes. These data strongly suggest that CACNA1C is a long-QT susceptibility gene and demonstrate the potential in using patient-derived iPSCs and CRISPR/Cas9 to understand underlying mechanisms linking variants to disease.                                            The final paper this month is Blood Pressure-Associated Genetic Variants in the Natriuretic Peptide Receptor-1 Gene Modulate Guanylate Cyclase Activity and comes from Sara Vandenwijngaert, Chris Newton-Cheh and colleagues on behalf of the CHARGE+ Exome Chip Blood Pressure Consortium, the CHD Exome+ Consortium, the Exome BP Consortium, the GoT2D Consortium, the T2D-GENES Consortium, and the UK Biobank CardioMetabolic Consortium Blood Pressure Working Group.                                            This team wanted to understand how variants in the NPR-1 gene affect the function of the atrial natriuretic peptide receptor-1. They performed a meta-analysis across over 491,000 unrelated individuals, including both low frequency and rare variants in NPR-1 to identify their association with blood pressure. They identified three nonsynonymous variants associated with altered blood pressure at genome-wide significance and examined the function of these variants in vitro.                                            Using cells expressing either wild type NPR-1 or one of the three identified variants, they explored the impact of the variants on the ability of cells to catalyzes the conversion of guanosine triphosphate to cyclic 3′,5′-guanosine monophosphate in response to binding of atrial or brain natriuretic peptide. Increased levels of cyclic GMP are known to decrease blood pressure by inducing by natriuresis, diuresis, and vasodilation.                                            Two variants which associated with high blood pressure in the population meta-analysis were associated with decreased cyclic GMP in response to ANP or BNP in vitro, while one variant which associated with lower blood pressure in humans was associated with higher cyclic GMP production in vitro. These data show that variants affecting loss or gain of function in guanylate cyclase activity could have downstream effects on blood pressure at the population level.                                            That's it for this month. Thank you for listening. We will be back with more next month. This podcast was brought to you by Circulation: Genomic and Precision Medicine and the American Heart Association Council on Genomic and Precision Medicine. This program is copyright American Heart Association 2019.  

TIM TAKKEN MSc PhD is a medical exercise physiologist and associate professor in pediatrics at the Wilhemina Children’s Hospital of the University Medical Center Utrecht, the Netherlands. He has a special interest in clinical pediatric exercise physiology. He is currently director of the Clinical Exercise Testing Laboratory in the Wilhemina Children’s Hospital, Utrecht. Further he is the chair of the Dutch chapter of CPX international, boardmember of the European Group of Pediatric Work Physiology and the Principal Investigator for the Dutch Physical Activity Report Card for Children. Dr Takken published over 220 peer-reviewed papers and authored 4 books.This episode covered how to approach exercise and physical activity in those individuals with chronic health conditions. The paper can be found at:https://www.ncbi.nlm.nih.gov/pubmed/21304338

Jane Ferguson:  Hi, everyone. Welcome to Getting Personal: Omics of the Heart, the podcast from Circulation: Genomic and Precision Medicine. It's May 2019, and this is episode 28. So let's see what papers we have in the journal this month.                              First up, a paper from Mengyao Yu, Nabila Bouatia-Naji and colleagues from the Inserm Cardiovascular Research Center in Paris, entitled GWAS-Driven Gene-set Analyses, Genetic and Functional Follow-Up Suggest Glis1 as a Susceptibility Gene for Mitral Valve Prolapse.                              In this paper, they set out to characterize the genetic contributions to mitral valve prolapse, or MVP, to better understand the biological mechanisms underlying disease. They applied the gene-set enrichment analysis for QWAS tool and the pathway enrichment tool DEPICT to existing GWAS for MVP in a French sample to identify gene sets associated with MVP. They find significant enrichment of genes involved in pathways of relevance to valve biology and enrichment for gene expression in tissues of relevance to cardiovascular disease.                              They zeroed in a Glis family zinc finger gene Glis1 with consistently strong pattern of evidence across the GWAS enrichment and transcription analyses. They replicated the association between Glis1 and MVP in a UK biobank sample. They found that Glis1 is expressed in valvular cells during embryonic development in mice, but is mostly absent at later times. They targeted two Glis1 orthologs in zebrafish and found that knockdown of Glis1 B was associated with a significant increase in the incidence of severe atrioventricular regurgitation. These data highlight Glis1 as a potential regulator of cardiac valve development with relevance for risk of mitral valve prolapse.                              Next up is a paper from Gina Peloso, Akihiro Namuro, Sek Kathiresan and colleagues from Boston University, Kanazawa University, and Mass General Hospital. In their paper, Rare Protein Truncating Variance in APOB, Lower LDL-C, and Protection Against Coronary Heart Disease, the team was interested in understanding whether protein truncating variance in APOB underlying familial hypobetalipoproteinemia confer any protection against coronary heart disease.                              They sequenced the APOB gene in 29 Japanese families with hypobetalipoproteinemia as well as in over 57,000 individuals, some with early onset CHD and some without CHD. They found that presence of an APOB truncating variant was associated with lower LDL cholesterol and lower triglycerides, and also with significantly lower risk for coronary heart disease. This study confirms that variance in APOB, leading to reduced LDL and triglycerides are also protective against coronary heart disease. :                            The next paper entitled Mortality Risk Associated with Truncating Founder Mutations in Titin comes to us from Mark Jansen, Dennis Dooijes, and colleagues from University Medical Center Utrecht. They analyzed the effect of titin truncating variance on mortality in Dutch families. Titin truncating variants are associated with dilated cardiomyopathy, but have a very variable penetrance.                              In this study, the authors looked at three titin truncating variants, established to be founder mutations, and traced the pedigrees back to 18th century ancestors. They looked at 61 individuals on the transmission line and 360 of their first-degree relatives. They find no evidence for excess mortality in variant carriers overall. However, when they restrict it to individuals over 60 years of age, they did find a significant difference in mortality, which was also observed in individuals born after 1965. What these data tell us is that these titin truncating variants have a relatively mild phenotype with effects on mortality only manifesting later in life in many carriers. Given increases in life expectancy over the past several decades, the prevalence of morbidity and mortality attributable to titin truncating variants may increase. Genetic screening may identify genotype-positive, phenotype-negative individuals who would benefit from preventative interventions.                              Continuing on the theme of genetic variance, we have a paper from John Giudicessi, Michael Ackerman, and colleagues from the Mayo Clinic, Assessment and Validation of a Phenotype-Enhanced Variant Classification Framework to Promote or Demote RYR2 Missense Variants of Uncertain Significance. In this paper, they aim to find a better way to classify variants of unknown significance, of VUS, in the RYR2 gene. Variants in this gene are commonly associated with catecholaminergic polymorphic ventricular tachycardia, or CPVT.                              They examined 72 distinct variants in 84 Mayo Clinic cases and find that 48% were classified as VUS under ACMG guidelines. The rate was similar in a second sample from the Netherlands, with 42% of variants originally classified as VUS. They developed a diagnostic scorecard to incorporate a pretest clinical probability of CPVT, which included various clinical criteria, including symptoms and stress test results. Application of the phenotype enhanced ACMG criteria brought the VUS rate down to 7% in Mayo Clinic and 9% in the Dutch samples. The majority of VUS were reclassified as likely pathogenic.                              This study highlights how incorporation of disease-specific phenotype information can help to improve variant classification and reduce the ambiguity of reporting variants of unknown significance.                              We also have a number of research letters in the journal this month. From Karine Ngoyen, Gilbert Habib, and coauthors from Marseilles, we have a paper entitled Whole Exome Sequencing Reveals a Large Genetic Heterogeneity and Revisits the Causes of Hypertrophic Cardiomyopathy, Experience of a Multicentric study of 200 French Patients. In this study, they examined the genetic contributions to hypertrophic cardiomyopathy, or HCM, in 200 individuals as part of the HYPERGEN study and compared the benefits of whole exome sequencing compared with targeted sequencing of candidates' sarcomeric genes. All subjects had HCM documented by echocardiography.                              In the whole exome sequencing data, they first looked for mutations within 167 genes known to be involved in cardiomyopathies or other hereditary diseases. Of these 167 virtual panel genes, they find variants in 101 genes. Following whole exome sequencing, over 87% of the patients had an identified pathogenic, or likely pathogenic, mutation compared with only 35% of patients who only had targeted sequencing of sarcomeric genes.                              This highlights the generic heterogeneity of HCM and suggests that whole exome sequencing has utility in identifying variants not covered by sarcomeric gene panels.                              The next letter is from Wouter Te Rijdt, Martin [Vandenberg] and colleagues from University Medical Center Groningen and states that [dissynchronopathy] can be a manifestation of heritable cardiomyopathy. They hypothesized that left bundle branch block, also designated as dissynchronopathy, may be a manifestation of familial cardiomyopathy.                              They analyzed patients from a database of cardiac resynchronization therapy and identified super-responders whose left ventricular dysfunction was normalized by therapy. They carried out targeted sequencing in 60 known cardiomyopathy genes in 16 of these super-responder individuals and identified several variants, including a pathogenic variant in troponin T in one individual and variants of unknown significance in nine individuals. Pedigree analysis identified multiple family members with dilated cardiomyopathy.                              This study highlights that dissynchronopathy can be a manifestation of DCM, but that affected individuals may still benefit from cardiac resynchronization therapy.                              The next letter entitled Targeted Long-Read RNA Sequencing Demonstrates Transcriptional Diversity Driven by Splice-Site Variation in MYBPC3 comes from Alexandra Dainis, Euan Ashley, and colleagues from Stanford University. They set out to understand whether transcriptome sequencing could improve the diagnostic yield over genome sequencing in patients with hypertrophic cardiomyopathy. In particular, they hypothesized that long-read sequencing would allow for identification of alternative splicing linked to disease variance. They used long-read RNA and DNA sequencing to target the MYBPC3 gene in an individual with severe HCM who carried a putative splice-site altering variant in the gene. They were able to obtain heart tissue for sequencing and included several HCM and control subjects in addition to the patient with the MYBPC3 variant.                              They identified several novel isoforms that were only present in the patient sample, as well as some additional isoforms, including retained introns, extended exons, and an additional cryptic exon, which would not have been predicted based on the DNA variant. While the effects on protein function is not known, the transcripts are predicted to be translated.                              This analysis highlights the effect of a rare variant on transcription of MYBPC3 and provides additional evidence to link the variant to disease. This is a really nice approach, which could be used to probe causality and mechanisms, not only for cardiovascular disease, but for other rare variants in many disease settings.                              We finish with a perspective piece from Nosheen Reza, Anjali Owens, and coauthors from the University of Pennsylvania entitled Good Intentions Gone Bad, The Dangers of Sponsored Personalized Genomics. They present a case of a 23-year-old woman who presented for genetic counseling and evaluation after discovering she carried a likely pathogenic MYH7 variant associated with cardiomyopathy. She had no significant medical history, but had participated in employer-sponsored genetic testing motivated to identify potential variants related to cancer given a family history of cancer.                              After receiving her results, she experienced considerable anxiety and stopped exercising out of fear of cardiac complications. She visited an ER after experiencing chest pain, something she had not experienced previously. There was no appropriate counseling available at her institution for her genetic test results, leading her to seek out the additional counseling. Thus, while she was initially motivated to complete genetic testing because her employer offered it free of change, she ended up incurring costs related to the followup evaluation and counseling. Ultimately, she had no significant clinical findings. Although the variant had been listed as likely pathogenic, other sources consider it to be of unknown significance.                              This story highlights the psychological and financial impact that genetic testing can have on individuals, particularly when carried out without any pretest counseling or accessible post-test support when variants are identified.                              Despite the considerable promise of personalized medicine, there are many complexities to be considered, particularly with direct-to-consumer testing and employer-sponsored testing. This perspective highlights the ethical considerations and urges caution to maintain the best interests of patients.                              That's all for this month. Thanks for listening. I look forward to bringing you more next month.                              This podcast was brought to you by Circulation Genomic and Precision Medicine and the American Heart Association Council on Genomic and Precision Medicine. This program is copyright American Heart Association 2019.  

Jane Ferguson: Hi everyone. Welcome to episode 20 of Getting Personal Omics of the Heart, the podcast brought to you by the Circulation: Genomic and Precision Medicine Journal and the American Heart Association Council on Genomic and Precision Medicine. I'm Jane Ferguson from Vanderbilt University. It's September 2018 and let's dive straight into the papers from this month's issue of Circulation: Genomic and Precision Medicine.                                 We're starting off with some pharmacogenomics. Bruce Peyser, Deepak Voora and colleagues from Duke University published an article entitled, "Effects of Delivering SLCO1B1 Pharmacogenetic Information in Randomized Trial and Observational Settings."                                 Although statins are generally well tolerated, 5-15% of patients taking statins for LDL lowering and cardiovascular protection end up developing statin associated muscular symptoms. Because onset of muscular symptoms associated with discontinuing statin use, as well as increased cardiovascular morbidity, there is a clear need to identify ways to prevent or reduce symptoms in these people. Variants affecting statin related myopathy have previously been discovered through GWAS, including a variant in the SLCO1B1 gene, which also has been shown to relate to statin myalgia and discontinuation of statin use. The risks appear to be greatest with simvastatin, indicating the people at risk of muscle complications may do better on either low-dose Simvastatin or another statin. However, there's still some uncertainty surrounding the risks and benefits of various statins as they pertain to risk of muscular symptoms.                                 The authors have previously shown that pharmacogenetics testing led to increased number of people reporting statin use, but effects of pharmacogenetic testing on adherence, prescribing, and LDL cholesterol had never been tested in a randomized control trial. In this study, they randomized 159 participants to either genotype informed statin therapy or usual care, and then followed them for months to eight months.                                 25% of participants were carriers of the SLCO1B1 star five genotype. The authors found that statin adherence was similar in both groups, but gene type guided therapy resulted in more new statin prescriptions and significantly lower LDL cholesterol at three months, and levels that were lower but no longer significantly different at eight months.                                 In individual's randomized to usual care who then crossed over to genotype informed therapy after the trial period ended, there was an additional decrease in LDL cholesterol. Overall, genotype informed statin therapy led to an increase in re-initiation of statins and decreases in LDL cholesterol, but did not appear to affect adherence.                                 The authors also examined the effects of commercial genetic testing for SLCO1B1 variants in an observational setting by looking at over 92000 individuals with data available in the EHR. They found the people who receive genetic testing results had a larger drop in LDL cholesterol compared to untested controls. Overall, the study indicates that carriers of the SLCO1B1 risk variant may benefit from genotype informed statin therapy, while for non-carriers receiving their results may has limited effects.                                 If you want to read more on this, Sony Tuteja and Dan Rader from UPenn wrote an editorial to accompany this article, which was published in the same issue.                                 We're staying on the topic of statins and LDL for our next paper. This article comes from Akinyemi Oni-Orisan, and Neil Risch and colleagues from the University of California and is entitled, "Characterization of Statin Low-Density Lipoprotein Cholesterol Dose-Response Utilizing Electronic Health Records in a Large Population-Based Cohort."                                 They were interested in understanding what determines variation in statin induced LDL reduction, particularly the genetic component, and they used a large EHR derived data set, the Kaiser Permanente Genetic Epidemiology research on adult health and aging cohort to address this important question. An EHR dataset does have intrinsic limitations, but also has some clear strengths, not only as a readily available and cost-effective data source for large sample sizes, but also because it reflects real world clinical care in diverse individuals, which is not always well represented within the selective constraints of a randomized trial.                                 There were over 33000 individuals who met their inclusion criteria. To account for differences in potency between different statins and doses, the authors generated a defined daily dose value, with one defined daily dose equal to 40 milligrams per day of Lovastatin. The slope of the dose response was similar across statin types and across different sex and race or ethnicity groups. But there were differences by statin type in the response independent of dose, as well as differences in absolute responses by sex, age, race, smoking, and diabetes.                                 Based on these differences, the authors revised the defined daily doses and they highlight how previously defined equivalencies between different statins may not be accurate. They found that individuals with East Asian ancestry had an enhanced response to therapy compared with individuals of European ancestry.                                 The authors identified related individuals within the data set and the estimated heritability of statin response using parent-offspring and sibling pairs. They found only modest heritability, indicating that non-genetic factors may be more important in determining variability in statin response. Overall, this large single cohort study adds to our knowledge on determinants of statin response and raises further questions on the relative effects of different statins and doses within patient subgroups.                                 Okay, so now let's talk about GWAS and Athero. Sander van der Lann, Paul de Bakker, Gerard Pasterkamp and coauthors from University Medical Center Utrecht published a paper entitled, "Genetic Susceptibility Loci for Cardiovascular Disease and Their Impact on Atherosclerotic Plaques."                                 Over the past decade, genome-wide association studies in large cohorts have been very successful in identifying cardiovascular risk loci. However, relating these to subclinical disease or two mechanisms has been more challenging. The authors were interested in understanding whether established GWAS loci for stroke and coronary disease are associated with characteristics of atherosclerotic plaque, the idea being that some of the risk loci may alter disease risk by determining the development and stability of plaque. They identified seven plaque characteristics to study and histological samples, including intraplaque fat, collagen content, smooth muscle cell percentage, macrophage percentage, calcification, intraplaque hemorrhage, and intraplaque vessel density.                                 They selected 61 known loci and examined association of those SNiPA with black phenotypes in over 1400 specimens from the athero express biobank study. Out of the 61 loci, 21 were associated with some black phenotype compared with zero of five negative control loci, which were chosen as established GWAS loci for bipolar disorder, which, presumably, should share limited mechanistic etiology with plaque. They used the software package VEGAS to run gene-based analyses. They also assessed SNiPA relationships with gene expression and methylation in multiple tissues derived from two independence Swedish biobanks, which included atherosclerotic arterial wall, internal mammary artery, liver, subcutaneous fat, skeletal muscle, visceral fat, and fasting whole blood.                                 One CAD locus on chromosome 7q22 that survived correction for multiple testing was associated with intraplaque fat, and was also an EQTL for expression of several genes across multiple tissues. In addition, it was also a methylation QTL.                                 The authors focused on this locus and looked at correlation of expression within the LDL receptor and noted associations with HDL and LDL cholesterol in the global lipids genetics contortion data, which suggests that this locus may have a role in the metabolism. At this locus, the HBP1 gene expressed foam cells may be an interesting candidate as a causal gene in determining plaque-lipid accumulation and cardiovascular risk.                                 So next up, we have a paper that is also about athero and is coauthored by many of the same group as did that previous study. So yeah, this group's productivity is kind of making the rest of us look bad this month. So Martin Siemelink, Sander van de Lann, and Gerard Pasterkamp and their colleagues published, "Smoking is Associated to DNA Methylation in Atherosclerotic Carotid Lesions."                                 Okay. So I think one of the few things we can all definitely agree on is that smoking is bad. But, does smoking exert any of its cardiovascular damage by altering within atherosclerotic plaques? That's the question this group set out to answer.                                 They carried out a two-stage epigenome-wide association study, or EWAS, with discovery and replication of differentially methylated loci with tobacco smoking within carotid arteriosclerotic plaques of a total of 664 patients undergoing carotid endarterectomy and enrolled in the arthero-expressed biobanks study. In discovery, they found 10 CpG loci within six genes that associated with smoking. Four of the CpG loci replicated. These four loci mapping within six genes showed reduced methylation in current smokers compared with former or never smokers.                                 However, there was no difference in specific plaque characteristics based on methylation at any of the four loci. There was also no significant difference in plaque gene expression at these loci based on smoking status. However, a SNiPA at a nearby locus located in the 3' UTR of the PLEKHGB4 Gene was associated with methylation at AHRR, and was a [inaudible 00:09:58] QTL for PLEKHGB4 of expression but not a AHRR expression. The authors speculate that PLEKHGB4 may co-regulate AHRR expression. The authors also examined blood methylation in a subset of the same subjects, and they were able to replicate previously identified CPG sites associated with smoking.                                 This is a really complex area, and it's hard to identify mechanisms and causality from these multiple layers of data, but the authors demonstrate the importance of using disease relevant tissues to start to understand how environmental factors interact with genetics and other underlying physiology to modify methylation and function within the vasculature.                                 Our final full-length research paper this issue from Brian Byrd and colleagues Michigan, is actually the subject of our interview today. So I won't go into too much detail on it right now, but keep listening for an interview with Brian about their paper, "Human Urinary mRNA as a Biomarker of Cardiovascular Disease: A Proof-of-Principle Study of Sodium-Loading in Prehypertension."                                 Our review article this month is about the "Dawn of Epitranscriptomic Medicine" from Konstantinos Stellos from Newcastle University and Aikaterini Gatsiou from Goethe-Universität Frankfurt. In this paper, they're taking us to the next level beyond just RNA, but towards RNA epigenetics. Given the large number of possible modifications that can and are made to RNA during RNA name metabolism, there's huge potential to gain a new biological and mechanistic understanding by studying the RNA epitranscriptome. I think we'll ignore this at our peril. So if you need to catch up on this new field, this comprehensive review will get you right up to speed.                                 Moving on, our research letters are short format papers that allow authors to present focused results. These are also a great avenue to submit findings from replication studies that might not necessitate a full-length paper. So if you have some data from a replication study that you've been procrastinating writing up, a short research letter is a great format to consider.                                 This month, Bertrand Favre, Luca Borradori and coauthors from Bern University Hospital published a letter entitled, "Desmoplakin Gene Variants and Risk for Arrhythmogenic Cardiomyopathy: Usefulness of a Functional Biochemical Assay." The desmoplakin is essential for the cell-cell adhesion complex's desmosomes. Mutations in this gene have been associated with a wide range of phenotypes, including some in skin and hair, but also in heart, which can manifest arrhythmogenic or dilated cardiomyopathy. This protein anchors intermediate filaments, so mutations that alter binding to intermediate filaments may pathogenicity.                                 The author selected seven reported amino acid altering mutations in desmoplakin, and they screened for effects on binding using a novel fluorescence binding assay. They found that three of the seven mutations had a clear impact on binding. This assay is a novel way to assess functional impact of desmoplakin variants, and may be useful to inform the severity of future phenotypes in individuals carrying a desmoplakin mutation.                                 Finally, if you want to stay up-to-date on the genetics of aortic disease and Marfan syndrome, you can find a letter from Christian Groth and colleagues and an author response from Norifumi Takeda and colleagues regarding their previously published paper on impact of pathogenic FBN1 variant types on the progression of aortic disease in patients with Marfan syndrome.                                 I am joined today by Dr. Brian Byrd from the University of Michigan, who is the senior author on a Manuscript published in this month's issue, entitled, "Human Urinary mRNA as a Biomarker of Cardiovascular Disease: A Proof-of-Principle Study of Sodium-Loading in Prehypertension."                                 So welcome Brian. Thanks so much for coming on the podcast. Brian Byrd:          Thank you for having me. Jane Ferguson: So before we get started, could you give a brief introduction of yourself to the listeners and maybe tell us a little bit about how you got into the field? Brian Byrd:          Absolutely. So I am a cardiologist and a physician scientist. I'm an assistant professor at the University of Michigan, where I have a laboratory engaged in clinical investigation. My background is that I did my Internal Medicine Residency at Vanderbilt University. And after I finished residency, I entered Nancy Brown's lab. She's the Chair of Medicine at Vanderbilt, as I know you're aware. And she had a laboratory focused, and still does have a laboratory focused, on the investigation of high blood pressure, with a lot of focus on understanding high blood pressure as it occurs in humans. And I got a Master of Science degree in clinical investigation while I was in her lab, and we did some work on a number of topics related to the renin-angiotensin-aldosterone system, which has been a long-standing interest of mine ever since then.                                 So, at the same time, I was learning how to take care of patients with very complex blood pressure problems, who required three, or four, or five, or six blood pressure medications, in some cases, to control. And it's with that background that I became very interested in the science that underlies treatment-resistant high blood pressure in people and what we might be able to do about that. Jane Ferguson: Wow. Nice. Yeah and I think that background of sort of the combination of clinical and experimental is really nice and really important. I think your paper actually exemplifies that really nicely, so using humans but also some basic science techniques and combining them to really have a very patient focused instead of mechanistic interrogation.                                 So as I mentioned, you just published this really nice manuscript using urine as a source of mRNA biomarkers, which has relevance to hypertension and potentially also to other diseases. But before we get sort of too much into the weeds on the specific details, for any of our listeners who didn't get a chance to read your paper yet, maybe you could briefly summarize what you did? Brian Byrd:          Okay, so the general overview of what we were interested in was that the patients who have treatment resistant high blood pressure tend to have a lot of activation of a receptor in the kidney called the mineralocorticoid receptor. And this receptor helps control salt in bladder in the body. Obviously the amount of salt in the blood stays very, very homeostatic, but we if eat more salt one day then the next and there needs to be a system to help regulate the homeostasis. And so, you waste more or less salt in the urine depending upon how much sodium you're taking in.                                 And one of the functions of the mineralocorticoid receptor is to control this salt and bladder regulation or to fine tune it anyway. And the reason we know that that's an important receptor in patients with treatment-resistant high blood pressure is because of a series of studies done by David Calhoun and Brian Williams and others, showing that mineralocorticoid receptor blockers, or antagonists, are very effective in the treatment of tough to control high blood pressure.                                 And so, we had some insight that there would be something interesting to study there, and one of the things that we knew was that the mineralocorticoid receptor is a ligand activated transcription factor. So when it gets activated by it's ligan which canonically is a steroid hormone from the adrenal gland aldosterone, the receptor, which is in the cytoplasm, ordinarily dimerizes and translocates to the nucleus, where it controls the regulation of a number of genes. We also were aware that cells secrete RNA, and others had the idea that it might be inside vesicles because there's a lot of ribonuclease and biofluids. And you would think it might be difficult to pass the RNA if it were sort of naked as it were.                                 And it turns out that that's right. If you, for example, introduced synthetic RNAs into biofluids, the RNAs will be gone very quickly in a matter of seconds. So, we had this idea that we might be able to look at RNA that was being secreted by cells probably in vesicles, and assay the activity of the receptor potentially. We weren't sure if that was going to be possible or not.                                 One of the things we did was we used part of the available data to look at the transcriptome of vesicles in the urine that had been isolated from 3300 milliliters of urine by ultracentrifugation [inaudible 00:18:57]. Jane Ferguson: So it's a big centrifusion. Brian Byrd:          Exactly. Jane Ferguson: Like you [inaudible 00:19:00] Brian Byrd:          It must have been some project. So that was the work of Kevin Miranda and colleagues, and we were able to compare that transcriptome to the transcriptome of human kidney cortex samples from the GTEx project, which a large consortium focused on human transcriptomics.                                 And that was sort of the first part of what we presented in this paper, and the second thing that we did was we looked within a crossover study in a collaboration with Scott Hummel, one of my close collaborators here at the University of Michigan. We looked at individuals who had been put on a low salt diet activating renin-angiotensin-aldosterone system and causing more activation of the mineralocorticoid receptor. And then, those same individuals underwent saline infusion, so salt loading, and we knew that that would suppress the renin-angiotensin-aldosterone system. And we measured the [inaudible 00:20:02] measures of the renin-angiotensin-aldosterone system, but we also took the urine samples that had been recently banked from that experiment and we centrifuged them to try to palette the cells. We took the supernatant and we extracted RNA after trying to enrich for extracellular vesicles.                                 And with that approach, we measure targets that we thought would be regulated my the mineralocorticoid receptor, as well as some things that we did not think would be regulated by mineralocorticoid receptor. So that's the general overview of what we undertook. Jane Ferguson: Great. Right. So it's very cool. I guess we can break it down into sort of the two different parts, because I think it was a really nice examples of using public data to sort of start addressing your question and then actually doing a human experiment. But so for the GTEx data and the urinary data, you looked at few different tissues, right? And was kidney the one that you were thinking upfront would sort of most likely to correlate, or were you also looking at bladder and other sort of tissues that could potentially be of relevance to urine? But what sort of the ... I guess sort of tell me more about those different tissues that you looked at and what you found and what surprised you or not. Brian Byrd:          Great question. So, the kidney was on our minds from the outset. We knew that Mark Knepper at the National Institute of Health had published in the [inaudible 00:21:25] National Academy of Sciences back in 2004 that there are urinary extracellular vesicles. And he had found proteins that are very characteristic of the aldosterone sensitive distal nephron, that part of the kidney that we're interested in, embedded in the vesicles.                                 So we became quite interested in the idea that it seemed that there was likely a population of vesicles in the urine that is of kidney origin. And that's not to say that there weren't also plenty of vesicles from other origins as well, and there could very well be RNA that is not vesicle enclosed, but is rather ribonucleic protein bound or even bound to other carriers potentially. That could be there as well, and it's possible that the origin of those things could be any number of tissues. I don't really think that we know yet where the possible tissue origins are.                                 But we were curious to know ... I guess the direct answer to your question is we thought from the outset that we probably would find some sort of signal related to the kidney. But we wanted to also consider the possibility that our findings were not very specific to the kidney. And so we thought that the brain would be an interesting negative control. If we say very high correlation with the brain, it would suggest that maybe what we're looking for is a signal that's not really coming from the kidney.                                 And we also wanted to look at the bladder just to try to understand whether or not the signals that we're detecting could be coming from the bladder. It's certainly true that some aspects of the system that we're interested in are present in the bladder, so I wondered whether that might even serve as a signal amplifier for what we were looking for since there's, presumably, quite a bit of bladder tissue right around the urine. It might be contributing vesicles.                                 So that's sort of the rationale for why we looked at those things. Jane Ferguson: And you found mostly enrichment for kidneys. So sort of I guess what you were hoping to find came true? That actually there was sort of evidence that even though there may be contribution from other tissues, that really kidney seem to be the predominant contributor to the expression of the genes in the urine. Brian Byrd:          I think there's a lot of truth to that. One of the things I would say is we found high correlation looking across all genes. But it occurred to us ... As soon as we thought that, we realized, wait a second, that could be driven by ubiquitously expressed genes. Housekeeping genes.                                 So we really wanted to stratify our analysis by things we thought would be expressed in the kidney as well as things that we thought would be ubiquitously expressed to make sure that we could see signals that correlate ... That the transcriptome of the kidney, per se, had a good correlation with those same in terms of the abundance of the gene counts or recounts. They said it was similar to what was in the vesicles.                                 And so, we looked in the literature, and we found that a group had already established a number, 55 genes actually, that were highly kidney enriched as well as over 8000 genes that were ubiquitously expressed. And so we started the analysis from this perspective of the stratification. We thought that was a very important aspect of the analysis. And it's definitely true that if you look at our findings with respect to the kidney enriched genes, as you might expect, they correlate quite well with what is in the urinary extracellular vesicles compared to the kidney cortex.                                 You look at the brain as you might expect the expression of those kidney enriched genes is not well correlated with what's happening in the urine. And then, with respect to the bladder, it's sort of somewhere in between. Jane Ferguson: Okay. Interesting. So I know that some people look at small non-coding RNAs in urine, but you were mostly focused on mRNAs. Is that right? Brian Byrd:          That's right. I thought of this as sort of frontier, something that I knew from some early publications was probably measurable. But I didn't know what it would signify, if anything, with respect to physiology. And I knew that there were quite a few papers about micro RNAs and I wanted to do something a little bit innovated, partly.                                 But the main reason that I was interested in the RNAs was because I could relatively easily tie those to the existing literature from animal models. Preclinical animal models and cell culture studies showing what happens when the mineralocorticoid receptor's activated. That was really the driving reason that I was interested in the RNA. Because if you think about what is the approximate event that might be a readout for activation of a new growth hormone receptor like the mineralocorticoid receptor, it's really the transcriptional events that happen when the receptors translocates to the nucleus and serves its ligan activated transcription factor role. Jane Ferguson: Right. So, [inaudible 00:26:43] sort of the first part of analysis, you saw these really nice correlations between expression and kidney and in urine. And then, a lot of the times when you tried to publish that kind of thing, people are like, "Okay, so what? So you didn't do any intervention. We don't really know what that means."                                 But I like that you took it to the next step and you did sort of a human intervention experimental model. So tell me more about that model and how that worked. Brian Byrd:          Right. Well, I'll just mention also that the work that was done in terms of RNA [inaudible 00:27:14] was done in collaboration with Mark Bertini in Italy as well as Dr. [inaudible 00:27:19]. They were fundamental to getting that work done.                                 With respect to the collaboration with Scott Hummel, one of my colleagues here at the University of Michigan, what we did in that setting was to look at whether or not we could identify within these urinary mRNA signals that are in the supernatant in the urine, whether we could identify changes in physiology. That was the question that was of greatest interest scientifically.                                 And for a very practical or blind perspective, the question was could we detect the activation of the receptor that might determine whether or not people should get a certain medication. Of course, we're not saying that that's an established fact yet, but this is sort of concept, that there's something here to explore further.                                 And so, what we found was that a number of genes that are regulated by the mineralocorticoid receptor, including genes encoding the subunits of the amiloride-sensitive epithelial sodium channel that regulates the salt that I was talking about earlier. We found that those genes changed with sodium loading in terms of their abundance in the expected direction.                                 We also found that several of the assays that we made changed ... I'm sorry. That they correlated with the serum aldosterone concentration. So the concentration of the ligan for the receptor whose readout we were looking for. And we also noticed an inverse correlation with urinary sodium excretion, which is what we would expect if we really identified a readout of the mineralocorticoid receptor's activity.                                 So this study supported the idea that we have identified a way to measure this nuclear hormone receptors activity in living humans. Jane Ferguson: Right. Which is really nice. So there's probably a huge amount of extra things you could do with this, some sort of different ways you could look at it. So how did you pick the time point? So, I suppose when you think about it, I mean the genes, they're transcribed and then that takes a little bit of time, and then it takes a little bit of time for that to sort of make its way into the urine and to be excreted.                                 So how did you decide on sort of what time points to use, and do you think you would see the same things or different things [inaudible 00:29:39] if you did repeated sampling or if you looked at different time points? Brian Byrd:          That's a fantastic question. So this was a study that had already been completed, and I had mentioned to Scott what we were working on. And he said, "You know, we have these samples from this study and it might be possible for us to collaborate."                                 So, we didn't get to pick the timeframes. Jane Ferguson: Right. Brian Byrd:          So, that's a great point. And what I would say is that, as you can imagine, we're very focused on exactly the questions you're asking now. What about sort of signal refinement? What about the chrono-biology of these signals, and how do we understand when we see what in the urine?                                 So, I'm actively pursuing those questions. Jane Ferguson: Right. So, I know as well, there was quite a lot of sort of technical challenges I think to doing this work. Sort of getting to be even able to amplify and get a signal from these RNAs that are really present, sort of pretty low abundance in urine compared to tissues or biofluids that we're used to working with.                                 So tell me maybe a little bit about that process and sort of how much optimization was required to get these essays to work? Brian Byrd:          Great question. So, I had known [inaudible 00:30:58] since 2014 when I took a course on isolation of extracellular vesicles in Heidelberg, Germany. And I had talked to him at a meeting in Washington DC, and I had mentioned what we were trying to do. And he said, "You know, if you were trying to do that, you might want to consider preamplification." You know, using something like 15 cycles of preamplification. And he was willing to share that protocol that he had with me, because they were interested in similar issues. So, I was able to use that protocol to evaluate these gene targets in the urine. And so that was immensely helpful.                                 And the other thing that we did was we used locked nucleic acid probes to try to increase the sensitivity and specificity of our assays. Finally, we just tried to use good logic in the design of the assays. So we were concerned that the RNA might be fragmented, so where it was possible to do so within the design constraints that I'll mention in a second, we made multiple assays per gene target just in case this was fragmented. Which makes the analysis a little more complicated, but I think it was probably the right thing to do, given the state of knowledge that we had then.                                 And one of the other things we did was we made sure that the primers either ... Within a primer, there was an intron or between the primers there was an intron, so that if we actually did try to amplify DNA, abundant amounts of DNA, with those primers just to make sure that our theorizing about the inability to amplify things was actually factual. And that turned out that we couldn't amplify anything at 40 cycles with those.                                 So, we spent a lot of time thinking about how not to get fooled, but also to have adequate signal detection. And have included in the supplement quite a bit of information about the technical merits of the assays and showing how close the technical replicates were. They tended to be very, very similar to one another. We didn't see a signal in every urine sample for every participant at both time points, and I think that was interesting to me about that there tended to be a very binary result, so that you'd either see three technical replicants for the QPCR assays, our QPCR assays that were extremely similar to each other, or you would see no CT value detected.                                 [inaudible 00:33:47] That these were valid assessments of very low copy numbers. Jane Ferguson: Right. And that's probably related to up front of what happens to urine right after it's collected and stored, or during that RNA extraction. But it seems like once you've got RNA, then downstream assays were sort of ... They held through, but I guess ... I mean, and you obviously didn't have necessarily a huge amount of control over how these urine samples were collected. So it's kind of nice that you were able to see something even though these were collected possibly in a way that was not optimized for preserving RNAs.                                 But do you think those ... Are there ways that you could make this even sort of more streamlined and better as far from the get go of how you collect the urine, whether you could be extracting stuff right away? Is that anything you sort of looked into of how this could be improved? Brian Byrd:          That's really been the focus of the labs work since we completed that project, is sort of understanding how would we do this in a prospective study in the best possible way so that the results are highly repeatable, that we get a CT value in everybody so that we're really ... I mean, as you can imagine, that actually has something to do with the input volume of urine that you use. So if you have too little input volume, then you won't be able to detect the targets that you might be interested in every person.                                 However, if you have more, then you can do more with that. But then you have to think about how you're going to deal with the larger volumes of urine. There are lots of questions that we've been interested in related to extract the RNA and the stability of the RNA. And so we have done some experiments of that type, and we continue to work in that area. And I do think that those questions you're asking are the right questions with respect to next steps. Jane Ferguson: All right. So you looked at sort of specific targets, which I think made a lot of sense. Sort of this proof of principle. But do you think this would work on a transcriptome wide level? I mean, could you look at all the genes, or do you think that's just sort beyond the possibility right now given sort of the RNA fragmentation and how you have to sort of amplify it before being able to detect anything? Brian Byrd:          I think it's possible. So the group that had preceded our work with 3300 mils of urine, isolating the vesicles from there, eight have showed that that's something that can be done. The question that's of interest to me is does it actually require such large volumes of urine? And I think the answer to that question is going to be no from what we're overseeing so far.                                 And so, we're thinking along exactly the lines that you are. And certainly some of the feedback we've gotten as we've discussed this project with people is, "Hey, could you look at everything rather than picking targets at [inaudible 00:36:41]."                                 I think there's advantages and disadvantages. I think we chose based on prior knowledge in a way that was rational. But at the same time, it may turn out that there are many things about activation of the mineralocorticoid receptor in humans, especially in the living in-tact human, that don't exactly mirror what's found in rabbits, rats, mice or cells, which are really the systems that have been evaluated the most thoroughly in the past.                                 So I'm very interested in exactly what you're proposing. Jane Ferguson: Yeah. I mean, I think it's exciting because it's obviously relevant for hypertension, but potentially a lot of other conditions, to be able to look at that sort of dynamic change. So I think it's really exciting. It's very cool. Brian Byrd:          And I appreciate your asking about this study. We were excited to do this work and very, very excited to see where we can in the future with this. And I agree with the point you were making, that here we've gone from a rather specific application driven question and we've, I think, made some insights that are probably useful outside the application that we had in mind. And it may turn out that the application where this is the most important is not even the one that we considered in the first place at all.                                 And so I'm pleased by that. I'm pleased by the fact that I think in a sense we're working in what Donald Stokes described as pasture's quadrant, which is a sense that the work is driven both by curiosity and by an intent to use the results. Jane Ferguson: Right. Brian Byrd:          And so that's really what gets me out of bed in the morning, is working that exact space. So that's what we were glad to have done and continue to do. Jane Ferguson: Yeah. No, I think it's grea.t and I feel like a lot of people will read this paper and be like, "Hey, I have urine stored in the freezer. What can I do with this now?" Brian Byrd:          Contact me. Let's talk. We'll see what we can do. But we certainly tried to describe the methods in such a way that people could easily follow in our footsteps if they want to apply these methods. Jane Ferguson: Yeah. Now having read through them, I think that ... Really thorough. I really liked the sort of attention to detail. It was definitely one of those ones where I was like, "Oh yeah. I can see exactly how I could do this if I wanted to. So I think that was great. Brian Byrd:          Thank you. Jane Ferguson: So yeah. Congratulations on the paper. Really nice work and thanks so much for talking to me. Brian Byrd:          Thank you. It was a delight. Jane Ferguson: That's it from me for September. If you haven't had enough yet, you can access all the papers online and you can choose to digest the papers in video format. Available on our website or the Circulation YouTube channel. Thank you for listening and subscribing. I look forward to bringing you more next month.  

Jane Ferguson: Hello. Welcome to episode 19 of Getting Personal: Omics of the Heart, the issue from August 2018. I am Jane Ferguson, and this podcast is brought to you by the Circulation: Genomic and Precision Medicine Journal and the American Heart Association Council on Genomic and Precision Medicine. Before I dive into the papers from this month, a reminder that early bird registration for AHA Scientific Sessions runs until September 4th, so go register now if you haven't already to take advantage of reduced rates. The meeting will be held in Chicago from November 10th through 12th, and it's the first year of the new three-day meeting format. It's already promising to be a really great meeting, and I'm hoping to see a lot of you there.     The August issue has a number of really interesting papers. First up, Gardar Sveinbjornsson, Eva Olafsdottir, Kari Stefansson, and colleagues from deCODE genetics-Amgen report that variants in NKX2-5 and FLNC cause dilated cardiomyopathy and sudden cardiac death. This team leveraged available DNA samples from the Icelandic population to carry out a genome-wide association study in 424 cases of dilated cardiomyopathy and over 337,000 controls. They applied whole genome sequencing to all of these samples, allowing them to identify common and rare variants. In total, they tested over 32 million variants.     They found two variants that were significantly associated with DCM at genome-wide significance, a missense variant in NKX2-5 and a frameshift in FLNC, both associated with heart failure and sudden cardiac death. Further, the NKX2-5 variant was associated with atrioventricular block and atrial septal defect. Although these variants are rare and not documented in other populations, they are significant contributors to familial DCM in Iceland. Because of the unique population structure of Iceland and known genealogy, the researchers were able to trace the NKX2-5 variant back to a common ancestor born in 1865. They traced the FLNC variants to a common ancestor born in 1595.     While the specific variants identified in this study may not be present in other populations, they are located in genes with known relevance for cardiac function. NKX2-5 encodes a cardiac transcription factor, which is required for embryonic cardiac development, and other variants in this gene have been associated with cardiac dysfunction in other populations. FLNC encodes filamin-C, a muscle cross-linking protein. Variants in FLNC have previously been ascribed to associate with myofibrillar myopathy, muscular dystrophy, and cardiomyopathy. This study adds to our knowledge of the genetics of dilated cardiomyopathy and supports screening for NKX2-5 and FLNC variants, particularly in the Icelandic population, which would allow for early intervention and monitoring in carriers.     Staying with the topic of dilated cardiomyopathy, Inken Huttner, Louis Wang, Diane Fatkin, and colleagues from the Victor Chang Cardiac Research Institute in Australia report that an A-band titin truncation in zebrafish causes dilated cardiomyopathy and hemodynamic stress intolerance. We actually talked to Dr. Wang about this research last year when he was presenting this as a finalist for the FGTB Young Investigator Award. You can go back in the archives to episode 10 from November 2017 if you'd like to hear more.     Titin mutations are responsible for a large number of cases of dilated cardiomyopathy, but there are also individuals with titin mutations that remain asymptomatic. This group used zebrafish as a model of human titin mutations and generated fish with a truncating variant in the A-band of titin, as has been identified in families with DCM. They found that homozygous mutants had a severe cardiac phenotype with premature death, but that heterozygous carriers survived into adulthood and developed spontaneous DCM. Prior to onset of DCM, the heterozygous fish had reduced baseline ventricular systolic function and reduced contractile response to hemodynamic stress, as well as ventricular diastolic dysfunction.     Overall, the mutant fish displayed impaired ability to mount stress responses, which may have contributed to development of disease. Extrapolating this to humans, this could suggest that hemodynamic stress may be a factor that contributes to timing and severity of disease in individuals with titin variants. Hemodynamic stress can be exerted by exercise, pregnancy, and other diseases contributing to ventricular volume overload. Modifying these hemodynamic stressors in at-risk subjects could potentially help to modulate the severity of DCM phenotypes.     Moving on to the topic of coronary artery disease, Vinicius Tragante, Daiane Hemerich, Folkert Asselbergs, and colleagues from University Medical Center Utrecht in the Netherlands report on druggability of coronary artery disease risk loci. This group was interested in using results from genome-wide association studies for CAD to identify new targets that may be amenable for drug repurposing. They used results from published GWAS for CAD and created a pipeline to integrate these loci with data on drug-gene interactions, chemical interactions, and potential side effects. They also calculated a druggability score based on the gene products to prioritize targets that are accessible and localized to increase the chance of a drug being able to find the target without affecting core systemic processes or housekeeping genes.     Their pipelines allowed them to identify three possible drug-gene pairs, including pentolinium to target CHRNB4, adenosine triphosphate to target ACSS2, and riociguat to target GUCY1A3. They also identified three proteins to be prioritized for drug development, including leiomodin 1, huntingtin-interacting protein 1, and protein phosphatase 2, regulatory subunit b-double prime, alpha). While these predictions were all made in silico and need to be extensively tested in clinical trials, the pipeline did identify many current therapies for CAD and myocardial infarction, including statins, PCSK9 inhibitors, and angiotensin II receptor blockers. These positive controls support that this method can successfully discover effective CAD therapies.     Staying on the topic of drugs, Kishan Parikh, Michael Bristow, and colleagues from Duke University report on dose response of beta-blockers in adrenergic receptor polymorphism genotypes. Two clinical trials have reported pharmacogenomic interactions between beta-blockers and beta-1 adrenergic receptor genotype in the setting of heart failure with reduced ejection fraction. In a retrospective analysis in almost 2,000 subjects from the BEST and HF-ACTION studies, the authors analyzed whether genotype at the Arg389Gly polymorphism in beta-1 adrenergic receptor, or an indel in the alpha-2C adrenergic receptor interacted with drug dose to affect mortality and hospitalization.     They found that ADRB1 genotype affected mortality in response to drug dose with less all-cause mortality in high versus no or low-dose beta-blockers in individuals homozygous for arginine at position 389, but not in individuals carrying a glycine at that position. In individuals on high-dose beta-blockers, genotype did not affect outcomes, but there was a significant difference by genotype in all-cause mortality in individuals on no or low-dose beta-blockers. These data support the guideline recommendations to use high-target doses of beta-blockers in HFrEF.     Switching gears towards precision medicine and genotype-guided approaches, Laney Jones, Michael Murray, and colleagues from Geisinger were interested in the patient's perspective. In their paper, Healthcare Utilization and Patients’ Perspectives After Receiving a Positive Genetic Test for Familial Hypercholesterolemia, they explored the impact of providing genotype test results for familial hypercholesterolemia to subjects participating in the MyCode Community Health Initiative. In MyCode, exome sequencing is conducted in participants, and results are returned for pathogenic and likely pathogenic variants in genes representing actionable conditions based on American College of Medical Genetics secondary findings and recommendations.     It is estimated that 3.5% of MyCode participants will be carriers of such variants, and this number may increase as more variants are discovered. In this pilot study, the authors screened for individuals with mutations in LDLR, APOB, or PCSK9, consistent with FH. They identified 28 individuals, of which 23 were eligible for inclusion in the study. Only five of the 23 subjects had previously been diagnosed with FH. Receipt of genetic test results led to change in medications in 39% of individuals. 96% of the subjects had previous LDL measurements, but only four subjects had ever met LDL goals. After genetic test results, three individuals met their LDL goals.     Seven individuals consented to participate in interviews about their experience. Almost all of these subjects already had a personal or family history of high cholesterol or heart disease, and all subjects felt that they were being adequately treated. Only three of the seven subjects mentioned using diet and exercise to control their high cholesterol, with most individuals being relatively unconcerned because they felt their medication was effective in controlling disease risk.     While the numbers studied here are too small for any statistical testing or inference, the paper describes the results from the interviews, including some excerpts from patients, which really highlight the complexities of returning results and of helping patients understand what their results mean. Given increasing genetic testing and returning of results, studies like this are really important to help us figure out the most effective ways to communicate results and support patients and their care providers.     Also from a patient-centric perspective, we have an article from Susan Christian, Joseph Atallah, and colleagues from the University of Alberta in Canada on when to offer predictive genetic testing to children at risk of an inherited arrhythmia or cardiomyopathy, the family perspective. This article considers the timing of cascade testing to predict inherited arrhythmias and cardiomyopathy in children of affected individuals. European and North American guidelines differ on when or if they recommend genetic testing in children.     In this study, surveys were circulated to foundations and patient groups to solicit familial perspectives on when genetic testing should be offered to children. In total, 213 individuals responded. In the case of long QT syndrome, 92% of respondents thought testing should be offered before the age of five, while 77% of respondents thought genetic testing should be offered before the age of 10 for hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy.     Overall, the potential benefits of genetic testing, including guiding therapies, sport participation, and decreasing worry were ranked more highly than potential risks of discrimination or increasing worry that could occur from genetic testing. Overall, the responses indicated that families would welcome the option of genetic testing for at-risk children from a young age and support initiating early discussions with families to explore costs and benefits of early genetic testing.     Finally in this issue, we have a review from Paul Franks and Nicholas Timpson from Lund University and the University of Bristol entitled Genotype-Based Recall in Complex Cardiometabolic Traits. This review looks at the increasing practice of selecting samples or individuals from larger cohorts or biobanks based on their genotype to carry out additional studies. The article focuses on examples of such genotype-based recall studies in cardiometabolic disease, highlights approaches and new methods, and discusses the ways these types of studies can be used to extend and supplement randomized trials and large population-based studies.     As always, you can find all the articles, accompanying editorials, and video summaries online. Our website recently underwent some redesigns and has moved. You should be redirected if you have the older site bookmarked, but you can also find us directly at ahajournals.org/journal/circgen. Also, thanks to everyone who participated in the Twitter poll last month. You were pretty evenly split on what you want to hear in the podcast, but please continue to leave suggestions and feedback on what we're doing and where we can improve things. That's it for the August issue of Circulation: Genomic and Precision Medicine. Thanks for listening, and tune in next month for more.    

Dr. Carolyn Lam:               Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke-National University of Singapore.                                                 We know that excessive sedentary time is bad in terms of health outcomes, but does it matter how that sedentary time is accrued, whether in short or long bouts? Today's feature paper gives us some answers. More soon, right after the summary of this week's journal.                                                 The first original paper in this week's journal provides insights into the mechanisms underlying neointima formation in arterial restenosis. Co-first authors, Dr. Cheng and Shi, corresponding author Dr. Li from Wuhan University in China, and their colleagues, performed an elegant series of experiments in which they demonstrated that interferon regulatory factor 4, or IRF4, which is a member of a family of key, innate, immune regulators known to play a role in cardiometabolic disease, actually protects arteries against neointima formation.                                                 They further probed the mechanism underlying this protective effect and found that IRF4 promoted the expression of Krüppel-like factor 4 by directly binding to its promoter. Genetic over-expression of Krüppel-like factor 4 in smooth muscle cells reversed the neointima promoting effect of IRF4 ablation. Whereas, ablation of Krüppel-like factor 4 abolished the protective function of IRF4, thus indicating that the protective effects of IRF4 against neointima formation were Krüppel-like factor 4 dependent.                                                 These findings suggest that the previously undiscovered IRF4 Krüppel-like factor 4 axis plays an important role in vascular proliferative pathology and thus may be a promising therapeutic target for the treatment of arterial restenosis.                                                 The next paper highlights that high-spacial resolution in gene expression signatures can reveal new regulators, genetic pathways, and transcription factors that are active in well-defined regions of the heart.                                                 Now we know that traditional genome-wide transcriptome analysis has been disadvantaged by the fact that the signals are derived from tissue homogenates. Thus, the authors of this current paper, including Co-First authors Dr. Lacraz and Junker, corresponding author Dr. Van Rooij from University Medical Center Utrecht in the Netherlands used tomo-seq to obtain genome-wide gene expression signature with a high spacial resolution, spanning from the infarcted area to the remote areas to identify new regulators of cardiac remodeling.                                                 Using this technique, they identified SOX9 as a potent regulator of cardiac fibrosis. In vivo loss of SOX9 reduced the expression of many extracellular matrix genes, which coincided with a blended cardiac fibrotic response upon ischemic injury.                                                 These data therefore were able to unveil currently unknown relevance of SOX9 as a key regulator of cardiac fibrosis, thus underscoring that tomo-seq can be used to increase our mechanistic insights into cardiac remodeling, and to help guide the identification of novel therapeutic candidates.                                                 The next paper reports the primary results of the effect of ferric carboxymaltose on exercise capacity in patients with iron deficiency and chronic heart failure, or EFFECT-HF study, which is a randomized control trial of intravenous ferric carboxymaltose, compared to standard of care on the primary end point of change in peak Vo2 from baseline, to 24 weeks in patients with symptomatic, chronic heart failure with reduced ejection fraction and iron deficiency.                                                 In this report from Dr. van Veldhuisen from University Medical Center Groningen and colleagues, intravenous ferric carboxymaltose was shown to significantly increase serum ferritin and transferrin saturation. At 24 weeks, peak Vo2 had decreased in the control group, but was maintained in the group receiving intravenous ferric carboxymaltose.                                                 Although a favorable effect on peak Vo2 was observed with ferric carboxymaltose, compared to standard of care in the primary analysis, this effect was highly sensitive to the imputation strategy for peak Vo2 among patients who died.                                                 They also reported that patient's global assessment and functional class, as assessed by New York Heart Association, improved on ferric carboxymaltose compared to standard of care.                                                 Whether ferric carboxymaltose is associated with an improved outcome in these high risk patients, deserves further study.                                                 The final study provides important long term clinical data to guide lead management decisions in patients with cardiac implantable electronic devices.                                                 Dr. Pokorney from Duke University Medical Center in Durham, North Carolina, and colleagues, analyzed over 6,000 Medicare patients and found that device extraction was associated with a lower adjusted five year infection rate, compared with a cap and abandon strategy. There was a lower absolute five year mortality with extraction, but after adjustment there was no association between extraction and a lower five year mortality.                                                 In summary, therefore, elective lead extraction for non-infectious indications in this Medicare cohort had similar long term survival, but lower risk of device infections at five years, compared to capping and abandoning leads.                                                 Patient and provider preferences are critical to decision making when considering extraction versus capping and abandonment of leads.                                                 Well, that wraps it up for your summaries. Now for our feature discussion.                                                 For today's feature discussion, we are talking about sedentary time and a metabolic risk of having too much of it. But, today's paper is so interesting because it tells us that it's not just the total amount of sedentary time that may matter, but how we accrue the sedentary time. Very, very novel concept in my point of view and I'm so pleased to have the first and corresponding author of this paper, Dr. Keith Diaz from Columbia University Medical Center with us, as well as Associate Editor from Johns Hopkins, Dr. Wendy Post.                                                 So pleased to have you both. Keith, could we just dive right into it? Tell us what population you were looking at, and what you found. Dr. Keith Diaz:                    Sure, so we were studying a population of participants enrolled in the Hispanic Community Health Study, so it's a US populations of over 16,000 Hispanic adults. And essentially what we found was that sitting for prolonged bouts, so sitting for one, two hours at a time, was associated with poor glucose regulation. Dr. Carolyn Lam:               Well, yikes. I've actually been sitting for a few hours in a row right now, actually. I think these results are phenomenal, but could you maybe expand a little bit on the details, like how long is too long? And, how often a break needs to happen for you to see differences in the metabolic risk? Dr. Keith Diaz:                    It's a good question and, to be honest, we don't know. I think that's where the research needs to head, but right now it seems to be that taking a break every 30 to 60 minutes could be beneficial. I think that's what we've found thus far. Dr. Wendy Post:               Keith, we were really excited to get your paper in. I think everyone on the Associate Editorial Board was especially interested in it because we can all relate. As Carolyn said, she's been sitting for a long time and when we have these meetings we have two hour meetings at a time and maybe we need to start saying that in the middle we should all stand up and take a break. So we can all relate to this.                                                 But I think one the biggest questions that we had related to data itself, was the association between the total sedentary time and the sedentary bout duration. Maybe you can tell us a little bit more about those correlations in the interaction and tell us also how you also measure sedentary bout duration and total sedentary time in this observational cohort. Dr. Keith Diaz:                    Sure, so I'll start with that latter question. So, we measured sedentary time [inaudible 00:09:32] subjectively. So we actually used an activity monitor called an accelerometer to see how sedentary they are. And how we quantified sedentary bouts is we just looked at how long consecutively a person sat without moving. That was considered sedentary bout. In terms of correlation, what we found is that there are very closely linked. So, people who sit for long hours during the day for total volume, also sit in long bouts. And so what we wanted to do was try to figure out and piece apart, which one is more important? When we're trying to ... If we're thinking about guidelines and what we should be doing about our sedentary time, is it important to reduce our volume or interrupt our bouts? And so what we found is that they're not independent, and that they're in many ways synergistic. And that the association of prolonged sedentary bouts with glycemic biomarkers varied according to how much total volume you sit and vice-versa. Dr. Wendy Post:               Can you expand a little bit more on that? So tell us about the interaction that you found between sedentary bout duration and total sedentary time. Dr. Keith Diaz:                    Sure, so we did find that there was a specifically significant interaction between the two variables and so what we tried to do is actually categorize people as to whether they were high for both characteristics or high for just one of them. And so what we found was that those participants who are high for both, so they had high volume and sat in long bouts, they had the worst glucose regulation, and that those individuals that were high for just one of the characteristics had a little bit better glucose regulation. And so really what we thought the take home message was when thinking about how do we improve our sedentary behaviors is that it's targeting both. It's not sitting for large volumes during the day, but also making sure to take frequent breaks every 30 or 60 minutes. Dr. Wendy Post:               And tell us about the glucose measures that you included in your study. Dr. Keith Diaz:                    Yep, we had a couple glucose measures. One we had people do a two hour glucose tolerance test, so they took a glucose drink and then we measured their blood sugar levels two hours after having that drink. We also measured their H1Ac levels as well as their fasting glucose and fast to link insulin measures from which we can then derive measures of something called HOMA IR, which is a measure of insulin resistance. Dr. Wendy Post:               And the associations that you saw were primarily with the HOMO IR and the two hour glucose levels but less with the hemoglobin A1c? Dr. Keith Diaz:                    Correct. Dr. Wendy Post:               So it really appears to be that insulin resistance that's most affected by the total sedentary time and sedentary bout duration. Tell us about potential confounders and how you factored that into your analysis. Dr. Keith Diaz:                    Yeah, there was quite a number of potential confounders between this relationship of sedentary behavior and glycemic biomarkers. One of them in particular that we were concerned about most were things like body mass index or exercise or physical activity levels. And so we took a look at what we adjusted for those confounders how the relationship changed. And what we did find was that there was an attenuation and association between sedentary behavior and the glucose markers, but there was also ... were still statistically significant. So suggestive that maybe they're partly in the pathway of body mass index or exercise but they didn't make the relationship go away. I should add that we looked at a couple other confounders, we looked at things like inflammation, C-reactive protein, as well as whole bunch of other measures of cardiovascular risk factors. I'll stop there. Dr. Wendy Post:               And what about the fact that study is cross-sectional, are there any caveats related to the study design that you'd like to point out to the audience? Dr. Keith Diaz:                    Yeah, I think that's an important point, that this is cross-sectional, so by no means can we infer causality that sedentary behavior causes glucose dysregulation, it's just purely an association. So I think anyone listening to this podcast should keep that in mind when reading this paper or listening to this podcast. Dr. Wendy Post:               So if you were writing the next set of guidelines what would you recommend in terms of how you implement these findings into guidelines? Not to imply that we think that these cross-sectional observational data mean that we're ready to change guidelines but, if these were replicated in randomized trial or some other more objective data study design, how do you think we should use these results to change our behaviors? Dr. Keith Diaz:                    I think these guidelines point ... or, with the current guidelines are, sit less, move more, where the guidelines that came out from AHA in October of 2016. In part, they were not as specific because we don't have quite the quality of guidelines or data that we need for more qualitative guidelines, or quantitative guidelines. I think if we're able to replicate these data with [inaudible 00:14:10] or point us towards at least is, also, that we should be interrupting our sedentary bouts. And so what I'd like to see hopefully if we can replicate something I'd like guidelines that say every 30 minutes or every 60 minutes of sitting you should stand up and move. And hopefully with future studies that are coming out that we can make them even more specific and something along the lines of every 30, 60 minutes you stand up and walk for 5 minutes or you just stand up for 1 minute. That's where I'd like to see the science head and I think this study points us in the that direction of maybe we have to start thinking about breaking up our sedentary bouts. Dr. Carolyn Lam:               All right you guys, I don't know about you, but I am literally standing up right now while I'm listening to you both. This is so interesting and I love the way, Wendy, you reflected the robust discussions we had as team when we were working through this paper. Congratulations again, Keith, for just this remarkable paper. Actually, maybe I could just ask, Wendy, what do you think? What do you think our next steps that may need to get these kinds of recommendations, perhaps into guidelines? Dr. Wendy Post:               I think as was alluded to before, these are observational data so they're important for hypothesis generation, but really to have evidence that would lead to changes in guidelines maybe having a randomized trial, where obviously you can't have very hard outcomes, but randomized trials of some duration that could potentially lead to changes and important outcomes, would then maybe lead to changes in guidelines. But there isn't anything that we would lose from trying to implement these kinds of behavior, changes into our lifestyle since the downside and the risk is pretty low. So even if they don't make the strongest level of evidence at this point, I think we can still all be mindful of this and so.                                                 One thing that we've been trying to do in our preventive cardiology group at Hopkins is trying to implement walking meetings. In fact, I just had an email discussion with one of my colleagues about meeting tomorrow and she said, "Well, where do you want to meet?" And I said, "Well, why don't we go for a walk? The weather should be nice." And so I think if we're all mindful of trying to, not only increase our amount of physical activity, but trying to limit the sedentary bout duration by being creative and trying to change, sort of, long standing traditions of having meetings sitting in an office, then that could be helpful.                                                 So, just something for our audience to think about as well. Dr. Carolyn Lam:               That's brilliant. You know, the one thing that I was thinking, though, just thinking about the reception of these data in my country, in where I practice, in Asia. This was a purely Hispanic or Latino population. I suppose there is a perception that that population may be predisposed to cardiometabolic disease and so on, and so you know, what's the applicability to us in Asia? So, I'm really happy, particularly to hear how you've taken it on. I mean, it's a simple thing, why not, right? Just to be more active. There's surely can't be something wrong with that. What do you think of that? Dr. Wendy Post:               Totally, I think it's important to emphasize the unique nature of these data and that they come from a Hispanic study, which is a really important addition to our literature in epidemiology and cardiovascular disease and certainly there are significant differences in lifestyle among different communities within the United States and across the globe, as you've experienced having lived in different countries. And so, I think we need obtain more data about how there might be differences based on various traditions and different lifestyles, and try to target those who are at greatest risk. Dr. Carolyn Lam:               Keith, did you have anything to add to that? Dr. Keith Diaz:                    Yeah, I think Wendy is right on and certainly I don't think we have any reason to suspect that sedentary behavior acting differently in Hispanics versus other populations, and so I still think going forth with this notion that we all should be reducing our sedentary behaviors is important to highlight. Dr. Carolyn Lam:               Fantastic. Well, thank you both for a really wonderful discussion. This is really cool, I think a lot of people will be talking about this.                                                 Listeners, you've heard it first, though, in Circulation on the Run. Thank you for joining us today and don't forget to tune in next week.