>> I THINK WE WILL GET STARTED.
I WANTED TO ASK IF THOSE
STUDENTS WHO HAVE REGISTERED
FROM FAES TO TAKE THIS COURSE,
THIS IS ABOUT THE HALFWAY MARK.
SO WE ASK YOU IF YOU'D TAKE A
MINUTE OR TWO AND SEND ME AN
E-MAIL WITH YOUR THOUGHTS AS TO
WHETHER -- WHAT THE COURSE HAS
BEEN FOR YOU, GOOD, BAD,
INDIFFERENT, OR PREFERABLY ANY
SUGGESTIONS THAT YOU HAVE FOR
MAKING IT BETTER TO MEET YOUR
NEEDS.
OKAY.
SO I JUST PUT THIS TOGETHER AS A
VERY, VERY BRIEF INTRODUCTION TO
THE TOPIC TODAY, BECAUSE ANCIENT
PEOPLE NOTICED THAT SOMETIMES
AFTER THEY DIDN'T KNOW, TRAUMA,
INFECTION, WHAT NOT, THERE WAS A
SWOLLEN HOT PAINFUL, RED LESION.
AND IT BURNED OR FELT I GUESS
THAT'S THE BASIS OF THE ORIGIN
OF SETTING ON FIRE, AND THE
GREEKS CALLED IT INFLAMMATION.
AS WE WILL HEAR TODAY, THIS IS A
COMPLEX MECHANISM WHICH PROTECTS
THE ORGANISM, US, FROM A WHOLE
VARIETY OF INJURIOUS THINGS FROM
BUGS TO TRAUMA, EVEN TO
OVEREXERCISE.
AND AT THE SAME TIME, IT'S THE
PROCESS THAT INITIATES HEALING.
SO IT'S VERY TIGHTLY REGULATED.
WHAT TURNS IT ON, WHAT TURNS IT
OFF, AND THE VARIOUS REGULATORS
AND DIFFERENT CELLS HAS EMERGED
OVER THE PAST, I DON'T KNOW,
40 -- 30, 40 YEARS, INCREASING
PACE STILL TO BE A VERY COMPLEX
PROCESS.
PRODUCING BOTH ACUTE
INFLAMMATION AND WITH CHRONIC
DISEASES, CHRONIC INFLAMMATION.
IN THIS ENTIRE COMPLEX, VARIOUS
INHERITABLE DISEASES HAVE PROVEN
TO BE EXTREMELY IMPORTANT IN
PROVIDING VITAL CLUES AS TO WHAT
THE MECHANISM AND THE REGULATION
OF THESE COMPLEX PROCESSES ARE
ALL ABOUT.
SO WE'RE VERY FORTUNATE TODAY TO
HAVE 2 SPEAKERS WHO HAVE MADE
VITAL CONTRIBUTIONS IN THIS
FIELD.
SO THE PROGRAM IS GOING TO BEGIN
WITH JOHN GALLIN, I'M SURE YOU
ALL KNOW, DIRECTOR OF THE NIH
CLINICAL CENTER.
I DON'T KNOW.
I'M ALWAYS AMAZED WHEN I TRAVEL
AROUND AND TALK TO GRADUATE
STUDENTS AND MANY ARE UTTERLY
SURPRISED TO HEAR THERE IS A
HOSPITAL HERE AT THE NIH.
I DON'T KNOW OF YOU ARE AWARE OF
IT.
IT'S THE LARGEST RESEARCH
HOSPITAL IN THE WORLD, AND
DR. GALLIN HAS DIRECTED IT IS
RESPONSIBLE TO A GREAT EXTENT
FOR THE ENLARGEMENT OF THAT
HOSPITAL A FEW YEARS AGO.
SO EVEN IF YOU'RE WORKING IN A
LAB ALL THE TIME, I THINK YOU'D
FIND IT EXTRAORDINARILY EXCITING
TO HAVE AN OPPORTUNITY TO VISIT
THE HOSPITAL AS A GUEST, NOT A
PATIENT.
AND SEE MORE OF WHAT GOES ON
THERE.
SO DR. GALLIN TRAINED AND
GRADUATED FROM MEDICAL SCHOOL IN
NEW YORK AND TOOK HIS TRAINING
IN NEW YORK AT CORNELL AND AT
BELLEVUE HOSPITAL, AND THEN CAME
HERE TO THE NIH, BRIEFLY WENT
BACK TO NEW YORK TO FINISH A
RADCY.
BUT IT WAS DURING THE --
RESIDENCY.
BUT IT WAS DURING THE TIME OF
REALLY BEGINNING OF THIS GREAT
EXCITING WAVE OF DISCOVERY AND
INFLAMMATORY AND INFECTION.
AND SO DURING HIS CAREER HERE,
HE HAS BEEN DIRECTOR, SCIENTIFIC
DIRECTOR OF NIAID, AND ALSO
HEADS THE LABORATORY OF HOST
DEFENSES.
AND IS THE DIRECTOR OF THE
CLINICAL CENTER AS I'VE TOLD
YOU.
NOW, HIS RESEARCH HAS INVOLVED
DISEASE, CHRONIC GRANLOMATOUS
DISEASE WHICH I'M SURE WE'LL
HEAR ABOUT THIS AFTERNOON.
NOW, IN CONJUNCTION WITH THIS,
DR. GALLIN HAS WORKED THROUGH
MANY YEARS WITH DOUG KUHNS, OUR
SECOND SPEAKER.
AND HE TOOK HIS Ph.D. AT THE
UNIVERSITY OF PITTSBURGH IN
BIOCHEMISTRY AND MOLECULAR
BIOLOGY, AND WAS AT WALTER REED
FOR A WHILE.
FOR THE PAST 23 OR 24 YEARS, HAS
HEADED A UNIT AT FREDERICK WHICH
HAS WORKED INTIMATELY WITH THE
GROUP HERE STUDYING THESE
DISORDERS ASSOCIATED WITH
LEUKOCYTE FUNCTION AND INFECTION
OF ALL DIFFERENT TYPES.
SO THIS IS A WONDERFUL EXAMPLE
OF TRANSLATIONAL RESEARCH AT ITS
SORT OF APEX AND WE'RE VERY GLAD
THAT BOTH OF YOU HAVE AGREED TO
COME AND SPEAK TO US.
JOHN, YOU'RE GOING TO LEAD OFF?
>> THANK YOU VERY MUCH.
A LOT OF FUN TO HAVE THE
OPPORTUNITY TO SHARE SOME OF OUR
EXCITEMENT ABOUT WHAT WE DO, AND
MAYBE SOME WILL GET TURNED ON BY
THIS GENERAL AREA AND DO
SOMETHING ITSELF.
WHAT I THOUGHT WE WOULD DO
TODAY, AND DOUG AND I HAVE
WORKED CLOSELY TOGETHER FOR OVER
20 YEARS, SO WE'RE GOING TO DO A
LITTLE TAG TEAM HERE.
WHAT WE THOUGHT WE WOULD DO IS
SHOW YOU FIRST SOME EXAMPLES OF
SOME PATIENTS, SINGLE PATIENTS
WHO MADE A DIFFERENCE IN TERMS
OF OUR UNDERSTANDING OF SOME
ASPECTS OF INFLAMMATION.
WHAT I'LL DO AT THE END IS TRY
TO SHOW YOU HOW STUDIES IN A FEW
PATIENTS WITH A RARE DISEASE HAS
THE POTENTIAL FOR SOME REAL
IMPLICATIONS FOR SOME VERY
COMMON DISEASES AND MAY OPEN UP
SOME AVENUES AS WE THINK ABOUT
THERAPEUTICS IS CHRONIC COMMON
DISORDERS.
SO THIS IS OUR DECLARATION.
WE, LIKE MOST PEOPLE AT NIH,
AREN'T FORTUNATE TO OWN A LOT OF
STOCK TO DECLARE THE CONFLICT OF
INTEREST.
AND THIS IS THE BUILDING YOU
JUST HEARD ABOUT.
I HOPE THERE IS NO ONE IN THIS
ROOM THAT FAILED TO REALIZE THAT
WE HAD A CLINICAL CENTER,
BECAUSE IT'S 25% OF THE SPACE ON
THIS CAMPUS.
THAT'S OVER 4 MILLION SQUARE
FEET, WHICH IF YOU DON'T THINK
THAT WAY IT'S A LOT.
AND THERE IS OVER 6,000 PEOPLE
WHO WORK IN THIS BUILDING TO
TAKE CARE OF THE PATIENTS AND TO
DO THE CLINICAL RESEARCH
STUDIES.
SO THE MAJOR EMPHASIS IN THIS
BUILD THAT WE PRIDE OURSELVES
ARE ON 2 THINGS.
FIRST, IN HUMAN WITH NEW
THERAPEUTICS, SO ABOUT 45% OF
THE 1500 CLINICAL PROTOCOLS THAT
ARE UNDER WAY RELATE TO CLINICAL
TRIALS.
THE SPECIAL THING ABO THOSE
TRIALS, THEY'RE ALL -- OVER 90%
ARE PHASE I AND PHASE II.
FIRST IN HUMAN STUDIES.
IF YOU GO TO THE UNIVERSITIES,
THERE IS MORE OF AN EMPHASIS ON
PHASE 3, THAT IS, REAL PROOF OF
EFFICACY RATHER THAN A
SUGGESTION.
THE SECOND THING WE DO ARE
STUDIES OF PATIENTS WITH RARE
DISEASES AND WE'RE GOING TO TELL
YOU ABOUT SOME OF THOSE PATIENTS
TODAY.
I DON'T KNOW IF THEY'VE HEARD
FROM BILL GALL, BUT YOU MIGHT
NEXT YEAR.
BILL GALL RUNS THIS PROGRAM, THE
UNDIAGNOSED DISEASES PROGRAM
WHICH HAS GOTTEN A FAIR AMOUNT
OF PUBLICITY.
WHAT WE DID WAS OPENED THE DOORS
OF THE CLINICAL CENTER.
IT'S A MYSTERIOUS PROBLEMS THAT
PEOPLE DON'T UNDERSTAND IN
MEDICAL CENTERS AROUND THE
COUNTRY AND THESE PATIENTS CAN
COME HERE AND GET A
MULTIDISCIPLINARY APPROACH TO
THEIR PROCS.
YOU GET THE CARDIOLOGIST,
INFECTION DISEASE.
45 PEOPLE IN A ROOM TALKING
ABOUT ONE PATIENT AFTER THE
CHART.
AND BILL JUST DIAGNOSED A NEW
DISEASE WHICH WAS IN THE "NEW
ENGLAND JOURNAL OF MEDICINE"
ABOUT CALCIUM DEPOSITION IN
MAJOR BLOOD VESSELS, A KIND OF
COOL DISREGULATION OF ATP
LEADING TO CALCIUM GOING.
YOU MIGHT WANT TO READ IT --
DEPOSITION.
YOU MIGHT WANT TO READ IT.
WE'RE STUDYING 758 DIFFERENT
TYPES OF RARE DISEASES, COHORTS,
REPRESENTING OVER 8,000
PATIENTS.
AND THEY'RE OVER 600 PROTOCOLS
STUDYING THESE PATIENTS.
342 OF THOSE ARE CLINICAL
TRIALS.
266 ARE NATURAL HISTORY STUDIES,
WHICH ARE JUST STUDIES TO
UNDERSTAND THE PATHOPHYSIOLOGY
OF THE DISEASE.
AND OFTEN ONCE YOU UNDERSTAND
THAT, YOU GET IDEAS FOR NEW
THERAPEUTICS.
SO THIS BE AROUND FOR A LONG
TIME.
THIS WAS AN OLD GREEK FINDING I
GOT OUTOF THE GREEK TEMPLES.
AND IT'S AS YOU HEARD,
CHARACTERIZED AS HEAT READINESS
SWELLING AND PAIN, AND P NOT
PART OF THE CLASSIC DESCRIPTION
BUT ASSOCIATED WITH LOSS OF
FUNCTION.
SO THAT'S WHAT WE'RE GOING TO
FOCUS ON.
AND JUST TO CONVINCE YOU THAT
THIS IS NOT NEW, I WAS WANDERING
AROUND THE COUNTRYSIDE IN
VIRGINIA AND WENT TO A FLEA
MARKET A FEW YEARS AGO AND FOUND
THIS BOOK ON THE PRACTICE OF
MEDICINE FROM 1849 BY A GUY
NAMED GEORGE WOODS WHO WAS AT
THE UNIVERSITY OF PENNSYLVANIA.
AND THERE ARE ONLY ABOUT 3
ARTICLES, COMPONENTS OF THIS
BOOK.
ONE OF THEM WAS INFLAMMATION.
THIS QUOTE, INFLAMMATION IS THE
MOST IMPORTANT OF DISEASE
CONDITIONS AS EITHER IT TENDS OR
FORMS AN ESSENTIAL PART OF THE
GREAT MAJORITY OF SERIOUS
DISEASE AND IN MOST INSTANCES
CONSTITUTES THE CHIEF SOURCE OF
DANGER.
FOR THOSE WHO FOLLOW THE
LITERATURE, THE DANGER SIGNAL
HAS BECOME VERY POPULAR AS IF
IT'S A NEW IDEA.
AT LEAST IN IN THE 1840s, THEY
WERE QUITE AWARE OF THIS.
IT WAS A THIRD OF THE TEXTBOOK
OF MEDICINE IN THOSE DAYS.
SO AS WAS SUGGESTED BY WIN,
IRRITANTS OF ANY SOURCE CAN
INDUCE INFLAMMATION WHICH HAS
BEEN DIGNIFIED, CALLED INMATE
IMMUNITY.
WHEN I STARTED OFF HERE IN EARLY
70s, TEAM SAID WHY DON'T
YOU -- PEOPLE SAID WHY DON'T YOU
DO SOMETHING WORTH WHILE RELATED
TO IMTECHNOLOGY?
WHY DO YOU STUDY THIS?
WE'VE GRADED.
THAT'S THE EARLY IMMUNE RESPONSE
THAT ADOPTS TO THE IMMUNE
RESPONSE.
THE MEDIATORS THAT YOU'VE HEARD
ABOUT UNDOUBTEDLY INCLUDE
CYTOKINES, LIPID MEDIATORS AND
COSTIMULATORY MOLECULES.
AND THE FEEDBACK MECHANISMS
BETWEEN THE ADOPTIVE AND THE
INFLAMMATORY RESPONSE ALWAYS
INCLUDE CYTOKINES, ANTIBODIES,
CELL MEDIATED IMMUNITY.
THE IDEA IS TO ELIMINATE THE
IRTANT.
IF YOU DO, YOU GET RESOLUTION
WITH WOUND REPAIR APOPTOSIS,
ANTIINFLAMMATORY CYTOKINES,
ANGIOGENESIS WITH NEW BLOOD
VESSEL FORMATION, AND IF YOU
DON'T, YOU CAN GET A CHRONIC
DISEASE, LOOP TOYED, RHEUMATOID
ARTHRITIS, ARTHRO SCLEROSIS AND
POST ISCHEMIC EVENTS FOLLOWING
STROKE AND MYOCARDIAL
INFARCTION.
YOU CAN THINK ABOUT
INFLAMMATION, THE COMMON ELEMENT
IN THE BLOOD ARE THE NEUTROPHILS
WHICH COMPROMISE IN A NORMAL --
COMPRISE, IN A NORMAL HOST,
MAYBE 60% OF THE BLOOD WHITE
CELLS.
THEY FLOW IN 2 COMPARTMENTS,
THEY FLOW IN THE MIDDLE OF THE
BLOOD VESSELS FREELY,AND THEN
THERE IS WHAT WE CALL A
MARGINATED POOL OF CELLS THAT
ROLL ALONG THE BLOOD VESSELS IN
A VERY WELL DESCRIBED FASHION
ADHERING AND DISADHERING FROM
THE ENDOTHELIAL CELLS THROUGH
INTERACTIONS OF INTEGRINS, THE
INTEGRIPS ON THE NEUTROPHILS AND
[INDISCERNIBLE] ON THE
ENDOTHELIAL CELLS.
IN RESPONSE FEW A SIGNAL THERE
IS UP REGULATION.
THEY BECOME VERY STICKY IN THE
NEUTROPHILS, THEY ADHERE.
THEY'RE MOTILE MACHINERY, IN RYE
RESPONSE TO SIGNALS SUCH AS
CHEMO TTRACTANTS, C5A, PROST
GLANDENS, AND OTHERS,
INTERLEUKIN 8.
THEY START MIGRATING BETWEEN THE
VESSELS.
THEY DEFORM.
THE NEUTROPHILS START SECRETING
GRANULAR COMPONENTS IN A VERY
ORGANIZED WAY.
THEN THEY DO SOMETHING LIKE
INGEST THE PARTICLES, SUCH AS A
MICROBE SHOWN IN GREEN OR MAYBE
A CRYSTAL AS IN GOUT.
AND THINGS HAPPEN WHICH WE'LL
DISCUSS  A MINUTE AND
INFLAMMATORY ENSUES.
AND WE'VE LEARNED A LOT FROM
PATIENTS WHO HAVE DISORDERS OF
SELECTIVE COMPONENTS OF THIS
PATHWAY.
SO I SHOW, FIRST, A PATIENT WHO
HAS AN ABNORMALITY IN THE
ABILITY TO WHITE CELLS TO STICK
TO THE ENDOTHELIUM, BECAUSE OF
AN ABNORMALITY OF CD18 GENE AND
IT'S CALL LEUKOCYTE ADHERENCE
DEFICIENCY TYPE ONE.
WHEN THAT HAPPENS THE WHITE
CELLS CAN'T GET OUT OF THE BLOOD
STREAM A NUMBER OF CELLS IS
ABOUT TWICE NORMAL IN THE BASIL
STATE.  THERE IS ABOUT 15,000 IN
THE BASIL STATE.
IF THEY GET INFECTION OR
INFLAMMATION, THIS IS GO
EXTREMELY HIGH, UP TO LIKE
70,000.
THIS OCCURS AT BIRTH.
THE FIRST MANIFESTATION IS
USUALLY THAT THEY DON'T SHE SHED THE
UMBILICAL CORD.
IF YOU KNOW HAVE A NEWBORN CHILD
WHERE THE BELLY BUTTON, THE
COURT DIDN'T FALL OFF, THINK
THIS DISEASE.
SECOND MANIFESTATION, COMMON IN
MOST OF THE ORDERS OF
NEUTROPHILS, THEY HAVE ROTTEN
FEET.
AND HERE YOU SEE THEY GET A
COMBINATION OF PERRY DONE TITUS,
WHER THE ABSORPTION.
GULF OF MEXICOS REVEALING --
GUMS REVEALING THE ROOTS.
THEIR TEETH FALL OFF VERY EARLY.
AND THEY GET BAD INFECTIONS
BECAUSE THEY CAN'T MOUNT A
NORMAL INFLAMMATORY RESPONSE.
THEY CAN'T GET RID OF BACTERIAL
INFECTIONS.
THE SECOND DISEASE I AM GOING TO
QUICKLY SHOW YOU, A DISEASE
CALLED CHEDIAK-HIGASHI, CHS, AN
ABNOR MALTY OF EVERY CELL IN THE
BODY THAT HAVE LIESOSOMES.
SO WE FIRST DESCRIBE THIS IN
NEUTROPHILS, BUT DESCRIBED IN
THE 60s, THEN, BUT THEN -- AND
IT WAS RECOGNIZED THAT EVEN IN
HAIR, AS SHOWN HERE, YOU SEE
THESE GIANT INCLUSION BODIES IN
JUST -- PULLING OUT A PIECE OF
HAIR FROM SOMEBODY WHO HAS
CHEDIAK-HIGASHI COMPARED TO A
NORMAL HAIR.
AND THESE ARE THE GIANT GRANULES
THAT YOUSEE, THE GRANULES DON'T
DEVELOP PROPERLY FROM THE
[INDISCERNIBLE], THEY FUSE
TOGETHER.
THESE ARE THEIR GIANT GRANULES.
AND CLINICALLY, THE PATIENT GET
RECURRENT INFECTIONS BUT THEY
GET MORE THAN THAT.
THIS IS A SYSTEMATIC DISEASE FOR
ALL CELLS IN THE BODY.
THEY CAN GET ALBINO, THAT MEANS
THE PIGMENT IN THEIR EYES IS A
LITTLE ABNORMAL SO THEY'RE SORT
OF ALBINO.
THEY GET A PERIPHERAL
NEUROPATHY.
THE REASONS FOR THAT ARE NOT
TOTALLY -- THESE PATIENTS IN
THEIR MID 20s WILL BE
WHEELCHAIR BOUND.
BETWEEN THAT AND INFECTION PRO
SPENCETY, WHICH THEY ARE --
THEY'LL OFTEN GET ULCERS, SORES
BECAUSE THEY CAN'T MOVE.
PRESSURE SORES, THEY GET
INFECTED.
THAT WILL KILL THEM.
THEY ALSO HAVE THIS FUNNY HAIR
COLOR.
IT'S A SILVER GRAY HAIR.
THIS DISEASE EFFECTS REALLY
EVERY SPECIES.
MOBBY DICK, THE -- I DON'T KNOW
IF MOBY-DICK.
THE ALBINO KILLER WHALE HAS
CHEDIAK-HIGASHI.
AND THE MINK HAS THIS DISEASE.
PEOPLE DON'T BUY MINK COATS MUCH
TODAY, THEY USED TO.  AND THIS
COAT WAS VERY EXPENSIVE.
THE ANIMALS WERE SMALL.
AND YOU NEEDED A LOT OF PELTS TO
GET A COAT.
THE WHITE TIGER HAS
CHEDIAK-HIGASHI.
I CAN REMEMBER ONCE WHEN I WAS A
FELLOW HERE.
MY BOSS AT THE TIME, SHELLY WOLF
WHO WAS ONE OF THE GREAT PEOPLE
AT NIH, SAID YOU WANT TO GO DOWN
TO THE ZOO AND WORK ON A TIGER?
I SAID SURE.
WELL, SO WE DIDN'T REALLY WORK
ON THEM.
SOME VET GAVE US SOME BLOOD.
BUT WE DIAGNOSED THIS DISEASE IN
THE WHITE TIGERS.
THEY WERE HAVING TROUBLE.
THE CUBS WERE DYING.
THEY WOULDN'T GROW.
THIS IS ANOTHER KIND OF
DISORDER, A DIFFERENT KIND.
THIS WAS AN EGYPTIAN BOY THAT WE
FOLLOWED AT THE CLINICAL CENTER
WHO HAD 2 PROBLEMS.
HE COULDN'T HEAL PROPERLY.
YOU CAN SEE THE SCARS ON HIS
FACE.
AND HE HAD RECURRENT INFECTIONS
OF MULTITUDE OF DIFFERENT TYPES
OF BACTERIA IN PARTICULAR.
AND THAT'S WHAT HE PRESENTED
WITH.
HIS NEUTROPHILS WERE FUNNY
SHAPED.
IT'S SEE SOME PICTURES LATER,
BUT HIS -- THE NUCLEUS WAS SORT
OF BIPOLAR AND MISSHAPE THE.
IT DIDN'T HAVE THE MULTIPLE
LOBBIES THAT ARE -- LOBES THAT
ARE NORMALLY WELL ARTICULATED.
THIS RIGHT STAIN, YOU DON'T SEE
ANY.
THAT'S BECAUSE THEY LACK ONE
CLASS OF GRANULES THAT RIGHT
STAINS STAIN FOR CALLED THE
SECONDARY GRANULES, THE SECOND
GRANULES THAT ARE APPEARING IN
THE BONE MARROW DURING THE
DEVELOPMENT OF A
[UNINTELLIGIBLE]TRO CELL.
THESE -- NEUTROCELLS.
THEY HAVE POOR WOUND HEALING.
THEY HAVE HYPEREXTENSABLE
JOINTS.
THEY HAVE PROLAPSE OF THE AORTIC
VALVE.
THEY WERE HYPEREXTENSABLE FIBERS
IN THE VALVE.
THIS PATIENT DIED IN HIS LATE
20s OF AORTIC INSUFFICIENCY.
WE WERE STUDYING HIM.
ONE OF THE FOLKS IN THE GENOME
INSTITUTE, ONE OF THE FELLOWS
WAS THERE NAMED JULIE AND SHE
GAVE A SEM LAR ABOUT A FUNNY
KIND OF NEUTROPHIL ABNORMALITY
IN A MOUSE SHE WAS STUDYING.
SHE HAD DISCOVERED A GENE IN A
KNOCKOUT BOWS.
THIS CEBT.
SHE SHOWED ME THE NEUTROPHILS.
I SAID GEE, THIS LOOKS LIKE MY
PATIENT.
I BET THIS GENE WOULD RELATE TO
OUR PATIENTS.
WE WENT FROM MOUSE TO MAN.
JULIE CAME AND WORKED WITH ME.
AND QUITE RAPIDLIAGE IT PROVES
THAT THIS PATIENT'S DEFECT WAS
IN THE SAME CHAIN OF THE MICE
THAT SHE COACCIDENTALLY HAD BEEN
DECIDING.
SO YOU CAN GO FROM MICE TO MAN.
AND THIS WAS A GREAT EXAMPLE OF
THAT.
I'LL SHOW YOU ANOTHER IN -- A
LITTLE LATER.
NOW, SOME OF THE PATIENTS HAVE
ABNORMALITIES IN THEIR
LEUKOCYTE'S ABILITY TO MIGRATE.
IN THE 1970s, 1975, WE
DESCRIBED A PATIENT WHO'S
PICTURE IS SHOWN IN THIS SLIDE
WHO HAD AN INTERESTING
PHENOTYPE.
SHE HAD BAD INFECTIONS.
AND SHE HAD THIS CHRONIC
INFLAMMATION THAT LED TO
ACTUALLY -- IN HER MOUTH THAT
LED TO CLOSURE OF HER MOUTH.
IN ORDER TO EAT, SHE HAD TO HAVE
SURGICAL PROCEDURES TO OPEN UP
THE ORAL OPENING SO SHE COULD
PUT FOOD INNOHEP MOUTH.
WHEN WE LOOKED -- IN HER MOUTH.
WHEN WE LOOKED AT HER
LEUKOCYTES, IN THOSE DAYS WE
WERE VERY INTERESTED HOW
LEUKOCYTES WOULD RADIANT.
THIS IS NORMAL IN RESPONSE TO
CHEMO TRACTANT.
YOU CAN SEE HOW WELL THEY LINE
UP ALMOST LIKE SUPREME COURT
JUSTICES WITH THE NUCLEARULOUS
IN THE BACK AND THEIR FEET DOWN
ON THE BOTTOM, BEING VERY
ATTENTIVE.
HER CELLS DID NOT DO THAT.
THEY HAD THESE FUNNY SORT OF
HERNIATIONS OF THE MEMBRANE WITH
THE NUCLEUS PROTRUDING.
AND IN CELLS I'M NOT GOING TO
SHOW YOU, WE THOUGHT HER CELLS
HAD CABLES OF MICROTUBULES
RUNNING THROUGH THEM THAT WE
DIDN'T UNDERSTAND.
WE REPORTED HER AND
UNFORTUNATELY, SHE DIED.
WE WENT ANOTHER 20 YEARS AND
NEVER SAW ANOTHER PATIENT THAT
LOOKED LIKE THIS.
UNTIL RECENTLY.
AND THIS IS WHERE I'M GOING TO
TURN THE PODIUM OVER TO DOUG
KUHNS.
HE'S BEEN SPENDING A LOT OF TIME
STUDYING ANOTHER PATIENT THAT
YOU'LL SEE HAS SOME VERY SIMILAR
FIVES, TRYING TO IDENTIFY THE
GENE THAT AT LEAST IN HIS
PATIENT EXPLAINS THE DISEASE.
SO DOUG, YOU WANT TO TAKE OVER?
I'LL COME BACK AND END BY
TELLING YOU ABOUT A COUPLE OTHER
PATIENTS WITH MOST OF MY
COMMENTS BEING ON THIS DISEASE
OF CHILDHOOD WHICH WE THINK WILL
HAVE IMPLICATIONS FOR A LOT OF
DISEASES.
SO LET ME GIVE YOU THIS.
[TECHNICAL DIFFICULTIES].
WE'RE NOT SURE.
BUT HAVE A MOLECULAR DEFECT.
IT'S IN 2 SISTERS.
THEY HAVE CURRENT INFECTIONS,
NEUTROPHILS DYSFUNCTION.
AND HER HER KNEE ATED MOROLOGY.
SO THIS IS ACTUALLY THE PATIENT
THAT WE HAVE BEEN FOLLOWING.
THIS IS A PATIENT OF STEVE
HOLLENS, WHO FOLLOWS THIS FAMILY
FROM QATAR.
2 SISTERS.
RIGHT NOW THEY'RE 7 AND 14, COME
FROM A [INDISCERNIBLE] MARRIAGE,
AND THEY HAVE FREQUENT SCAN AND
YOU WILLERATIONS.
THEY HAVE -- USERATIONS.
THEY HAVE SE THUS TROPENIA.
EVERY ONE THOSE THEY HAD
SUSPECTED NEUTROPHIL
DYSFUNCTION.
7-YEAR OLD HAS HAD REPEATED ORAL
INFECTIONS, SHE HAS DEVELOPED
ORAL STRICTERS, THE SIZE OF THE
OPENING HAS REDUCED TO THE POINT
WHERE SHE CAN ONLY BE FED BY
TUBE.
SHE ACTUALLY HAD A TWIN SISTER
WHO DIED AT THE AGE OF 3 FROM A
SEPTIC EVENT.
SO THIS IS A FAMILY TREE.
WE'VE ACTUALLY STUDIED THE
MOTHER AND FATHER AND MATERNAL
UNCLE.
THERE IS ONE SIB AND 2 SISTERS.
THE MOST STRIKING THING WE
FOUND, FIRST OF ALL, WHEN WE
LOOKED AT THIS, I HAVE TO TELL
YOU, I'M A BIOCHEMIST BY TRADE.
I SPENT A LOT OF TIME STUDYING
NEUTROPHILS.  THERE IS A CERTAIN
AMOUNT OF ENJOYMENT I GET JUST
FROM BEING ABLE TO CRACK OPEN
SOME OF THESE CASES.
THIS HAS BEEN ONE THAT'S
PARTICULARLY BEEN INTERESTG.
I HAVE SOME NORMAL NEUTROPHILS
HERE.
AND YOU CAN SEE, YOU KNOW, THE
RED CELLS IN A NORMAL MORE
FOLLOWING.
IF YOU LOOK AT THE PATIENT, YOU
CAN SEE THAT THE CELL, THE BITE
CELL, THE NEUTROPHILS, THE
OUTLINE OF THE MEMBRANE IS HERE.
THE GRANULES HAVE BEEN RETRACTED
AWAY FROM THE MEMBRANE.
I'LL SHOW YOU THIS LATER.
SAME THING DOWN HERE.  THIS IS
THE EDGE OF THE CELL AND THE
GRANULES HAVE BEEN PULLED AWAY.
WHEN WE ISOLATED THE CELLS,
SOMETHING VERY UNUSUAL HAPPENS.
NOW WE GET HERNIATIONS.
SO YOU SEE THAT THE NUCLEAR
LOBES ARE HERNIATED.
THEY'RE STILL WITHIN THE CELL
BODY.
THEY'RE HERNIATED ON THE CELL.
YOU CAN SEE IT BOTH OF THE
SISTERS.
THESE ARE NORMAL NEUTROPHILS.
IS GRANULES ARE UNIFORMLY
DISTRIBUTED THROUGHOUT THE CELL.
YOU CAN SEE THAT HERE, YOU HAVE
IF RETRACTION AWAY FROM THE
PERIPHERAL AND YOU SEE
HERNIATIONS OF THE NUCLEAR
LOBES.
THERE IS ALWAYS A PLASMA
MEMBRANE, AROUND THE NUCLEAR
LOBE.
IT'S STILL CONTAINED WITHIN THE
CELL BODY.
IF YOU LOOK BY SCANNING, THESE
ARE NORMAL ON THE LEFT.
AND YOU CAN SEE ON THE RIGHT,
PATIENTS CELLS AND YOU CAN SEE
SOME OF THE CELLS LOOK FAIRLY
NORMAL.
ALL OF A SUDDEN YOU SEE THE
HERNIATIONS ON THE CELLS.
EARLIER, SOMEWHERE AROUND 50-60%
OF THE CELLS WOULD SHOW THESE
HERNIATIONS, IF YOU TAKE
NEUTROPHILS AND STIMULATE THEM,
A CHEMO ATTRACTANT, BACTERIAL
PRODUCT, PEPTIDE THAT
NEUTROPHILS HAVE RECEPTORS FOR,
THIS UNDER GO A SHAPE CHANGE. 
THIS IS WHAT NEUTROPHILS CHANGE
THEIR SHAPE.
THEY'LL GO TO A POLARIZED CELL
WITH A [INDISCERNIBLE] POD, VERY
LEADINEDGE AS IN CHEMOTAXIS.
AND A EURO POD.
YOU CAN SEE THAT THE CELL FROM
THE PATIENTS DON'T UNDERGO THAT
SORT OF CHANGE.
AND WE CAN MONITOR THIS BY FLOW
SIT TROMTY.
YOU CAN SEE NEUTROPHILS,
[INDISCERNIBLE] IT CHANGES
WHENEVER YOU STIMULATE THE
CELLS.
THESE ARE THE NEUTROPHILS WHEN
AT BASIL, YOU TREAT THEM FOR A
HALF HOUR AND YOU CAN SEE THAT
THE FORWARD SCATTER CHANGES AND
SIDE SCATTER CHANGE.
THAT'S REPRESENTED DOWN HERE.
YOU CAN SEE THAT THE BLUE
HERRYMENTS THIS POPULATION.
THIS IS THE RIGHT ANGLE.
THE RIGHT ANGLE CHANGES ALSO.
FORWARD SCATTER CHANGES THE CELL
IN THE SIZE.
THAT MAY BE DUE TO THE
POLARIZATION IN THE CELL.
THE RIGHT ANGLE IS THE
GRANULARITY.
WE THINK IT'S THE CHANGE IN THE
[INDISCERNIBLE], CHANGING THE
RIGHT ANGLE SCATTER OF THE CELL.
SO YOU CAN FOLLOW THAT IN THESE
PATIENTS.
AND WHAT YOU SEE IN THE NORMAL
IS THAT THIS SHAPE CHANGE IS A
VERY TRANSIENT EVENT IN BOTH
FORWARD SCATTER AND RIGHT ANGLE
LIGHT SCATTER.
WHEN YOU STIMULATE THE CELLS BY
30 MINUTES, THEY HAVE A MAXIMUM
CHANGE AND BY ABOUT 3 HOURS,
IT'S RESTORED BACK TO BASELINE.
IF YOU LOOK AT THE 2 PATIENTS,
TH CAN'T UNDERGO ANY CHANGE IN
[INDISCERNIBLE] OR -- WE CAN DO
SOME THINGS IN THE LAB TO
ADDRESS THE FUNCTIONAL DEFECTS.
IF I CAN MAKE SURE THAT THIS
WORKS ... LET ME SEE.
THIS IS AN ASSAY THAT YOU TAKE
CELLS, YOU PUT THEM ON TO A
GLASS SI.
THE CELLS WILL STICK AND THEY'LL
SPREAD.
AND YOU JUST DO A TIME LAPSE
PHOTOGRAPHY.
AND WHAT YOU SEE IS THIS IS OVER
A TEN MINUTE PERIOD, CELLS GO
FROM NICE SPHERICAL CELLS TO
WHAT WE CALL A FRIED EGG SHAPE.
THIS IS IN A NORMAL PATIENT.
THIS IS ACTUALLY IN THE PATIENT.
WHAT YOU SEE HERE.
EVEN BEFORE WE START THE STUDY.
YOU START TO SEE THESE
HERNIATIONS ON THESE CELLS.
WHENEVER YOU GO AHEAD AND ALLOW
THEM TO STICK TO THE SLIDE, YOU
SEE THE CELLS ARE UNABLE TO
SPREAD.
WE HAVE ABNORM NUCLEAR MOROLOGY.
WE HAVE AN INABILITY TO SPREAD.
AND THIS ACTUALLY IS HER
BROTHER.
IF YOU LOOK AT THE BROTHER, HIS
CELLS SPREAD NORMALLY.
AND THAT WILL BECOME IMPORTANT
LATER ON.
THE NEXT THING THAT WE LOOKED AT
WAS CELL MIGRATION.
AS JOHN WAS SAYING, AS THESE
CELLS MOVE OUT INTO THE TISSUE,
THEY HAVE TO BE ABLE TO MOVE TO
THE SITE OF INFECTION.  THAT IS
DEPEND WANT UPON THE
POLYMERIZATION AT THE LEADING
EDGE.
IT'S A VERY DYNAMIC EVENT
OCCURRING.
WHERE THERE IS ACTON BEING PRO
LIMES ARED AND DEPROLIMERASED.
THERE IS POLYMERIZATION
OCCURRING OUT HERE AND THIS IS
MEDIATED BY SERVING OF THE
FILAMENTS BACK AT THIS POINT OF
THE CELL USING [INDISCERNIBLE]
ALSO KNOWN AS ACTON B PRO LITTLE
MERIZATION FACTOR.
THAT'S A FACTOR THAT TAKES ACTON
FILAMENTS AND CLIPS THEM.
NORMALLY ACTON GETS -- YOU HAVE
MONER ADDITION.
THIS IS 2 PRONG.
SERVING OCCURS TOWARD THE
POINTED END IN GENERAL.
SO YOU BACKLY -- THIS IS A VERY
DYNAMIC EVENT TO ALLOW FOR THIS
CELL MIGRATION TO OCCUR.
SO WE HAVE ASSAYS THAT GO AHEAD
AND MEASURE THIS.
AND THIS IS AN ASSAY THAT WE
HAVE IN THE LAB THAT'S ACTUALLY
RECENT ADDITION TO OUR LAB.
BASICALLY, WHAT YOU DO, IS
YOU'RE LOOKING FROM THE BOTTOM
OF THE SLIDE.
THIS IS A -- WE HAVE A CAMERA ON
THE BOTTOM.
YOU LOAD CELLS IN THE WELL AT
THE TOP.
AND THEN JUST USING FLOOR I
HADICS -- FLUORIDICS, THEY CATCH
ON THIS LITTLE LATCH.
YOU ADD AN ATTRACTANT.
WHEN YOU DO THAT AND LOOK OVER
THE NEXT HOUR, WHAT HAPPENS IS
THE CELLS WILL MIGRATE.
WE CAN TRACK INDIVIDUAL CELLS.
AND SEE HOW THE CELLS MOVE.
WE CAN MEASURE THE VELOCITYTIOUS
HOW DIRECT THEY ARE, AND WHEN WE
DO THAT IN A PATIENT, WHAT WE
SEE IS -- WELL, FIRST IN A
NORMAL, IF WE USE, AGAIN, THAT
SAME CHEMO ATTRACTANT, UNDER
[INDISCERNIBLE] CONDITIONS THERE
IS VERY LITTLE MOTION, RANDOM
MIGRATION.
IF YOU ADD A CHEMO ATTRACTANT,
THE CELLS MIGRATE DOWN TO THE
BOTTOM.
IF YOU LOOK AT THE PATIENTS,
THERE IS VERY LITTLE MOTILT
ASSOCIATED WITH THESE CELLS.
THERE IS -- WE USUALLY TRACK 10
OR 12 CELLS, ONLY 2 OF THEM
ACTUALLY MOVED IN THESE 2 CASES.
YOU CAN SEE DOWN HERE MAYBE 3 OR
4 MOVE BUT NOTHING LIKE WE SEE
IN A NORMAL.
SO NOW WE HAVE A SPREADING
DEFECT.
AND WE HAVE A CHEMO TACTIC
DEFECT.
AND WE HAVE A SHAPE CHANGE
DEFECT.
SO THE NEXT THING WE DECIDED TO
LOOK AT IS MY BIOCHEMISTRY CAME
BACK TO ME AND SAID OKAY, LET'S
USE A PROTEOMICS APPROACH.
SO -- FIRST I WANT TO -- WE
DECIDED TO GO AHEAD AND DO --
SINCE THEE ALL POINTED TO THE
CYTOSKELETON.
WE JUST DID A SIMPLE CONFOCAL
STUDY.
WE LOOKED AT THE CONTENT OF
FILAMENT [INDISCERNIBLE] USING A
PROBE.
AND IT BINDS ONLY TO FILAMENTIS
ACTON.
ON THE LEFT.
WE HAVE NORMAL CELLS.
YOU CAN SEE THAT THEY'RE FAIRLY
FAINT WITH STAINING.
STAINED WITH DABY TO SHOW THE
NUCLEAR.
THERE IS NOTHING REALLY BRIGHT
ABOUT ANY OF THE NORMAL CELLS.
IF YOU LOOK AT THE PATIENT
CELLS, ALL OF A SUDDEN YOU SEE
THAT THERE ARE CELLS THAT ARE
VERY BRIGHT.
IF YOU LOOK AT THE CELLS IN
PARTICULAR THAT ARE VERY BRIGHT,
YOU NOTE THAT THOSE ARE THE
CELLS THAT ARE HERNIATED.
AND SO A BETTER LOOK AT THAT IS
HERE WHERE YOU HAVE FOUR CELLS,
THE 2 UPPER CELLS, THESE HAVE A
NORMAL MORE FOLLOWING.
AND -- MORE FOLLOWING, AND
NORMAL STAINING.
THESE ARE MUCH BRIGHTER.
AND THEY HAVE HERNIATIONS ON THE
NUCLEI.
AS A MATTER OF FACT, THAT CELL
IS ACTUALLY HERNIATED TOWARD
YOU.
AND SO -- AND SO THIS ACTUALLY,
BECAUSE DABY IS A NUCLEAR STAIN,
IT'S THE NUCLEAR LOBES THAT ARE
BEING HERNIATED FROM THE CELL.
AND WE ACTUALLY WENT THROUGH AND
TOOK A FLOW [INDISCERNIBLE] AND
USED TO DETERMINE HOW MUCH
DIFFERENCE THERE WAS.
THESE ARE NORMAL CELLS.
AND ON THIS PARTICULAR DAY,
MOST, ALMOST 90% OF THE CELLS
WERE HERNIATED.
THEY'RE ABOUT 4-5 TIMES BRIGHTER
THAN THE NORMAL CELL.
SO THEY HAVE MUCH MORE
FILAMENTIS ACTON THAN THE NORMAL
THAT WE'VE SEEN.
SO THEN WE DID THE PROTEASE MIX
APPROACH.
THIS WAS ACTUALLY A PRETTY
INTERESTING WAY TO LOOK AT THIS.
WHAT YOU DO IS YOU TAKE YOUR
NORMAL CELLS, AND CELL EXTRACT
FROM NORMAL CELLS.
AND YOU STAIN THEM WITH
[INDISCERNIBLE] 3 AND TAKE YOUR
PATIENT CELLS AND STAIN THEM
WITH 5-5.
THEN YOU MIX THE 2 TOGETHER.
THEN YOU RUN -- ISO ELECTRIC
FOCUSING AND STANDARD
[INDISCERNIBLE] GEL IN THE OTHER
DIRECTION.
YOU, THEN, IMAGE THE GEL AND YOU
BASICALLY LOOK TO SEE WHERE --
WHAT IS GREEN AND WHAT IS RED.
IF THERE IS COLOCALIZATION, THE
RED AND THE GREEN WILL COME OUT
AS YELLOW BECAUSE IT'S -- IF
THERE IS A SITE THAT'S GREEN,
THEN THAT THE AORTIC ONLY
EXPRESSED IN THE -- THAT'S ONLY
EXPRESSED IN THE
[INDISCERNIBLE].
RED ONLY IN THE CONTROL.
SO WHEN WE DID THAT, WE GOT GELS
THAT LOOKED LIKE THIS.
AND THIS IS -- WE ALWAYS
COMPARED NORMAL TO PATIENTS.
WE WERE ABLE TO RUN 2 NORMAL, 2
PATIENT.
WHEN WE DID, THAT YOU COULD SEE
THIS IS WHAT THE MERGE OF THE
2 -- THESE 2 GELS LOOKED LIKE.
THERE ARE SUBTLE DIFFERENCES.
AND WHEN WE DID THAT, YOU LOOK,
AND THIS IS WHAT THE 2 GELS LOOK
COMPLETELY SIDE BY SIDE.
THERE ARE MANY SPOTS, THERE WERE
ABOUT 45, I THINK, 45 SOME SPOTS
THAT WERE DIFFERENT.
WE ONLY LOOKED AT SPOTS THAT
HAD -- THAT WERE GREATER THAN
1.3 FOLD DIFFERENT BETWEEN
NORMAL AND PATIENT.
AND AS YOU LOOK AROUND, FIRST OF
ALL, YOU SEE SOME OF THESE THAT
ARE -- WHOOPS.
IN PINK AND BLUE.
THOSE ARE CELLS WE SAW IN ONE
PATIENT BUT NOT THE OTHER, SO WE
DECIDED THOSE AREN'T RELEVANT SO
WE ELIMINATED THOSE.
WE JUST FOCUSED ON THOSE SPOTS
THAT SHOWED DIFFERENCES THAT
WERE CONSISTENT BETWEEN BOTH
PATIENTS AND THE 2 NORMALS.
IF YOU LOOK AT THOSE AND PLOT
THEM OUT, WHAT WE FIND IS THAT
THERE WERE SOME PROTEINS THAT
WERE AS MUCH AS 6 FOLD LESS IN
THE NORMAL.
LESS THAN NORMAL.
SOME THAT WERE ELEVATEED IN
[INDISCERNIBLE] NORMAL.
IF YOU LOOK AT THIS, THERE WERE
SOME VERY INTERESTING PLAYERS
ALONG HERE.
YOU NOTICE THERE IS BETA ACTON,
BETA ACTON FORMS, SO WE WERE
LOOKING -- WE WERE THINKING
THERE WAS GOING TO E CHANGES IN
THE ACTON CYTOSKELETON, AND
THERE WAS.
BUT WE DECIDED TO GO FOR THE LOW
HANGING FRUIT FIRST.
THE MOST OBVIOUSLY WAS WHERE WE
LOOKED AT COFILEN, WHICH WAS
DOWN REGULATED VERSES NORMAL,
BUT IT ALSO -- THE PATIENTS HAD
A SPOT THAT WAS UPREGULATED.
THESE 2 SPOTS ARE COFILEN.
THERE ARE 2 DIFFERENT SPOTS.
THIS ONE IS EXPRESSED PRIMARILY
IN THE [INDISCERNIBLE].
THIS ONE IS EXPRESSED MORE IN
THE PATIENT.
SO WE WENT AHEAD AND TOOK
LYSATES AND RAN THEM ON A GEL
AND -- BY WESTERN BLOCK, WHETHER
THERE WAS COFILEN PRESENT IN THE
PATIENTS AND NORMALS.
TURNS OUT THERE WAS EQUAL
AMOUNTS IN THE PATIENTS AND
NORMAL.
THE NEXT QUESTION REALLY WAS ARE
THEY DIFFERENTIATELY REGULATED.
WHAT MADE LIFE EASY, THERE IS AN
ANTIBODY THAT LOOKS FOR SERINE
PHOSPHATE AT THE POSITION OF
COFILEN.
IT BECAME CLEAR THAT THE
PATIENTS DID NOT PHOSPHORYLATE
COFILEN.
WHEREAS THE NORMAL AND THE
BROTHER DID PHOSPHORYLATE
COFILEN NORMALLY.
SO WE ACTUALLY SEQUENCED
COFILEN.
COFILEN WAS NORMAL.
SO THAT'S NOT THE MOLECULAR
DETECT.
SOMEHOW REGULATION OF COFILEN IS
DISRUPT THE.
SO COFILEN FOR THIS -- WHERE
DOES IT FALL?
COFILEN IS RIGHT DOWN HERE. 
THIS IS ACTON, POLYMERIZATION.
ALL THE EVENTS OF DYNAMICS.
COFILEN IS DOWN HERE.
IT IS A ACTON POLYMERIZATION
FACTOR.
>> IT'S JUST IS TO SEVERE ACT
INFILAMENTS.
IT'S REGULATED, DINASE WILL
BLOCK THE FUNCTION.
AND SLINGSHOT IS A PHOSPHOTASTE
THAT WILL ENHANCE THE FUNCTION.
WE SEQUENCE KINASE ALSO, AND IT
WAS NORMAL.
IT DOESN'T APPEAR TO BE IN THAT
PART OF THE PROTEIN.
SO THE INTERESTING THING ABOUT
THIS IS THAT BASED ON OUR
ANALYSIS, THE ACTING --
INHIBITED BY FOLLOW FORMATION OF
SERENE 3.
OUR PATIENT SHOULD HAVE VERY
HIGH ACTON DEPOT ACTIVITY --
IT'S NOT PHOSPHORYLATED.
THAT'S INCONSISTENT WITH OUR
DATA.
OUR DATA SAYS THAT WE GET VERY
HIGH LEVELS OF ACTON FILAMENTS
IN OUR CELLS.
THE ONLY WAY WE CAN RATIONALIZE
THAT IS THAT THE COFILEN
ACTIVITY IS DEPENDENT ON OTHER
FACTORS, DOING LITTLE MORE THAN
PROVIDING SEED ACTON FOR ACTON
PRO LIMMERIZATION.
IN OTHER WORDS, IT CAN CLIP LONG
ACTON FILAMENTS INTO SHORTER
ONES, BUT CAN'T TAKE IT ALL THE
WAY DOWN TO NONMERS, BUT CAN ADD
ON MORE SO YOU GET SHORTER ACTON
FILAMENTS.
THAT'S OUR RATIONALE.
WE'RE STILL LOOKING AT THAT.
MEANWHILE, WE WENT BACK TO OUR
LOW HANGING FRUIT AND LOOKED AT
ANOTHER PROTEIN THAT AT FIRST WE
IGNORED.
I DIDN'T KNOW WHAT IT WAS.
I WAS LOOKING AT WDR1.
IT TURNS OUT WDR1 IS PRESENT
MUCH AGAIN, IT'S DECREASED HERE,
BUT YOU START TO SEE IT HERE.
IF YOU LOOK TO SEE WHERE THAT
IS, IT TURNS OUT THIS IS WDR1 UP
HERE.
14, 15, AND 16.
THERE IS # -- 2 SPOTS THAT SEEM
TO BE ELEVATED IN THE PATIENT,
IN THE NORMAL, AND ONE THAT IS
ELEVATED IN BOTH PATIENTS.
WE DIDN'T HAVE THE LUXURY OF AN
ANTIBODY, BUT WE JUST -- AS AN
ANTIBODY FOR LOOKING AT
PHOSPHORYLATION, BUT WE WERE
ABLE TO SHOW THAT THERE SEEMS TO
BE EQUAL LEVELS OF WDR1 IN THE
PATIENT AS IN THE FORMALS.
SO IT'S THERE. -- NORMALS.
SO IT'S THERE.
I'M COMING BACK TO THE FAMILY
TREE.
BECAUSE WE HAD THIS ANOMALY, I
WENT AHEAD AND ACTUALLY
SEQUENCED WDR1.
WHAT WE FOUND WAS THAT THE ONE
SISTER HAD A MUTATION.
IT POSITIONED 76.
THERE IS A [INDISCERNIBLE]
TRANSFORMATION TO
[INDISCERNIBLE].
AND WHEN WE LOOKED AT THE REST
OF THE FAMILY, IT TURNS UT THAT
THE OTHER PATIENT WHO HAD THE
SAME MUTATION.
THE SIB WAS HETEROZYGOUS.
THE PARENTS WERE HETEROZYGOUS.
THAT APPEARS TO BE THE MUTATION.
WE LOOKED FURTHER AND IT TURNS
OUT THAT THAT PARTICULAR
[INDISCERNIBLE] 26 IS HIGHLY
CONSERVED IN EVERYTHING FROM
MOUSE DOWN TO [INDISCERNIBLE].
IT'S VERY HIGH LAY CONSERVED
AMINO ACID IN THAT PARTICULAR
AREA.
SO WHAT IS WDR1?
IT TURNS OUT THAT WDR1 IS A WD
REPEAT.
>> A TRYHTOPHAN, A SPARITATE
REPEAT PROTEIN.
THE PROTO TYPICAL PROTEIN IS THE
BETA SUBUNIT OF G PROTEIN.
WHAT THEY ARE ARE BETA
PROPELLERS WITH THE WD REPEAT
DOMAINS ACTUALLY THESE -- THESE
BLADES OF THE PROPELLER.
ANTIPARALLEL BETA SHEETS.
AND SO IN OUR CASE, WDR1, IT
TURNS OUT, HAS 11 TRYHTOPHAN
REPEAT DOMAINS.
IT'S ALSO, AS I READ FURTHER, IT
TURNS OUT THAT IT'S AN
INTERACTING PROTEIN 1.
AND IT BINDS THE ACTON COMPLEX.
AND OFTEN BECAUSE OF THIS -- THE
WAY THIS STRUCTURES, IT MAY END
UP BEING A SCAFFOLD PROTEIN FROM
BRINGING COMPLEXES TOGETHER.
WHAT ELSE DO WE KNOW ABOUT IT?
IT TURNS OUT THERE IS A KNOCKOUT
MOUSE FOR WDR1 AND IT'S LETHAL.
THERE IS A HYPOMORPHIC MUTATION
THAT WAS GENERATED IN MICE USING
MUO GENESIS.
IT'S CALLED A RED EARS, AND WHAT
BASICALLY IT HAS IS A DELETION
OF 2 AMINO ACIDS, POSITION 346
AND 347.
AND THIS MOUSE DEVELOPS
INFLAMMATORY LESIONS ON ITS EARS
AND TAIL AT 3-6 WEEKS.
IT GETS WORSE OVER TIME.
THE DEFINING FEATURE WAS A
LEUKOCYTE INFILTRATION,
ACCOMPANIED BE EPIDERMAL HYPER
PLASHA WHICH MAKES ME THINK BACK
TO ALL THE PROBLEMS WITH THE
MOUSE.
IN OUR PATIENT.
NECK CROSSES, EDEMA AND
CARTILAGE DESTRUCTION.  THIS IS
A PICTURE OF THE THIS IS A
WILDTYPE MOUSE.
IS IS THE EARS OF THE RED
EARED MOUSE.
AND THE PAPER THAT DESCRIBED
THIS, CHARACTERIZED THAT THE
CHEMO TACTIC AND CYTOKELLTLE
DEFECT WITH DISRUPTION OF ACTING
POLYMERIZATION.
SO BASICALLY, THE HYPOTHESIS
THAT WE'RE WORKING ON NOW WAS
DEVELOPED IN THIS PAPER, WDR1
ACTIVELY PROMOTES COFILEN.
AND CAPS THE BARBED END.
IT NOT ONLY PROMOTES COFILEN
ACTIVITY BUT IT BINDS TO THE
BARBED END AND PREVENTS MONOMER
ADDITION SO THAT YOU CAN
ACTUALLY DEGRADE ALL THE WAY
DOWN TO INDIVIDUAL MONOMERS.
SO WHERE DO WE GO?
ALL THE DATA WE DID WERE
DESCRIBED USING FRESHLY ISOLATED
[INDISCERNIBLE].
AT THIS POINT THE PATIENT HAD
UNDERGONE A SUCCESSFUL BONE
MARROW TRANSPLANTATION.
WE NO LONGER HAVE CELLS, WHERE
DO WE GO?
THERMOFIBROBLASTS MAY BE A TOOL.
WE TRY A WOUND HEALING MODEL.
AND WHAT YOU HAVE HERE, THIS IS
ACTUALLY NORMAL FIBROBLASTS,
WITH A BARRIER BETWEEN THE -- ON
THE CULTURE PLATE.
YOU REMOVE THE BARRIER.
AND THEN YOU LET THE CELLS GROW.
OR MIGRATE.
THIS IS ACTUALLY OVER 24-36
HOURS.
AND WHAT YOU SEE, THIS IS THE
GAP CLOSES.
SO THIS IS A WOUND HEAL MODEL.
YOU CAN SEE IT TAKES A WHILE.
THIS -- I THINK WE HAVE PICTURE
EVERY 20 MINUTES, AND SO THIS IS
A VERY LONG.
BUT YOU CAN SEE THAT THE
EVENTUALLY THERE IS A CLOSING OF
THE GAP BETWEEN THE CELLS.
OKAY?
YOU TRY THIS IN THE PATIENT.
AND ALTHOUGH WE THINK WE SEE A
DIFFERENCE, IT WOULD BE VERY
HARD TO BE ABLE TO QUANTITATE A
DIFFERENCE.
TO ME, IT LOOKS AS THOUGH THERE
IS A MUCH MORE RAPID CELLS
GROWING STRAIGHT ACROSS, THEY
CLOSE MUCH MORE RAPIDLY.
BUT IT'S DIFFICULT TO USE IN
SOME SORT OF ASSAY TO BE ABLE TO
LOOK CAREFULLY.
SO INSTEAD -- [INAUDIBLE]
>> I DON'T KNOW.
THERE IS A LOT OF VARIABLES
THAT -- MAYBE SOMETIMES THE
AMOUNT OF CELL CONCENTRATION CAN
HAVE THAT WE PUT ON THE SLIDE
MAY MAKE A DIFFERENCE.  THERE
ARE SOME ISSUES THAT WE HAVEN'T
BEEN ABLE TO RESOLVE ON THIS.
IT LOOKS BASICALLY LIKE THEY
GROW STRAIGHT TOGETHER RATHER
THAN SOME OF THE ROUTES THAT
[INDISCERNIBLE] GOES.
SO INSTEAD, WE'RE ACTUALLY GONE
TO AN ADHERENCE INDUCED
UNIFORMITY OF CELLULAR
MORPHOLOGY.
THAT SOUNDS PRETTY -- THAT'S A
MOUTHFUL.  WHAT IT REALLY MEANS
IS THE MICROPATTERN SLIDES.
I DON'T KNOW HOW MANY PEOPLE ARE
ASSOCIATED -- HAD ANY USE OF
MICROPATTERN SLIDES.  WHAT THESE
ARE, ARE SLIDES WHERE THE
MANUFACTURER COATS THEM WITH A
MATERIAL THAT THE CELLS DO NOT
ADHERE TO.
THEN THEY BASICALLY USING
[INDISCERNIBLE], THEY REMOVE
CERTAIN MICROPATTERNS.
AND THEY COAT THOSE WITH
[INDISCERNIBLE].
SO THEN YOU ACTUALLY CAN LAY
YOUR FIBROBLASTS ON TO THOSE.
WHAT YOU SEE IS THAT A
FIBROBLAST, ALL OF A SUDDEN,
TAKES THE SHAPE OF WHATEVER
MICROPATTERN THAT YOU PUT ON
THERE.
AND IN THIS CASE, THESE Hs,
YOU CAN SEE THAT THE CELLS
BECOME SQUARE RATHER THAN THE
TYPICAL FIBROBLAST APPEARANCE.
AND BECAUSE THEY CAN ADHERE
ACROSS THESE, THEY CREATE STRESS
FIBERS ACROSS THOSE REGIONS.
THESE ARE STAINED AND YOU'RE
LOOKING AT FILAMENTIS.
AND WHAT YOU'RE SEEING HERE ARE
STRESS FIBERS ACROSS THESE AREAS
WHERE THERE IS NO ATTACHMENT.
THEY CAN ONLY ATTACH THROUGH
HERE.
SO YOU CAN SEE ON THE NORMAL,
THAT YOU GET THESE VERY NICE
STRESS FIBERS.
IF YOU LOOK AT THE PATIENT, YOU
SEE THEY DON'T FORM STRESS
FIBERS.
THERE SEEMS TO BE MORE OF A
HOMOGENOUS DISTRIBUTION OF THE
STAINING THROUGHOUT THE BODY OF
THE CELL AND NO LOCALIZATION ON
THE PERIPHERY.
NOT ONLY THAT, THE THING THAT'S
INTERESTING ABOUT THIS, YOU GET
MULTIPLE SHAPES.  SO IF YOU USE
THE Y SHAPED PATTERNS, YOU CAN
SEE HERE THAT YOU HAVE TO FORM
STRESS FIBERS ACROSS ALL THE --
SO YOU GET THESE CELLS WITH
STAINING ON THE PERIPHERY.
IF YOU LOOK AT THE PATIENTS, IN
THIS CASE, THE CELL CAN'T SEEM
TO CONFORM.
SOME DON'T CONFORM WELL.  THERE
IS A GENERAL DIFFUSE STAINING
RATHER THAN THE STAINING ON THE
PERIPHERY.
THEY ALSO HAVE WHAT THEY CALL
THE CROSS BOW.
AGAIN, WE SEE VERY SIMILAR, THE
STRESS FIBERS ARE GOING TO GROW
FROM HERE.
YOU SEE THEM HERE, HERE, MIGHT
SEE A LITTLE HERE.
IN GENERAL, THEY HAVE TROUBLE
CONFORMING TO THESE
MICROPATTERNS.
AND THEN THE FINAL IS USING THE
CIRCLE.
THEN, YOU SEE THESE NICE STRESS
FIBERS THAT FORM ON ALL THE
CELLS IN THE NORMAL BUT WHEN YOU
LOOK AT THE PATIENT FIBROBLASTS
YOU GET, AGAIN, THE STAINING.
WE THINK WE HAVE AN ASSAY NOW TO
BE ABLE TO LOOK AT FIBROBLASTS
AND DETERMINE WHAT THE DEFECT
IS.
THE NEXT STEP IS NOW TO -- WE'RE
IN THE PROCESS OF TRYING TO
TRANSEFFECT THE FIBROBLASTS WITH
WILDTYPE TO SEE IF WE CAN
CORRECT THIS DEFECT IN VITRO.
WE'RE LOOKING TO SEE THE
STRUCTURAL ANALYSIS TO SEE IF WE
CAN SEE A DIFFERENCE.
FINALLY, WE'RE GOING TO BE
LOOKING AT SOME OF THESE
PROTEINS TO SEE IF THEY'RE THE
SAME THING WE SAW IN THE
NEUTROPHILS, DIFFERENCES IN
PHOSPHORYLATION, COFILEN AND
SAME EXPRESSION OF WDR1 IN THE
FIBROBLASTS.
SO FIRST I SHOULD TELL EVERYBODY
WHO WAS INVOLVED, PEOPLE IN MY
LAB UP IN FREDERICK, DANNY HAS
DONE A YO MAN'S TASK ON MANY OF
THESE STUDIES.
MOST OF THE CONFOCAL AND STUDIES
WITH THE -- THE MICROPATTERNS.
DAN AND CHRIS DID MOST OF OUR
SEQUENCING.
THIS IS -- THIS PATIENT IS A
PATIENT OF STEVE HOLLAND, AND
AMY SUE HAS CONTRIBUTED A LOT.
HARRY HAD PATIENTS THAT HE HAD
ABOUT 20 YEARS AGO, ALSO, HE
NEVER WROTE UP THAT WERE TRYING
TO GET BACK THAT HAD A VERY
SIMILAR PHENOTY THAT HOPEFULLY
WE'LL BE ABLE TO LOOK AT.
AND THEN ALL THE IMAGE ANALYSIS
LAB PROVIDED THE EMs AND THE
CONFOCAL AND TOMMY GAVE ME THE
IDEA FOR THE SITEU SLIDES.
SO THAT'S IT.
[APPLAUSE]
>> WE'LL HAVE QUESTIONS IN A FEW
MINUTES.
SO HOPEFULLY YOU'RE BEGINNING TO
GET THIS IDEA THAT YOU CAN STUDY
A FEW PATIENTS AND MAYBE LEARN
SOME FUNDAMENTAL PRINCIPALS
ABOUT, IN THIS CASE, NEUTROPHIL
FUNCTION BUT MORE IMPORTANTLY
FIBROBLAST FUNCTION.
IS THERE A BURNING QUESTION THAT
YOU WANTED TO QUESTION?
[INAUDIBLE]
>> OR WHY WAS EXCLUSIVELY THE
MOUSE?
>> MOSTLY IN THE ORAL CAVITY.
>> AND DID YOU LOOK MAY BE FOR A
CYTOKINE EXPRESSION?
MAYBE SOME --
>> WE DID NOT SEE ANYTHING.
>> WHAT'S INTERESTING ABOUT THE
FIBROBLASTS, THEY DON'T SHOW THE
NUCLEAR HERNIATIONS.
IT SEEMS TO BE MANIFEST
SPECIFICALLY IN THE NEUTROPHILS,
WHERE WE SAW IT THE MOST.
WE HAVEN'T SEEN IT --
OCCASIONALLY WE'LL SEE A
LYMPHOCYTE WITH HERNIATION, BUT
THAT PARTICULAR SEEMS TO BE
STRICTLY LIMITED TO THE
NEUTROPHIL.
THAT I DON'T KNOW WHY.
>> DO YOU HAVE ANY OF THE
CYTOKELLTLE [INAUDIBLE] NOT THAT
WE -- JOHN IN HIS PAPER, THEY
HAD SEEN SOME MICROTUBULE
DEFECTS.
WE HAVEN'T LOOKED AT THAT.
I'M JUST NOW GETTING THE
[INDISCERNIBLE] BACK FROM THE
FIBROBLAST.
WE DID NOT SEE ANYTHING IN
PARTICULAR IN THE NEUTROPHIL.
YOU HAVE TO SEARCH REALLY HARD
FOR THAT.
>> WHAT CAUSES THE 3 OR 4 LOADS
OF THE NEUTROPHIL TO SEPARATE?
>> I'M ASSUMING THAT THERE IS A
DISRUPTION OF THE MICRO
FILAMENTS, THAT MAYBE THAT
CORTICO ACTON MAY BE DISRUPTIVE.
THAT'S AFTER THE BARRIER AND
WHEN IT'S NOT IN TACT, THE CELLS
CAN HERNIATE OUT.
THAT'S WHAT MY HYPOTHESIS IS.
>> [INAUDIBLE]
>> ANY OTHER QUESTIONS NOW?
YEAH.
>> [INAUDIBLE]
>> HAVE YOU STUDIED OTHER ANIMAL
MODELS [INAUDIBLE]
>> NO.
>> [INAUDIBLE]
>> I'M ACTUALLY THE NEUTROPHIL
MONITORING LAB.
WE TEND TO FOCUS ON HUMANS.
WE HAVEN'T DONE ANY OF THE MOUSE
STUDIES.
THE -- WE HAVEN'T DONE ANY MOUSE
STUDIES.
MOST OF THE MOUSE STUDIES I
PRESENTED WERE FROM THE
LITERATURE.
>> [INAUDIBLE]
>> WHAT?
>> [INAUDIBLE].
>> ARE YOU ASKING THE THE --
>> YEAH, THE SHAPE CHANGE.
[INAUDIBLE]
>> SO WHAT WE THINK IS HAPPENING
IS THAT THE -- WHAT'S
INTERESTING, YOU DON'T SEE IT IN
A PREFERERAL BLOOD SMEAR.
FOR SOME REASON, ISOLATION OF
THE CELLS IS SUFFICIENT TO
INDUCE SOME OF THIS.
SO THEY'RE TEETERING ON THE EDGE
IS WHAT I THINK IT AMOUNTS TO.
THE MINUTE WE TAKE THEM OUT OF
SERUM, IT SEEMS TO PROMOTE THIS
HERNIATION.
I'M NOT SURE EXACTLY WHY, BUT
CLEARLY, THERE IS SOME
DISRUPTION IN THE CYTOSKELETON
THAT IS SOMEHOW INVOLVED.
MORE THAT WE HAVE TO LOOK AT.
>> THESE CELLS ARE TERMINAL.
NEUTROPHILS LIVE IN CIRCULATION
FOR ABOUT 67 HOURS, THEY -- 6
HOURS, THEY DON'T REPRODUCE OR
DIVIDE AT ALL.
>> [INAUDIBLE]
>> IS THE WHAT EFFECTED?
>> [INAUDIBLE]
>> I DON'T KNOW.
WE'VE NEVER DONE APOPTOSIS STUDY
ON THIS PARTICULAR STUDENTS.
I DON'T KNOW IF THE TURN OVER
TIME CHANGES ON HER OR NOT.
ONE OF THE PROBLEMS IS THEY WERE
FROM QATAR, SO WE ONLY GOT THEM
IN OUT EVERY 6 MONTHS.
WE PLANNED AN AWFUL LOT OF
EXPERIMENTS IN A VERY SHORT
AMOUNT OF TIME, AND ALSO, SHE
WAS ONLY 5, 6 YEARS OLD.
SO GETTING THE AMOUNT OF BLOOD
WE NEEDED -- AND SHE'S
NEUTROMEANIC.
GETTING ALL THE BLOOD WAS NOT
ALWAYS EASY.
SO WITH THE CHANGES IN THE DERMO
FIBROBLASTS, IT'S LIKELY IT'S
DUE TO CHANGES IN T
[INDISCERNIBLE] I WOULD IMAGINE.
>> [INAUDIBLE] WE'RE NOT DOING
ANY IN PARTICULAR [INAUDIBLE].
TOOK THEM OUT OF CULTURE AND PUT
THEM ON TO THE SLIDE AND THEN
THEY ACQUIRE THE SHAPE.
BUT I DON'T THINK THERE IS --
OTHER THAN THE STRESS OF HAVING
TO CONFORM TO THE [INAUDIBLE] IS
THE ONLY SIGNAL.
>> ONE MORE.
>> ONE MORE.
>> IS THERE MYOSIN ASSOCIATED
WITH THE ACTON HERE?
>> WE HAVEN'T LOOKED AT THAT
YET.
THERE ARE SOME STUDIES THAT
WE'RE LOOKING AT ACTON
POLYMERIZATION YET.
WE HAVEN'T LOOKED AT ALL THAT.
>> TYPE FOR MORE QUESTIONS.
>> SO WHATEVER AORTIC GOING TO
DO NOW IS GO THROUGH A FEW MORE
EXAMPLES OF HOW THESE PATIENTS
HAVE HELPED US UNDERSTAND MORE
ABOUT THE VARIOUS STEPS IN THE
SEQUENCE OF INFORMATION.
NEXT FOCUS ON THE INTERACTION OF
[INDISCERNIBLE], RELEASED FROM
MICROBES WHICH INVADE TISSUES.
WITH THE NEUTROPHILS.
[TECHNICAL DIFFICULTIES]
>> PNEUMONIA MENINGITIS.
THEN SHE HAD A LITTLE OVER A
YEAR OF AGE, [INDISCERNIBLE].
SHE HAD RECURRENT MIDDLE EAR
INFECTIONS.
SHE HAD RECURRENT GRAM POSITIVE
[INDISCERNIBLE] OR STREP
PNEUMONIA ACDOMINATE ABSCESSES,
THEY HAD A SEVERE INFECTION OF
HER LEFT LEG WITH
[INDISCERNIBLE] WHICH RESULTED
IN AMPUTATION AT THE HIP OF HER
LEFT LEG WHEN SHE WAS 9 YEARS.
AND NEEDLESS TO SAY, HER MOM WAS
PETRIFIED.
SHE TOOK HER OUT OF SCHOOL AND
SAID I DON'T WANT MY KID EXPOSED
TO ANY OTHER KIDS WITH
INFECTIONS.
AND SHE STAYED AT HOME.
SHE SAID HAVE YOU GOT ANY IDEAS?
I SAID COME ON UP, WE'LL START
LOOKING  YOUR DAUGHTER.
AND SHE CONTINUED TO HAVE
INFECTIONS BUT THEY BE AS SHE
GOT THROUGH ADOLESCENTS,
INTERESTINGLY, HER FREQUENTLY OF
INFECTIONS SEEMED TO DISY POOR.
SO THAT WAS BEWILDERING.
WE STARTED STUDYING HER WHEN SHE
WAS 9 YEARS OLD.
AND ONE OF THE -- WE WENT
THROUGH ALL THE ASSAYS, THE KIND
OF ASSAYS THAT DR. KUHNS JUST
RELAYED TO YOU.
I'LL TELL YOU ABOUT SOME OF THE
RESULTS.
WE STARTED DOING INVIVO.
ONE WAS TO MAKE BREEZE BLISTERS
ON THE FOREARM OF THE SUBJECT
BUT PUTTING A SUCTION DEVICE ON
THE SKIN.  YOU LEAVE IT THERE
FOR ABOUT A HALF HOUR.
YOU RAISE THESE BLISTERS, THEN
YOU CAN ASPIRE RATE WHAT'S THERE
INSIDE OR YOU CAN GILL ATEEN OFF
OR CHOP OFF THE TOP OF THESE
BLISTERS, AND THEN PUTA LITTLE
TEMPLATE OVER THEM AND BATHE
THESE WOUNDS IN WHATEVER YOU
WANT AND COLLECT MATERIALS OVER
TIME.
AND WHEN YOU DO THAT, YOU GET
CELLS COMING AND THEN YOU CAN
LOOK AT VARIOUS MEDIATORS OF
INFLAMMAONS, SO WE DID THAT ON
HER.
THIS IS A SUMMARY OF
EXPERIMENTS, 3 OR 4, LOOKING AT
THE NUMBER OF OXIDATIVE CELL
THAT'S CUMULATE IN THE FLUID,
THE GRAY IS THE RESULTS OF A LOT
OF NORMALS.
LOOKING AT THE AMOUNT OF CHEM
ATTRACTANT C5A, AND THE LINE,
THE SHADED AREA ARE THE NORMALS.
SHE HAD FEWER NEUTROPHILS AFTER
24 HOURS.
LESS INTERLEUKIN 8.
LESS INTERLEUKIN 6.
THROUGHOUT THE TIME PERIOD.
SO WE THOUGHT THAT WAS
INTERESTING.
THAT WAS THE FIRST TIME WE FOUND
ANYTHING ABNORMAL IN HER, SO WE
DID MORE THINGS.
ANOTHER THING THAT WE CAN DO
WITH HUMANS IS WE INJECT
INTRAVENOUS ENDOTOXIN, VERY TINY
AMOUNTS, PREPARATION CALLED
IL -- RE2.
E. COLI ENDOTOXIN PREP.
THIS SOUNDS TERRIBLE BUT IT'S
EQUIVALENT TO A TYPHOID VACCINE,
BUT INTRAVENINOUSLY NOT
INTRAMUSCULARLY.
I SEE THESE ARE NOT LABELED IN
THIS DISPLAY, BUT -- THIS IS AT
ABOUT 24 HOURS.
YOU CAN SEE THE TEMPERATURE GOES
UP AND FALLS.
IT ACTUALLY -- THE NUMBER OF
NEUTROPHILS DROPS AT 30 MINUTES,
THEN GRADUAL LEUKOCYTE GOES UP
AT ABOUT 8 HOURS.
SOME IMMATURE CELLS COME FROM
THE BONE MARROW.
THE PRODUCTS ARE RELEASED.
YOU CAN SEE [INDISCERNIBLE] AS
WELL AS THE [INDISCERNIBLE] AND
WE LOOK AT OTHER THINGS LIKE C
REACTIVE PROTEIN AND THIS IS THE
ENDOTOXIN BINDING PROTEIN.
THE YELLOW LINE SHOWS THIS
PATIENT.
YOU CAN SEE SHE HAS A SEVERE
DIFFERENCE FROM NORMAL, DECREASE
FROM NORMAL IN TERMS OF HER
FEVER RESPONSE, ABILITY TO
MOBILIZE, NEUTROPHILS, AND
[INDISCERNIBLE] FROM HER BONE
MARROW.
AND ACCOMPANYING PRODUCTS IN HER
BLOOD.
SO AGAIN, SHE HAS THESE
RECURRENT INFECTIONS.
SHE DOESN'T SEEM TO RESPOND IN
VIVO TO ENDOTOXINS.
SO DOUG AND I WROTE THIS PATIENT
UP IN 1997 AS AN EXAMPLE OF --
THROUGH OTHER STUDIES WHICH I'M
NOT GOING TO SHOW YOU NOT ONLY
ENDOTOXIN, BUT INTERLEUKIN 1
HYPORESPONSIVENESS.
SHE WAS THE FIRST PATIENT
DESCRIBES IN THE LITERATURE WHO
HAD THIS PHENOMENON.
AND WE WERE ABLE TO DEMONSTRATE
THAT HER MONOCYTES DID EXPRESS
CD14, THE RECEPTOR FOR ENDOTOXIN
OR LPS.
AND SHE BOUND LPS IN A SPECIFIC
MANNER, BUT FAILED TO PRODUCE
TNF AND GRANULOCYTE AFTER
STIMULATION WITH LPS AND FAILED
TO RESPOND TO INTERLEUKIN 1.
WHICH USED TO BE CALLED
[INDISCERNIBLE].
WITH SHELLY WOLF.
ISOLATED PIRO GEN, IDENTIFIED IT
AS INTERLEUKIN 1 AND LATER WENT
ON TO ALL SORTS OF
[INDISCERNIBLE].
THIS PATIENT FAILED TO RESPOND.
AND WE THOUGHT THIS WAS A DEFECT
VERY LIKELY IN THE SIGNAL
TRANSDUCTION PATHWAY.
WHEN THIS PAPER CAME OUT, PEOPLE
CALLED US UP AND SAID WE CAN
FIGURE OUT WHAT THE PROBLEM IS.
SEND US THE STUFF.
SO WE SENT IT.
WE SENT HER CELLS.
AND THEY STRUGGLED WITH IT.
AND THEY FAILED.
THEY WEREN'T ABLE TO COME ONE
ANY MOLECULAR DEFECT.
SO WE ARE JOINED THE PARTNERSHIP
WITH STEPHANIE VOGEL, WHO AT THE
TIME WHEN WE STARTED WAS OVER AT
THE UNIFORM SERVICES MEDICAL
SCHOOL AND LATER WENT ON TO THE
UNIVERSITY OF MARYLAND WHERE
SHE'S AT NOW.
AND WE ALSO STARTED LOOKING IN
THE LITERATURE WHICH WAS COMING
OUT THEM, A LOT OF THE WORK ON
THE TOLL LIKE RECEPTOR PATHWAY.
JEWELS HOFFMAN'S LAP WAS
DESCRIBING THIS PATHWAY AND
DESCRIBING SOME ANIMALS WHO --
[INDISCERNIBLE] WHO DIDN'T
RESPOND TO EITHER E-COLI
MATERIALS.
AND THIS IS NOT A COAT THAT WAS
PURCHASED, BUT RATHER COVERED
WITH ASPERGILLUS.
THIS HAS A MUTATION, WHICH I'M
GOING TO TELL YOU ABOUT IN A
SECOND.
IT LAICS THE PATHWAY FOR
SIGNALING ENDOTOXIN OR FUGI
MATERIAL.
AND -- FUNGY MATERIAL.
A DEFECT PROTEIN INTERLEUKIN 1
RECEPTOR FOR IRAK4 WHICH I'LL
SHOW YOU IS IN THE PATHWAY FROM
WHERE ENDOTOXIN BINDS TO ITS
RECEPTOR AND SIGNALS THE
DOWNSTREAM EVENTS.
SO AT THE TIME, WE HAD BEEN
LOOKING AT AND SEQUENCING ALL
THE ELEMENTS THAT WE COULD THINK
OF IN THIS TOW LIKE RECEPTOR
PATHWAY.
WE FIGURED THIS IS WHERE THE
MUTATION WAS.
WE CAME UP WITH O WE LOOKED AT
THE WHOLE SERIES OF PROTEINS.
WHEN THIS CAME OUT.
WE SAID WE HAVEN'T LOOKED AT
THIS ONE.
WE LOOKED AT THIS PROTEIN.
SURE ENOUGH.
[INDISCERNIBLE] IRAK4 MUTATION.
ALMOST AT THE SAME TIME THAT WE
PUBLISHED OUR WORK IN THE
GENERAL EXPERIMENTAL MEDICINE,
SEAN PIERRE -- PUBLISHED IN
SCIENCE THE SAME MUTATION
SEVERAL PATIENTS.
AND WE'VE NOW PAIRED NOTES AND
SINCE THESE PAPERS WERE
PUBLISHED, THERE IS OVER 30
PATIENTS FOUND TO HAVE SIMILAR
MUTATION IN IRAK4 WHO HAVE
SUSCEPTIBILITY TO RECURRENT
INFECTIONS.
SHE GOES ARNE TALKING ABOUT --
AROUND TALKING ABOUT RARE
DISEASES, HOW HORRIBLE IT IS
THAT HAVE ONE OF THESE, NO ONE
CAN TELL YOU WHAT'S WRONG.
HOW PLEASED SHE IS TO HAVE A
DIAGNOSIS BUT HOW FRUSTRATING IT
IS TO HAVE NO TREATMENT.
ALL THE PATIENTS, EVERY ONE OF
THEM, HAS HAD A CLINICAL COURSE
LIKE THIS PATIENT IN THAT WHEN
THEY GET THROUGH ADOLESCENCE,
THEY STOP HAVING THESE
INFECTIONS FOR REASONS WE DO NOT
UNDERSTAND.
THE MUTATION PROCESS.
BUT IT'S AS IF THERE IS SOME
OTHER -- THE OTHER IMMUNE
MECHANISMS HAVE TAKEN OVER
AND -- ARE -- AND THEY DON'T GET
INFECTIONS.
NOW, SHORTLY AFTER WE IDENTIFIED
THE MUTATION IN THIS PATIENT, WE
STARTED SEEING SOME OTHER
PATIENTS WHO HAVE A -- MAKE A
LONG STORY SHORT, MUTATION IN A
DIFFERENT PROTEIN IN THIS
PATHWAY CALLED NEMO.
WHICH IS THE NUCLEAR MODULATED
PROTEIN WITHIN THIS CASCADE IN
ONE OF THE LIMBS OF THE PATHWAY
LEADING TO NK kappaB
ACTIVATION.
THIS PATIENT HAS A COMPLETELY
DIFFERENT PHENOTYPE.
THE HAIR IN THIS PATIENT IS
PECULIAR.
THERE IS THIS -- WHOOPS.
IT'S THIS SORT OF SWIRLING HAIR
PATTERN.
THE TEETH ARE VERY FUNNY.
THEY HAVE THESE CONED SHAPED
TEETH.
AND THEY HAVE REDUCED SWEAT
GLANDS.
AND THEY HAVE INTRACELLULAR
INFECTIONS WITH ORGANISMS LIKE
BACTERIA AND CMV.
THEY DO NOT GET INFECTIONS WITH
ORGANISMS LIKE E. COLI AND STREP
PNEUMONIA THAT I SHOWED YOU
EARLIER.
EVEN THOUGH WE DON'T UNDERSTAND
THESE AS WELL WE THINK WE DO OR
THERE IS SOMETHING DIFFERENT
ABOUT HAVING A MUTATION AT NEMO,
VERSES IRAK4, PROFOUNDLY
DIFFERENT PHENOTYPE.
SO WE'RE GOING TO BE WORKING ON
UNDERSTANDING THAT.
NOW THE LAST SET OF PATIENTS, WE
SPENT THE MOST TIME STUDYING AT
NIH.
THESE ARE PATIENTS THAT HAVE A
DEFECT, WHAT HAPPENED WHEN THE
NEUTROPHIL INTERACTS WITH A
PARTIAL, PARTICULARLY A
MICROORGANISM BUT OTHER THINGS
AS WELL.
THERE IS A TREMENDOUS BURST OF
OXYGEN CONSUMPTION.
WHEN THIS HAPPENS IN PATIENT WHO
DON'T HAVE THIS BURST OF OXYGEN
CONSUMPTION WHICH LEADS TO
PRODUCTION OF HYDRO GENPEROXIDE.
THEY HAVE PROBLEMS WITH 2
CLINICAL ABNORMALITIES.
THE MOST PRONOUNCED ARE
INFECTIONS.
THIS OCCURS ABOUT 1-200000 LIVE
BIHS IN THE WORLD.
THE MORTALITY IS ABOUT 2% DIE A
YEAR AFTER BIRTH PER YEAR.
THE THIRD DIE FROM THE
[INDISCERNIBLE], AND ABNORMALITY
OF AN ENZYME WHICH IS SHOWN HERE
IN THIS DIAGRAM, WHICH IS --
THEN GETS CONVERTED BY THE
ENZYME [INDISCERNIBLE] TO HYDRO
GENPEROXIDE.
WHICH, THEN, GETS CONVERTED BY
THE NEUTROPHILS ENZYME IN THE
PRESENCE OF CLEAR REASON, TO
BLEACH, WHICH THEN GETS
CONVERTED TO CHLORINE.
SO THESE PATIENTS ARE NOT
CAPABLE OF PRODUCING HYDROGEN
PEROXIDE OR ACID OR CHLORINE,
WHICH NORMALLY IS PRODUCED IN
LARGE AMOUNTS.
A MULTITUDE OF PROTEINS THAT
MUST ASSEMBLE FOR IT TO WORK.
IT'S NOT ONE PROTEIN.
AND THE PROTEINS INCLUDE A B.
[INDISCERNIBLE] WHICH
COMPROMISES A IT KILODALTON
MOLECULAR WEIGHT GLYCOPROTEIN
WHICH IS NON COVALENTLY LINKED
TO A PROTEIN OF B # 2, OR 22
KILODALTON PHAGOCYTE OXIDASE.
THESE PROTEINS ARE TRIGGERED TO
ACTIVATE WHEN CYTOSILK ELEMENTS,
PARTICULARLY 47 AND 67 PROTEIN
BINDS AND ASSEMBLES TO MAKE THIS
WHOLE PROTEIN.
WHEN THAT OCCURS ALONG WITH THE
FEW OTHER PROTEINS LIKE RAQ AND
ROW, THE ONLY THINGS HAMS.
YOU GET THIS REDUCTION OF
OBSGEN.
AND SO MUTATIONS OF ANY OF THESE
LEADING TO THIS DISEASE.
ABOUT 2/3 OF THE PATIENT HAVE A
FORM WHICH RELATES TO THE GP91
PROTEIN.
THE SECOND MOST COMMON IS THIS P
47 CYTOSILK ELEMENT, ABOUT A
THIRD OF THE PATIENTS.
THEN RARE PATIENTS WITH
MUTATIONS OF P22 AND P67.
RARELY YOU'LL SEE PATIENTS WHO
HAVE A DEFECT OF GLYCO6
PHOSPHATE, THE [INDISCERNIBLE]
OF THE NEUTROPHILS WHICH RESULT
IN AN ABNORMAL REGENERATION WHEN
N.A.D.P. GETS CONSUMED.
SO WHAT I WANTED TO TELL YOU
ABOUT IS A PAPER THAT WE
PUBLISHED A FEW WEEKS AGO IN THE
"NEW ENGLAND JOURNAL OF
MEDICINE," SUMMARIZING A 20 OR
30 YEAR EXPERIENCE IN IN 287
PATIENTS REPRESENTING 240
FAMILIES, 245 FILIES WITH THIS
DISEASE.
AND BASICALLY, THE PUNCH LINE IS
THAT SOME OF THESE PATIENTS HAVE
A LITTLE BIT OF NADPH OXIDASE
ACTIVITY LEFT.
MAYBE ONE PERCENT OF NORMAL, TWO
PERCENT OF NORMAL AT THE MOST.
THAT'S ENOUGH TO MAKE AN
IMPORTANT CLINICAL DIFFERENCE IN
THEIR LIVES.
AND ACTUALLY, THE PUNCH LINE IS
THAT IF YOU COULD IDENTIFY AT
BIRTH WHICH YOU SHOULD BE ABLE
TO DO WHICH PATIENTS HAVE THIS
RESIDUAL ACTIVITY, THAT WILL
TELL YOU THOSE PATIENTS ARE
GOING TO DO OKAY.
THE ONES THAT HAVE NONE, THEY'RE
GOING TO HAVE BIG PRONES.
THAT'S WHAT I'M GOING TO SHOW
YOU.
WHAT IS OREGONIC GRANLOMATOUS
DISEASE?
YOU GET CLINICALLY BAD
INFECTIONS AND YOU GET
GRANULOMAS, BIG SURPRISE.
AND THE KIND OF INFECTIONS CAN
BE VERY INDOLENT IN THEIR
PRESENTATION.
THIS 12-YEAR OLD BOY PRESENTED
IN THE CLINIC, HE WAS FINE.
CAME RUNNING UP AND SAID I GOT
THIS LITTLE THING ON MY FINGER.
AND HE WANTED TO GO HOME.
I SAID I GOT TO TAKE A LOOK AND
SEE WHAT'S IN THERE.
WE NICKED IT, LOOKED AT IT IN
THE MICROSCOPE -- THIS IS GOING
THE WRONG WAY.
AND THAT THE AORTIC WHAT WE SAW.
THIS IS A BRANCHED HYPOELEMENT
STUDDED WITH NEUTROPHILS.
THE STRIKING THING, IT'S INTACT.
IF A NORMAL PERSON HAD THIS, IT
WOULD BE CHEWED UP.
YOU'D SEE LITTLE SEGMENTS.
THE NEUTROPHILS ARE INCAPABLE OF
DESTROYINGHIS ORGANISM.
A FEW DAYS LATER, HE WASN'T SO
WELL.
HE DEVELOPED AN ABNORMAL GATE.
AND WE DID A BRAIN SCAN ON HIM
AT THAT TIME.
HE HAD LESIONS IN HIS BRAIN.  HE
HAD METASTATIC [INDISCERNIBLE]
THAT HAD GONE TO HIS BRAIN.
A FEW DAYS LATER, THERE WERE
LESIONS ON HIS BACK.
IT WAS ALL OVER HIS BODY.
AND MY COLLEAGUE, JACK BENNETT,
AT THE CLINICAL CENTER WHO'S
PROBABLY THE WORLD'S GREATEST
MIKOLOGIST SAID HE'S GOING TO
DIE.
THERE IS NOTHING YOU CAN DO FOR
HIM.
HE DIDN'T DIE.  WE GOT VERY
AGGRESSIVE.
WE GAVE HIM DAILY NORMAL WHITE
CELL TRANSFUSIONS.
THIS WAS IN THE ERA BEFORE
PEOPLE THOUGHT ABOUT BONE MARROW
TRANSPLANTATION.
HE GOT BETTER.
TOOK ABOUT 8 MONTHS.
HE SUBSEQUENTLY GOT MARRIED AND
NOW HE HAS 2 CHILDREN.  ONE OF
THE THINGS WE INSIST ON AT THE
CLINICAL CENTER IS BEING
PHENOMENALLY AGGRESSIVE WITH
PATIENTS LIKE THIS.
AND WE HAVE MANY VERY EXCITING
OUTCOMES.
HIS BROTHER HAD A DIFFERENT
PROBLEM.
HE HAD THIS LESION IN HIS NECK
WHICH IS A LARGE LYMPH NOTICED.
IF YOU DON'T TREAT THESE.
THEY'LL GET LARGER AND LARGER.
THE SKIN WILLRUPTTURE AND THEY
WILL DRAIN.
IF OTHER PATIENTS -- OTHER
PATIENTS HAVE THESE LESIONS IN
VITAL STRUCTURES.
THIS IS A BARIUM -- YOU'RE
LOOKING AT THE ESOPHAGUS.
YOU SEE THESE OBSTRUCTIONS,
THESE GRANULOMAS ARE WRAPPING
AROUND.
THEY CAN'T EAT.
TURNS OUT YOU CAN REVERSE THIS
PRETTY PROMPTLY IF YOU GET IT
EARLY WITH HIGH DOSE STEROIDS,
AND IT'S A MIRACLE DRUG FOR
THESE PATIENTS.
AND IT CAN OCCUR IN THE BLADDER. 
HERE YOU SEE ANOTHER PATIENT IN
THE BLADDER.
TH GET OBSTRUCTION AND THE
URINE CAN'T FLOW.
THE KIDNEY GETS SCREWED UP AND
IT CAN KILL THEM.
2 LESIONS.
THEY GET 2 PHENOTYPES.
INFECTIONS ON GRAND LOMAS.
THIS IS WHAT THEY LOOK LIKE
UNDER THE MICROSCOPE.
THEY'RE GIANT CELLS, FUSIONS OF
MACROPHAGES CAUSING THESE BIG
COLLECTIONS.
AND WE SPENT A LOT OF TIME
TRYING TO UNDERSTAND WHY THESE
OCCUR.
WE BELIEVE THAT HYDROGEN
PEROXIDE PLAYS A REGULATORY ROLE
ON INTERLEUKIN 8 TRANSCRIPTION.
I DON'T HAVE TIME TO SHOW YOU
THAT.
WE THINK THERE IS LACK OF A
FEEDBACK REGULATION OF THE
PRODUCTION OF THE INFLAMMATORY
MEDIATORS IN THESE CELLS.
WHAT I HAD LIKE TO TELL YOU,
WHAT WE'VE LEARNED FROM STUDYING
THESE PATIENTS ABOUT THIS ENZYME
OXIDASE.
WORKED WITH TOM IN OUR LAB AND
HARRY AND OTHERS.
WE IDENTIFIED 2.  PROTEINS FOR
THESE 4 PROTEINS.
THE P47 FOX PROTEIN -- WHOOPS.
AND P67.
TU'S LAB DESCRIBED THE GP IT
TEAM.
AND WE NOW KNOW THAT THE
ASSEMBLY OF THESE PROTEINS IS
THROUGH [INDISCERNIBLE] DOMAINS.
BINDING TO RICH SEQUENCES WHICH
ARE NOT INDICATED ON THIS SLIDE,
IN VERY SPECIFIC LOCATIONS.
THE SEAR ARENAS GET
PHOSPHORYLATED EXPOSING THESE
DOMAINS AND THEN THIS CASCADE OF
BUILDING THIS PROTEIN, THIS
ENZYME OCCURS.
ONE OF THE THINGS WE LEARNED
FROM ALL OUR PATIENTS IS THAT WE
DID GENE SEQUENCING OF THE
MUTATIONS IN ALL OF THEM.
AND GOING ACTUALLY OVERSAW ALL
OF THAT.
AND THESE ARE THE RESULTS.
AND SO EACH ONE OF THESE DOTS
REPRESENTS A FAMILY WITH A
MUTATION OR SINGLE PATIENT OR
FAMILY, DIFFERENT TYPES OF
MUTATIONS ARE INDICATED.
AND THERE ARE A FEW STRIKING
THINGS.
THE FIRST IS THAT IN THE GP91
FOX PROTEIN, THIS HUGE PROTEIN,
YOU HAVE MUTATIONS ANYWHERE AND
STILL GET CGD.
THAT WAS ONE OBSERVATION.
WE HAVE LESS DATA IN THE OTHER
PROTEINS BECAUSE THERE ARE FEWER
PATIENTS.
AND YOU CAN SEE WHERE THE
MUTATIONS ARE.
WE'RE GOING TO FOCUS ON THIS FOX
PROTEIN FIRST.
AND ONE OF THE THINGS WE LEARNED
THAT IS IF YOU HAVE A MUTATION
IN THE EXTRA CELLULAR LOOP OR IN
THE TRANSMEMBRANE REGION UNLESS
IT'S IN THE IRON BINDING DOMAIN,
WHICH IS WHERE THE ELECTRONICS
TRAVEL, THE PATIENTS DO PRETTY
WELL.
THEY SURVIVE.
IN CONTRAST, IF THE PATIENTS
HAVE A MUTATION IN THE
NUCLEOTIDE BINDING DOMAINS,
PARTICULARLY [INDISCERNIBLE]
MUTATIONS THEY DO POORLY.
THEY HAVE -- AND THEY PRODUCE
NEW SUPER OXIDE, WHEREAS THOUGH
WITH THE MUTATIONS OUT HERE IN
THE PERIPHERY PRODUCE A LITTLE
BIT.
SO WE ASSESS THE SUPER OXIDE
MORE RIGOROUSLY IN ALL OUR
PATIENTS BY COMPARING 2 ASSAYS
OF THE PRODUCTS OF OXYGEN
CONSUMPTION, SUPER OXIDE SHOWN
ON THE X AXIS AND
[INDISCERNIBLE] REDUCTION SHOWN
ON THE Y AXIS.
AND YOU CAN SEE THE DISPLAY OF
NORMALS -- I MEAN OF THE
PATIENTS RESPONSE.
AND THE RED DOTS ARE PATIENTS
WHO DIED.
AND THE POINT IS THAT MOST OF
THE PATIENTS WHO DIED PRODUCED
VERY LITTLE SUPER OXIDE.
AND YOU CAN SEE ALSO THERE IS
THIS -- YOU'D EXPECT THAT THE
ASSAYS WERE RELIABLE, A LINEULAR
RELATIONSHIP.
WE DID SURVIVAL CURVES ON THE 2
POPULATIONS, THE PATIENTS WHO
PRODUCED VERY LITTLE SUPER
OXIDE, IN THE LOWER LEFT
QUADERANT OF THIS SLIDE, ALL
THESE PATIENTS VERSES ALL THE
OTHERS.
AND THAT'S WHAT YOU SEE ON THIS
SLIDE.
THE PATIENTS WHO PRODUCED NO
SUPER OXIDE SHOWN IN RED DIDN'T
LIVE NEARLY AS LONG AS THOSE WHO
PRODUCED A LITTLE BIT.
WE WENT AND LOOKED AT ALL OF OUR
PATIENTS REGARDLESS OF THE
MUTATION, AND SEPARATED THE
SUPER OXIDE.
AND THAT'S WHAT THIS SLIDE
SHOWS.
AND WE DID THE CURVES OR
SURVIVAL CURVES ON THOSE THAT
PRODUCED VERY LITTLE
SUPEROXIDE -- WHOOPS.
SHOWN BY THIS BLACK LINE.
AND THEN INCREMENTALLY
INCREASING THE AMOUNTS OF SUPER
IDE BY THESE DIFFERENT COLORS,
WHICH WERE, THEN -- THE HAZARD
RATIO OR THE OUR OUR HOW THE
PATIENTS WILL SURVIVE WAS
DETERMINED AND YOU CAN SEE
COMPARING TO THE FIRST QUARTER
AISLES, THERE WAS A --
QUARTERALS, THERE WAS SORT OF A
LINEAR RELATIONSHIP BETWEEN HOW
MUCH SUPEROXIDE WAS PRODUCED AND
SURVIVAL.
YOU CAN DO THIS AT BIRTH, YOU
CAN DO IT IN UTERO.
IT'S REMARKABLY STABLE FOR THE
LIFE OF THE SUBJECT.  IT'S
IMPORTANT.
THIS IS THE FIRST BIOMARKER THAT
HAS BEEN AVAILABLE TO ENABLE TO
KNOW WHO SHOULD GET A BONE
MARROW TRANSPLANT AND WHO
SHOULDN'T.
IF YOU DON'T MAKE -- IF YOU'RE
IN QUARTAL ONE AND PROBABLY 2,
THERE SHOULD BE SERIOUS
CONSIDERATION FOR BONE MARROW
TRANSPLANTATION EARLY IN LIFE. 
THIS IS NO QUESTION THAT BONE
MARROW TRANSPLANTS DO BETTER AS
AN INFANT OR CHILD THAN IF YOU
WAIT UNTIL YOU'RE AN ADOLESCENT
OR OLDER.
THIS IS A SLIDE I SHOULD HAVE
PUT AFTER THE MUTATION SLIDE HA
SHOWS YOU THE DATA FOR THE
FUNCTION OF THE CELLS IN THE
GP91 FOX PROTEIN IN TERMS OF
SUPEROXIDE PRODUCTION, THE
PATIENTS WITH MUTATIONS IN THE
EXTRA CELLULAR DOMAIN, IN THIS
REGION, PRODUCED SOME
SUPEROXIDE.
AFTER POSITION 3 OR 9 WHICH THE
THE NUCLEOTIDE BINDING DOMAINS,
THEY PRODUCE NO SUPER BLOOD
PRESSURE OXIDE OR VERY --
SUPEROXIDE OR VERY LITTLE.
IT DOESN'T RELATE TO PROTEIN
PRODUCTION.
SOME OF THE PATIENTS IN THIS
BINDING DOMAIN MUTATIONS, THEIR
CELLS PRODUCED ZEBRINE THAT WAS
READILY DETECTABLE BUT DIDN'T
WORK.
POINTING OUT THE IMPORTANCE, THE
CRITICALITY OF THE BINDING
DOMAINS FOR THE FUNCTION OF THIS
ENZYME.
WHAT WERE THE CONCLUSIONS OF
THIS REPORT?
THAT RESIDUAL OXIDASE PREDICT
SURVIVAL, AND THAT GENETIC
ANALYSIS CAN PREDICT RESIDUAL
ROI PRODUCTION.
SO DOUG GETS CELLS FROM ALL OVER
THE WORLD.
FROM PATIENTS.
PEOPLE HAVE READ THIS, EVEN
THOUGH THIS PAPER HAS ONLY BEEN
OUT A FEW MEDICINE.
EMERGENCY ARE SAYING SHOULD WE
SEND OUR KID FOR A BONE MARROW
TRANSPLANT OR NOT.
WE THINK THIS IS A HELPFUL GUIDE
IN MANAGING THESE PATIENTS.
SO THE MESSAGE THAT I WANT TO
LEAVE YOU WITH, IN THE REMAINING
FEW SLIDES, WHICH IS IS THERE
ANY BROAD RELEVANCE TO THE STORY
ABOUT NADPH OXIDASE?
SURE, WE'RE FASCINATED BY THESE
28 P FAMILIES OR -- 287 FAMILIES
OR CHILDREN WHO HAVE THIS RARE
DISEASE BUT THAT'S NOT A PUBLIC
HEALTH PROBLEM.
WHAT I'M GOING IS TO SHOW YOU
NOW SUGGESTS WHY WE STUDY THESE
PATIENTS.
THEY DO HAVE POTENTIALLY BROAD
RELEVANCE.
AND THERE IS A GREAT COUPLE OF
REVIEW ARTICLES ABOUT WHAT I'M
ABOUT TO TELL YOU THAT YOU MAY
WANT TO LOOK AT, IF YOU WANT TO
LEARN MORE ABOUT WHAT HAS BEEN
CALLED THE KNOX FAMILY OF
PROTEINS STANDING R NADPH
OXIDASE.
THESE PROTEINS HAVE A LOT OF
RELEVANCE TO A NUMBER OF
DISEASES.
AND I GOT INTERESTED IN THIS IN
PARTICULAR IN A PAPER THAT ONE
OF THE PEOPLE IN MY LAB, WHO I
THINK YOU'VE HEARD FROM, STEVE
HOLLAND, WHEN HE WAS A FELLOW
WITH ME, GOT INVOLVED WITH THE
FOLKS IN THIS JCI PAPER, WHERE
THERE WAS A QUESTION OF WHETHER
IT HAS ANYTHING TO DO WITH
ATHEROSCLEROSIS.
A LOT OF PEOPLE HAVE BEEN
SPECULATING WAS AN INFLAMMATORY
DISEASE IN PART.
THESE MACROPHAGES GETTING INTO
THE BLOOD VESSEL, PRODUCING ALL
THESE REACTIVE PRODUCTS.
AND SO THESE INVESTIGATORS TOOK
ADVANTAGE OF A STRAIN OF THE
KNOCKOUT MICE AND THEY CROSS
THEM WITH THE MICE WHICH WE HAD
MADE WHICH P47 FOX DEFICIENCY.
THE APOE MICE CONTROLS DIDN'T --
WHICH HAD NORMAL P47 FOX, WERE
FED A HIGH FAT DIET.
THEY WERE SUFFICED AND STAINED
WITH OIL RED OH, STANDS FOR
LIPID PARTICLES.
YOU CAN SEE THE ANIMALS SHOWN BY
THIS EXAMPLE, LOTS OF OIL RED O
DEPOSITS.
THE ANIMALS THAT WERE CROSSED
BETWEEN THE APOE OR THE
[INDISCERNIBLE] MICE, THEY HAD
NONE.
SO CDG SEEMS TO BE PROTECTIVE OF
ATHEROCLOSER ROSIS OR LIPID
DEPOSITION IN THIS PARTICULAR
KNOCKOUT.
TO MAKE A LONG STORY SHORT WE
KNOW NOW THERE IS A BUNCH OF
KNOCKS ISO FORMS, WHICH -- 6
THAT ARE SHOWN HERE.
KNOX 2 WHICH IS UPPER MIDDLE
ONE, IS THE FIRST THAT WAS
DESCRIBED WHICH IS IN THE
NEUTROPHILS.
I HAVEN'T FIGURED OUT WHY IT'S
CALLED KNOX 2 AND NOT KNOX 1 BUT
IT IS.
AND YOU CAN SEE THE MOLECULAR
STRUCTURE OF THAT KNOX 2 OR
NEUTROPHIL ELEMENT.
THEN YOU YOU CAN SEE THE
SIMILARITIES WITH SOME OF THESE
OTHER FORMS.
TOP LEADO, WHO WORKS IN OUR LAB,
TOM, SPENT A LOT OF TIME
CHARACTERIZING DUOX, WHICH IS
EMERGING AS ONE OF THE IMPORTANT
SPECIES.
THESE PROTEINS ARE FOUND IN A
NUMBER OF ORGANS, WHICH ARE IN
HIGH LEVELS, SHOWN HERE
INCLUDING THE COLON, SALIVARY
GLANDS, INNER EAR, KIDNEY, BLOOD
VESSELS, TESTIES AND THYROID.
THEY HAVE BEEN ASSOCIATED WITH
ABNORMALITIES OF THESE PROTEINS
AND DISEASES SHOWN HERE.
AND IF YOU WERE TO DO A SEARCH
ON THESE IN THE LITERATURE
YOU'LL BE VERY IMPRESSED HOW
MANY PAPERS ARE COMING OUT EVERY
MONTH.
I JUST SHOW YOU ONE HERE.
THAT JUST CAME OUT A FEW MONTHS
AGO LINKING IN AN ANIMAL MODEL
THE OXIDASE 4, KNOX 4.
AS BEING ASSOCIATED WITH HEART
FAILURE AND ALSO WITH OXIDATIVE
STRESS FOLLOWING OCCLUSION OF
BLOOD VESSELS IN THE BRAIN IN
BOTH HUMANS AND IN MICE.
SO WE'RE NOW DOING A STUDY IN
OUR CGD HUMANS, A PROTOCOL THAT
WE'VE JUST STARTED WHERE WE NOW
CAN MEASURE ARTHRO SCLEROSIS IN
A LIVE SUBJECT, HOPEFULLY
HEALTHY, USING SOME OF THE
MODERN IMAGING TECHNIQUES WHERE
WE PUT OUR OBE WE CAN DO C.T.
SCANS OR MRI SCANS ON THE BLOOD
BLOOD VESSELS, WITH REMARKABLY
GOOD PRECISION MEASURE EARLY IN
PLAQUE FORMATION VESSELS.
SO WE ARE BRINGING IN ALL OUR
PATIENTS TO ASK THE QUESTION,
ARE THEY PROTECTED FROM ARTHLO
CLOSER ROSIS?
WE SHOULD HAVE THE ANSWER IN
ABOUT A YEAR.
I CAN COME BACK AND TELL YOU.
MY IMPRESSION IS THAT THEY ARE.
AND THAT'S BASED FROM AUTOPSY
LOOKING AT A LOT OF --
UNFORTUNATELY AUTOPSIES ON A LOT
OF THESE CHILDREN OVER A LONG
PERIOD OF TIME AND BEING, I
THINK THEY HAVE MUCH LESS EARLY
PLAQUE FORMATION COMPARED TO
NORMALS.
SO WE'LL SEE IF WE CAN FIND
THAT.
IF IT IS, INDEED, TRUE THAT
THEY'RE PROTECTED, THEN ONE OF
OUR GOALS AND WE'VE ACTUALLY
INITIATED THIS, IS WE'VE GONE TO
CHRIS AUSTIN AND THE FOLK WHOSE
RUN -- WHO RUN THE FACILITY IN
ROCKVILLE FOR LOOKING FOR
MOLECULAR ELEMENTS THAT WILL
BIND WITH TARGETS TO SEE IF WE
CAN IDENTIFY A TARGET THAT WILL
IN A CONTROLLED WAY MODULATE
NIDPH OXIDASE, SO THE QUESTION
IS CAN MODULATION SERVE AS AN
ANTIINFLAMMATORY AGENT TO
PERHAPS BE USEFUL IN DISEASES
SUCH AS ATHEROSCLEROSIS AND
OTHER DISEASES.
THAT'S WHERE WE'RE GOING.
AND WE'RE PRETTY EXCITED WITH
THE WHOLE IDEA THAT STUDIES IN
THIS GROUP OF PATIENTS WITH CGD,
A PHENOMENALLY RARE DISEASE,
SEEMS TO BE NOW MOVING INTO AN
AREA WHERE THEY MAY HAVE
RELEVANCE TO A LOT OF ILLNESSES.
SO THAT'S WHAT DOUG AND I SPEND
OUR TIME DOING.
AND WE THINK WE HAVE A LOT OF
FUN AND HOPE --
[APPLAUSE]
>> THANK YOU VERY MUCH.
THAT IS EXTREMELY EXCITED.
SO DO WE HAVE ANY QUESTIONS?
YES.
JUST WAIT A MINUTE.
>> HAVE YOU FORMULATED ANY
HYPOTHESES WHY YOUR PATIENTS
STOPPED GETTING INFECTIONS AFTER
ADOLESCENTS.
>> YEAH, BUT THEY'RE NOT WORTH
MUCH.
I'LL SHARE THEM WITH YOU.
THE PRESUMPTION IS THAT THEY --
THE OTHER IMMUNE SYSTEMS TAKE
OVER AND COMPENSATE FOR THIS
VERY FOCUSED ABNORMALITY.
BUT THE POBOTTOM LINE IS -- BUT
THE BOTTOM LINE IS WE DON'T
REALLY KNOW.
>> [INAUDIBLE]
>> THE PATHWAY ABNORMALITY
PERSISTS.
THERE IS NO -- EVERY PATIENT WHO
HAS THIS DISEASE, THE ABNOR
MALTY --
>> THE PATHWAY BETWEEN CHILDRE
AND ADULTS SIMILAR IN TERMS OF
EXPRESSION AND THINGS LIKE THAT.
>> IT'S POSSIBLE.
WE DON'T KNOW.
>> ANY OTHER -- WHAT ABOUT
CANCER, JOHN?
THAT SEEMS TO HAVE A LOT OF TALK
THESE DAYS ABOUT THE ROLE OF
INFECTION AND INFLAMMATORY IN
CANCER.
>> YES.
WELL, CERTAINLY FOR EXAMPLE THE
PROTEINS HAVE BEEN ASSOCIATED
WITH IN ANIMAL MODELS, GROWING
REASON TO BELIEVE THEY MIGHT BE
RELEVANT IN A NUMBER OF CANCERS,
SO THE MUTO GENIC CAPABILITY OF
REACTIVE OXYGEN SPEECHES IS
THOUGHT BY MANY TO BE VERY REAL.
BUT IT'S NOT NAILED DOWN YET.
SO THERE IS -- FOR EXAMPLE,
THERE IS ANIMAL MODELS FOR
PANCREATIC CANCER THAT WOULD FIT
THIS IDEA AND FOR THYROID CANCER
AND SOME ANIMALS WITH LUNG
CANCER, SO THERE  INCREASING
INTEREST BUT NO PROOF.
>> WHY ASPERGILLUS?
>> OR IS THAT JUST -- THERE. IS
A REASON FOR ASPIRE GILLIS.
A REASON FOR ASPIRE GILLIS.
 THE STORY IS VERY CLEAR THAT
YOU NEED HYDROGEN PERONC I'D TO
KILL ASPERJILLINGSES.
IN THE CLINICAL CENTER, THERE IS
THE MOST COMMON HOST THAT HAS
ASPERGILLUS IS IN CHRONIC
GRANLOMATOUS DISEASE.
IF YOU LOOK ACROSS THE WORLD,
THE MOST COMMON HOST IS THE
PATIENT WITH BONE MARROW
TRANSPLANTATION.
AND SO YOU CAN SAY WHY IS THAT?
AND ONE OF THE THINGS THAT
HAPPENS AFTER BONE MARROW
TRIANG WITH ALL THE -- TRON
PLANTATION WITH ALL THE
TREATMENTS, YOU CAN GET A HUGE
INCREASE IN FREE IRON THAT
CIRCULATES AND THAT YOU HAVE TO
GIVE IRON KEY LATERS TO PREVENT
HEMOCHROMETOSIS, AND IRON
DEPOSITION.
WE FOUND OUT THAT HYDRO
GENPEROXIDE IS ONLY ONE OF THE
HOST DEFENSE ELEMENTS.
ANOTHER IS SUBSTANCE WHICH IS
FOUND IN NEUTROPHILS CALLED
[INDISCERNIBLE] WHICH BINDS
IRON.
AND SO NOT ALL CDG PATIENTS GET
IT, JUST A LOT OF THEM.
SO WE HAVE DONE STUDIES AND
SHOWN THAT LACTOSE -- LACTOSE
OFFEREN IS A NATURAL KEY LATER
OF IRON THAT KEEPS IT IN CHECK.
IN BONE MARROW TRANSPLANTS, YOU
GET SO MUCH IRON THAT THERE IS
NOT ENOUGH LACTO PEREN.
SO ONE OF THE THINGS WE HAVE
WORKING ON IS TO SEE IF SOME OF
THE IRON KEY LATERS THAT HAVE
BEEN APPROVED IN BONE MARROW
TRANSPLANTATION FOR THE PURPOSE
OF SEQUESTER GOING IRON COULD
BE -- SEQUESTERING IRON COULD BE
USED TO HELP PREVENT AND TREAT
ASPERGILLUS.
SO THE 2 HOST DEFENSES ARE HI
DRO GENPEROXIDE AND REMOVAL OF
ON, STARVING IT FROM THE
ORGANISM SO THAT IT CAN'T GROW.
IRON IS USED AS A
[INDISCERNIBLE] BY ASPERGILLUS
FOR GROWTH.
>> SO [INDISCERNIBLE] SO DOES
THE MARK PHAGE DO SIMILAR
THINGS?
THE INFLAMMATORY [INDISCERNIBLE]
WE ARE LOOKING AT THE LIPID LOAD
ED MACROPHAGES.
IS THERE ANY [INDISCERNIBLE]
>> YES.
SO CDG MARKRO PHAGES DON'T MAKE
THEM EITHER.
BUT IT'S INTERESTING, IT DERIVES
FROM THE MODOCYTE.
IT MAKES HYDRO GENPEROXIDE.
AS IT DIFFERENTIATES, HYDROGEN
PEROXIDE GENERATION DISAPPEARS
UNLESS IT'S PRIMED WITH
SOMETHING.
SO YOU CAN PRIME IT WITH
SOMETHING LIKE TNF AND THEN IT
WILL BE READY TO PRODUCE HUGE
AMOUNTS OF HYDRO GENPEROXIDE.
>> HOW MANY INFLAMMATORY WE
SHOULD HAVE TO STAY HEALTHY?
[LAUGHTER]
>> THAT'S A GREAT QUESTION.
I HAVE A FRIEND, BARRY KOHLER,
WHO IS -- RUNS THE CLINICAL
RESEARCH FACILITY AT ROCKEFELLER
UNIVERSITY.
AND HE JUST WROTE A PAPER ON
MAYBE WE SHOULD GET RID OF A
BUNCH OF OUR NEUTROPHILS AS YOU
GET OLDER.
TO -- OR SHOULD DAMPEN THEIR
ACTION AND YOU NEED ENOUGH
INFLAMMATION TO KEEP YOURSELF
FROM GETTING INFECTED.
BUT TOO MUCH PROBABLY IS NOT
RIGHT EITHER.
THE OTHER CELLULAR ELEMENT THAT
WE TALK ABOUT A LOT THAT YOU
THINK ABOUT ARE PLATELETS.
YOU WANT ENOUGH TO KEEP YOURSELF
FROM BLEEDING TO DEATH BUT YOU
DON'T WANT SO MANY THAT YOU GET
PRONE TO HEART ATTACKS.
THAT'S WHY YOU TAKE ASPIRIN 3
TIMES A WEEK, BABY ASPIRIN 3
TIMES A WEEK.
AND MAYBE WE NEED SOMETHING LIKE
THAT FOR NEUTROPHILS.
MAYBE THE FANTASY WE HAVE OF
COMING UP WITH A MOLECULAR THAT
DAMPENS OXIDASE WILL BE IN THE
DRINKING WATER.
>> [INDISCERNIBLE].
>> WE DO PRETTY WELL, THOUGH.
>> DO YOUR PATIENTS HAVE AN EYE
PHENOTYPE?
>> A WHAT?
>> EYE PROBLEMS?
>> NOT NOW.
THAT WOULD BE UNUSUAL.
>> SO ARE WE TO ASSUME THERE ARE
NO GRANULOMAS IN THE LIVER?
>> NO.
THEY HAVE BIG GRANULOMAS IN THE
LIVER.
SO ONE OF THE THINGS I'D LIKE TO
LEAVE YOU WITH, SO I WENT TO
MEDICAL SCHOOL.
I HAD AN INTEREST IN SOME
RESEARCH.
I SPENT SUMMERS IN THE LAB.
AND I WAS THRILLED TO COME HERE
AS A FELLOW, GET EXPOSED AND
DEVIL INTO IT.
IN THE -- DELVE INTO IT.
IN THE CLINIC, U DON'T CHOOSE
THE PATIENTS SO MUCH.
WE MADE THE DECISION TO STUDY
HOST DEFECTS.
YOU TAKE WHAT YOU GET AND THAT'S
WHAT YOU SEE.
YOU GET A PATIENT THAT CLEARLY
HAS SOMETHING WRONG, BECAUSE
THEY GET INFECTIONS.
EASILY DECIDE IS NOT NORMAL.
AND THEN YOU STUDY THEM.
SO YOU SEE THE KIND OF PATIENT
DR. KUHNS STUDIED.
YOU SEE THE PATIENTS WITH CDG.
IT'S DIFFERENT FROM GOING IN THE
LAB AND SAYING OKAY, I'M GOING
TO MAKE A KNOCKOUT MOUSE JUST
FOR THIS.
THAT'S WHEN I'M GOING TO SPEND
20 YEARS STUDYING.
WE HAVE BEEN LUCKY TO INTERACT
WITH PEOPLE LIKE DOUG KUHNS AND
OTHERS WHO HAVE CERTAIN
EXPERTISE IN BIOCHEMISTRY AND
OTHER AREAS THAT COMPLEMENT WHAT
WE DO.
THAT'S HOW WE WORKED.
AND THE CLINICAL CENTER IS A
SPECIAL PLACE TO BE ABLE TO DO
THAT.
>> I WAS JUST WONDERING, HOW ARE
PATIENTS GOING AFTER BONE MARROW
TRANSPLANT?
DO THEY ENGRAFT OR WHAT IS THE
PROGNOSIS?
>> THERE ARE A NUMBER OF
PROBLEMS, THEY DO VERY WELL.
WE HAVE A GROUP OF PATIENTS THAT
BASICALLY HAVE BEEN CURED OF
THEIR DISEASE IN TERMS OF THEIR
PROBLEMS WITH INFECTIONS AND
GRANULOMAS.
YOU DON'T NEED A LOT OF NORMAL
CELLS TO DO CLINICALLY WELL.
SO FOR EXAMPLE, IN THE X LINK
FORM OF THE DISEASE, THE
HETEROZYGOUS, WOMEN THAT ARE
CARRIERS THAT CAN BE LIONIZED
FOR THEIR GENE, THEY CAN HAVE
90% NORMAL CELLS OR AS FEW AS
3%.
IF YOU HAVE 3-5%, YOU REALLY DO
SWINE FLU VERY WELL.
YO DON'T -- YOU REALLY DO VERY
WELL.
YOU DON'T NEED A LOT OF NORMAL
CELLS TO HAVE A GOOD DEFENSE.
THE KIDS GET GRAFT REJECTION,
PROBABLYOMPARABLE TO NORMAL
AND THAT CAN BE TERRIBLE.
AN INTERESTING PSYCHOLOGICAL
PROBLEM WE'VE NOTICED IN A
NUMBER OF PATIENTS WITH
DIFFERENT PHAGOCYTE DEFECTS.
YOU HAVE A CHRONIC ILLNESS, AND
SOMEONE DOES SOMETHING TO YOU
AND YOU BECOME MEDICALLY NORMAL,
CLINICALLY NORMAL.
THEY DON'T HOWHAT TO DO. --
WE'VE HAD A COUPLE OF KIDS THAT
COMMITTED SUICIDE.
THEY'RE SO DEVASTATED BY NOT
HAVING THEIR DISEASED.
IT'S REALLYTOTALLY UNEXPECTED.
AND IT'S A REAL BIG PROBLEM.
PREPARING THEM FOR BEING NORMAL.
AND NOT HAVING THIS PROBLEM.
SO I NEVER IMAGINED THAT.
>> JOHN, DOES SUPEROXIDE PLAY
ANY ROLE IN REGULATING THE --
YOU KNOW, THE DOWN SIDE OF
DESTROYING SUPEROXIDE?
>> SO PATIENTS WITH ALS, WHO
HAVE LOU GEHRIG'S DISEASE, THEY
HAVE AN ABNORMALITY OF
SUPEROXIDE -- THEY DON'T MAKE
IT.
THEY BUILD UP THEIR HYDROGEN
PEROXIDE.
THERE ARE A LOT OF PEOPLE THAT
THINK THAT'S IMPORTANT.
BUT SUPEROXIDE IS A VERY
TRANSGENT SPECIES.
IT'S PROBABLY NOT AROUND ENOUGH
TO INFLICT A LOT OF DAMAGE.
ANOTHER RADICAL, PROBABLY MORE
LONG LIVED, AND CAN HAVE MORE OF
A BIOLOGICAL IMPACT.
OKAY.
ALL RIGHT.
>> YOUHAD MENTIONED HOST GRAPH
DISEASE AND WORKING THE
TRANSPLANTATION WORKING BEST
EARLY.
HAVE YOU GIVEN THOUGHT TO GENE
THERAPY.
>> YES.
HARRY MALLIC, WHO'S NOW MY
BOSS -- I STEPPED DOWN AS LAB
CHIEF A FEW YEARS AGO, NOW I
HAVE A SECTION IN HIS LAB.
HE USED TO HAVE A SECTION IN MY
LAB.
HIS THING IS VERY MUCH WORKING
ON TRYING TO DO GENE THERAPY IN
CDG PATIENTS.
HE'S, INDEED, FIXED SOME MICE
THAT HAVE CDG, VERY NICELY.
HE'S FIXED CDG CELLS IN VIVO
VERY NICELY.  THERE IS A
PROTOCOL WHERE HE'S GIVEN GENE
THERAPY TO SOME CDG PATIENTS WHO
HAD WHAT EVERYBODY FELT WAS A
LETHAL THISFECTION, HE HAS AT
LEAST ONE PATIENT WHO T A VERY
GOOD TAKE LASTING 4 OR 5 MONTHS.
THE PATIENT GOT OVER AN
ASPERGILLUS INFECTION, WHICH
EVERYBODY -- WE THOUGHT THE
PATIENT, NO WAY, WAS GOING TO
SURVIVE.
BUT THE PROBLEM IS THAT HE'S NOT
HAD A ROBUST LONG TAKE OF GENE
THERAPY CORRECTED CELLS.
IT POOPS OUT.
SO HE'S WORKING ON THAT.
ONE OF HIS IDEAS NOW THAT HE'S
VERY EXCITED ABOUT IS CORRECTING
IPS CELLS FROM THESE PATIENTS AN
SEEING IF THAT'S A BETTER MODEL.
BECAUSE HE THINKS HE CAN GET A
BETTER HIGHER PERCENTAGE OF CELL
CORRECTED SO YOU CORRECT THE
CELLS IN AN IPS STATE AND YOU
DIFFERENTIATE THEM TO
NEUTROPHILS AND THEN YOU CONFUSE
THE NEUTROPHIL STEM CELLS AND
INSTILL THE STEM CELLS.
THAT'S HIS IDEA.
IN EUROPE, THERE HAS BEEN A FEW
REPORTS OF PATIENTS WHO WERE
CORRECTED AND THEY SUBSEQUENTLY
DIED FROM LEUKEMIA WHICH HAS
BEEN A BIG PROBLEM WITH GENE
THERAPY.
THANK YOU VERY, VERY MUCH.
THAT WAS REALLY VERY EXCITING.
THAT WAS REALLY VERY EXCITING.