WELCOME TO CLINICAL CENTER GRAND ROUNDS. TODAY IS GOING TO BE ONE OF OUR GREAT TEACHERS SERIES, WE'LL GET IN TO THAT IN A MOMENT. BUT FIRST WE HAVE OUR ANNUAL SPECIAL EVENT THAT WILL TAKE ABOUT FOUR MINUTES. AND THAT IS WE ARE GOING TO TODAY ANNOUNCE THE GREAT TEACHERS 'WAR. THIS IS ONE OF THE GREAT AWARDS ON THE CAMPUS STARTED IN 1985 TO HONOR ONE OF US FOLKS WHO SPEND THEIR DAYS, PARTS OF THEIR DAYS MENTORING AND TEACHING AS WELL AS DOING CLINICAL SCIENCE. AND SO I CONSIDER THIS ONE OF THE HIGHEST AWARDS AND HONORS A PERSON CAN GET HERE BECAUSE WHAT'S MORE IMPORTANT THAN TRAINING THE NEXT GENERATION. SO, TOO MAKE THIS AWARD WE HAVE REPRESENTATIVE FROM THE CLINICAL FELLOWS COMMITTEE, WHICH ACTUALLY SELECTS THE AWARDEE, THESE ARE THE FELLOWS WHO BENEFIT FROM THIS EXPERIENCE. DR. JOEL STODDARD WHO IS GOING TO BE THE REPRESENTATIVE WILL NOW COME TO THE PODIUM AND TELL YOU ABOUT THE AWARDS. >> THE IMPORTANCE OF MENTORINGS ING, EMBODIES THE CHARACTERISTICS OF ETHICAL AND COMPASSIONATE. A MENTOR GUIDES PROFESSIONAL GROWTH BY HELPING TRAINEES IDENTIFY AND IDENTIFY, SET ACHIEVE GOALS AND OVERCOME OBSTACLES. ALL OF THE INDIVIDUALS NOMINATED BY OUR NIH FELLOWS FOR THIS YEAR AWARD DESERVES RECOGNITION AS OUTSTANDING CLINICAL MENTORS. COMMITMENT TO TRAINING, CLINICAL INVESTIGATORS AT THE NIH. EACH YEAR THE AWARD IS GIVEN TO AN INDIVIDUAL WHO EXEMPLIFIES THE IDEALS OF MENTOR, TEACHER, CLINICS AND RESEARCHER. A FEW COMMENTS FROM OUR FELLOWS ABOUT THIS YEAR'S AWARD WINNER INCLUDE, HE IS WITHOUT QUESTION ONE. BEST TEACHERS I HAVE HAD. HIS ENTHUSIASM FOR TEACHING AND CLARITY WITH WHICH HE PRESENTS COMPLICATED SCIENTIFIC DATA ARE INCREDIBLE. CORE LECTURES ARE SOME OF THE MOST ANTICIPATED IN THE FELLOWSHIP PROGRAM. ALSO, BEING A PROGRAM DIRECTOR, HAVING HIS OWN LABORATORY RESEARCH, BEING A P.I. OF MULTIPLE CLINICAL TRIALS MAKES HIM EXTREMELY BUSY. CORRIDOR IS ALWAYS OPEN. PROVIDES PERSONALIZED TEACHING ON DAILY BASIS. HE SETS AN AM KELP BASED ON THE STRENGTH OF DATA RATHER THAN THE WEIGHT OF PREVAILING PRACTICE. HOW TO PRACTICE ABOVE THE STANDARD OF CARE. THIS YEAR'S RECIPIENT RECEIVED HIS MEDICAL AND PHILOSOPHICAL DOCTOR AT FROM THE UNIVERSITY OF MIAMI. HE COMPLETED HIS MEDICAL INTERNSHIP AND RESIDENCY AT BARNES HOSPITAL IN WASHINGTON UNIVERSITY IN ST. LOUIS MUCH IN 1982 HE CAME TO THE NCI AS CLINICAL ASSOCIATE IN THE MEDICAL BRANCH NOW CANCER THERAPEUTICS BRANCH. AFTER THREE YEARS WORKING WITH DOCTORS EPA AND MICHAEL HE ASSUMED POSITION OF SENIOR INVESTIGATOR IN THE BRANCH. HE IS AUTHORED MORE THAN 200 PEER REVIEWED SCIENTIFIC AND REVIEW ARTICLES, MENTORED OVER 25 PROFESSIONALS ON EDITORIAL BOARD OF NUMEROUS PROMINENT JOURNALS. HIS TRANSITIONAL RESEARCH GROUP INVESTIGATES THE CANCER DRUG RESISTANCE, SPECIFICALLY WITHIN ADRENAL TUMORS. WITH THE GOAL OF FINDING TARGETS FOR ENHANCING DRUG EFFECTIVENESS. PLEASE JOIN ME IN CONGRATULATING OUR 2012 DISTINGUISHED CLINICAL TEACHER AWARD WINNER, DR. ANTHONY. [APPLAUSE] >> ABOUT A YEAR AGO I WAS ASKED TO GIVE MEDICAL GRAND ROUNDS AT NORTHWESTERN, BEING A FIRM BELIEVER IN CARPE DIEM, MEANS NEVER MISS AN OPPORTUNITY TO EMBARRASS YOURSELVES I SAID, YES. THEN I ASKED HIM WHAT WOULD YOU LIKE ME TO TALK ABOUT HOW WOULD YOU LIKE ME TO DO THIS. THEY SAID, OH, DON'T WORRY WE JUST HAD DR. KASTNER, ALL OF YOU AT NIH ARE THE SAME. COULD YOU DO SOMETHING SIMILAR TO WHAT HE DID. SO I WAS VERY GRATEFUL TO BE THE INSTRUMENT TO DISABUSE THEM OF THE NOTION THAT EVERYONE AT THE NIH IS DR. KASTNER'S STANDARD. DR. KASTNER TRULY IS EXCEPTIONAL HE GRADUATED FROM PRINCETON AND PH D FROM BAYLOR, RESIDENCY AT BAYLOR THEN CAME TO NIH. INITIALLY AS FELLOW, CHIEF OF GENETICS AND GENOMICS IN 2001. CLINICAL DIRECTOR OF NHIAMS. FIRST NIH DEPUTY DIRECTOR FOR INTRAMURAL CLINICAL RESEARCH 2008 TO 2011. HE'S CURRENTLY SCIENTIFIC DIRECTOR FOR THE NATIONAL HUMAN GENOME PRESEARCH INSTITUTE. I'D LIKE TO TALK A LITTLE BIT ABOUT HIS RESEARCH BECAUSE I THINK IT'S VERY IMPORTANT. BASED ON A CHANCE ENCOUNTER WITH A PATIENT WITH MEDITERRANEAN FEVER EARLY IN HIS FELLOWSHIP DR. KASTNER STUDIED GENETIC DISORDERS OF INFORMATION FOR OVER 20 YEARS. IN 1992 HIS LAB MAPPED THE GENE TO CHROMOSOME 16P. SUBSEQUENTLY IDENTIFIED THE RESAYSTIVELY INHERITED GENE BY CLONING. PROMPTED BY IRISH PATIENT AGAIN INSPIRED BY A PATIENT, I THINK THIS IS A PATTERN WITH FMF-LIKE ILLNESS THE SYNDROME WAS DISCOVERED NOT ONLY DID THEY IDENTIFY THE SYNDROME, DISCOVERED THE GENE AND NAMED THE SYNDROME, I THINK ALL THE KNOWLEDGE WE HAVE RELATED TO THIS SYNDROME AND SIMILAR SYNDROMES RELATE TO INTERLEUKIN ONE BIOLOGY IS MAINLY THANKS TO DR. KASTNER'S WORK. AND THE CONCEPT OF AUTO INFLAMMATORY DISEASE DISORDERS OF INNATE IMMUNITIES IS DR. KASTNER AND HIS GROUP. OF THE COURSE OF HIS CAREER, DR. KASTNER HAS WON NUMEROUS AWARDS AND HONOR INCLUDING THE MENTORING AWARD, AMERICAN COLLEGE OF RHEUMATOLOGY DISTINGUISHED INVESTIGATE ARE AWARD, NUMEROUS NAMED LECTURESHIPS. IN 2010 HE WAS ELECTED TO THE NATIONAL ACADEMY OF THE SCIENCES. HE'S TRULY ONE OF THE NIH'S GREAT TREASURES AND INSPIRATION FOR ALL OF US. I CAN SAY FOR ME PARTICULARLY I HAVE A SMALL COLLABORATION, I'VE BEEN HUMBLED INSPIRED BY BEING ABLE TO WORK WITH DR. KASTNER. IT'S A PLEASURE AND MONITOR FOR DR. KASTNER TO THIS FIRST TALK IN THIS GREAT SERIES OF GREAT TEACHERS. [APPLAUSE] >> THANKS VERY MUCH, THEO, FOR THOSE VERY KIND WORDS. ENORMOUS ON ON TO BE HERE TODAY BEFORE YOU GIVING A TALK I HOPE THAT I CAN LIVE UP TO HIS STANDARDS IN TERMS OF PRESENTATION THAT YOU'LL ALL IN JULY AND HAVE AN OPPORTUNITY TO LEARN SOMETHING FROM. IT'S ENORMOUS MOB OR BEING HERE TODAY, WE'RE ALSO HONORED TO ACTUALLY BY VIRTUE OF THE FACT THAT WE HAVE A COUPLE OF PATIENTS IN OUR PRESENCE WHO ARE GOING TO BE TALKING TO US A LITTLE BIT ABOUT THEIR ILLNESSES AND WE ALSO HAVE COUPLE OF FILM CLIPS OF PATIENTS WHO WEREN'T ABLE TO BE HERE TODAY BUT WILL SHARE A LITTLE BIT OF THEIR ILLNESSES WITH US AS WELL. I GUESS FIRST OF ALL THE OBLIGATION, I WORK HERE AT THE NIH AND THERE FOR I HAVE NO COMMERCIAL ACTIVITIES TO DISCLOSE. YOU WILL BE QUIZZED. THE PARTICIPANT WILL DEMONSTRATE THE ABILITY TO DESCRIBE HOW MOLECULAR GENETIC CENTER STRATEGIES ADVANCE OUR UNDERSTANDING OF INFLAMMATION. FIRST IS THE CLASSICAL APPROACH OF USING GENETIC LINKAGE ANALYSIS AND SOME OF THE NEW TOOLS THAT WERE PRODUCED BY THE HUMAN GENOME PROJECT IN ORDER TO MAP SUSCEPTIBILITY GENES USING USUALLY EITHER SINGLE LARGE FAMILIES OR GROUPS OF MAYBE MEDIUM-SIZED FAMILIES. IN ORDER TO MAP THE GENE TO A PARTICULAR CHROMOSOMAL REGION. THEN ULTIMATELY NARROW DOWN THE REGION AND IDENTIFY THE CAUSATIVE GENE. WE'LL ALSO TALK A LITTLE BIT ABOUT THE IMPACT OF THE REVOLUTION IN DNA SEQUENCING, THAT IS OCCURRED IN THE LAST SEVERAL YEARS. THAT IS REALLY LED TO OUR ABILITY TO DO SO MUCH MORE, SO MUCH FASTER FOR SO MUCH LESS MONEY. AND SO THIS IS REALLY REVOLUTIONIZED WHAT WE'RE ABLE TO DO FOR OUR PATIENTS. AND ACTUALLY YOU WILL HEAR FROM ONE OF OUR PATIENTS IN WHICH WE'VE EMPLOYED THIS KIND OF APPROACH TO FIGURE OUT WHAT IS THE MOLECULAR BASIS OF HIS ILLNESS. AND THEN FINALLY, WE WILL TURN TO THE APPLICATION BOTH OF THESE SEQUENCING METHODS AND ALSO OF AN APPROACH CALLED GENOME-WIDE ASSOCIATION IN ORDER TO ALLOW US TO UNDERSTAND SOME OF THE CAUSATIVE PATHWAYS THAT ARE INVOLVED IN SOME OF THE COMMON DISORDERS THAT HAVE A GENETIC COMPONENT BUT NOT INHERITED AS MENDELIAN DISORDERS. THOSE ARE THE THREE THINGS THAT WE'RE GOING TO TRY TO DO IN THE NEXT SIX HOURS. LET'S SEE WHETHER OR NOT WE CAN ACCOMPLISH IT. SO, ANYWAY, WE'LL START WITH THE DAWN OF THE MODERN ERA OF HUMAN GENETICS, IT SOUNDS VERY DRAMATIC, SO AS THEO SAID, MY INTEREST IN THESE INHERITED DISORDERS OF INFLAMMATION ACTUALLY BEGAN WITH THIS MAN HERE, A MAN OF ARMENIAN ANCESTRY WHO PRESENTED TO THE NIH RHEUMATOLOGY NEW PATIENT CLINIC BACK IN THE FALL OF 1985. THAT WAS A LONG TIME AGO, SOME OF YOU MAY WONDER HOW I EVEN WAS ABLE TO SEE SUCH A PATIENT SO LONG AGO BEING SO YOUNG AS I LOOK NOW. BUT IN ANY CASE, I DID. SOMEHOW OR OTHER, THIS WAS A MAN WHO WAS IN HIS EARLY 20'S OF ARMENIAN ANCESTRY WHO PRESENTED TO US WITH EPISODIC ATTACKS OF MONOARTICULAR KNEE OR ANKLE ARTHRITIS BUT HAD BEEN GOING ON SINCE HE WAS AN INFANT. THEE ATTACKS WERE USUALLY ACCOMPANIED BY FEVER AND HE COULD HAVE A REDDISH RASH OVER THE INVOLVED JOINT, WE HAVE MASSIVE SWELLING OF WHATEVER JOINT IT WAS WHEN IT HAPPENED. OFTENTIMES WOULD BE HOBBLED AND EITHER USING A CANE OR EVEN ON CRUTCHES DURING THE TIME OF THE ATTACK. IN HIS EARLY 20'S HE HAD ALREADY HAD A COUPLE HUNDRED OF THESE ATTACKS OVER THE COURSE OF HIS LIFE. BUT AT THE TIME I SAW HIM HE WAS CLEAN ATTACKS AND HE LOOKED TOTALLY NORMAL, FELT FINE HAD NO PARTICULAR COMPLAINTS. JUST WANTED TO KNOW WHAT WAS CAUSING HIS RECURRING ATTACKS OF ARTHRITIS. HE HAD MINIMAL RESPONSE TO CORTICOSTEROIDS. IN ANY CASE, PARTLY ACTUALLY THROUGH INPUT OF OTHERS AND ISRAELI FELLOW WHO HAPPENED TO BE IN THE LAB I WAS WORKING IN AT THE TIME WE MADE THE DIAGNOSIS OF FMF, FA MILLION MEDITERRANEAN FEVER WHICH ACTUALLY WASN'T MY FIRST THOUGHT AS TO WHAT WAS GOING ON WITH THIS PATIENT. HE DOES HAVE FAMILIAL MEDITERRANEAN FEVER. JUST TO REVIEW MAYBE SOME OF YOU HAVE NOT SEEN A PATIENT WITH FMF LATELY I SHOULD PROBABLY REVIEW WITH YOU WHAT ARE THE KEY, SALIENT TEACHERS OF FMF THE CLINICAL FEATURES. FAMILIAL MEDITERRANEAN FEVER. IS A DISORDER THAT IS RECESSIVELY INHERITED AND IS SEEN IN PATIENTS OF MEDITERRANEAN ANCESTRY. THERE WE'RE THINKING ABOUT PEOPLE OF JEWISH, ARAB, ARMENIAN, TURKISH, ITALIAN ANCESTRY PRIMARILY ALTHOUGH OTHER MEDITERRANEAN COUNTRIES CAN ALSO SOMETIMES SEE PATIENTS. THESE PATIENTS CAN EITHER HAVE ATTACKS OF STERILE PAIR TIE NIGHTS. HERE YOU CAN SEE UP RIGHT FILM OF THE ABDOMEN IN A PATIENT HAVING AN ACUTE ATTACK OF FMF IN WHICH THERE ARE FLUID LEVELS IN THE LOWER LEFT. YOU CAN SEE A LEFT AND PATIENTS HAVING INFLAMMATION. SHARP, STABBING, KNIFE-LIKE CHEST PAINS. THESE PATIENTS CAN ALSO DEVELOP PERICARDIAL EFFUSIONS WHICH SOME OF THE TIME ARE ASYMPTOMATIC. THEY CAN HAVE ARTHRITIS LIKE PATIENT THAT I TOLD YOU ABOUT USUALLY NON-EROSIVE, MONKEY FORMING ARTHRITIS, IN 5% OF PATIENTS WHO ARE NOT TREATED THEY CAN DEVELOP A CHRONIC ARTHRITIS SOMETIMES AFFECTING THE HIP AND THESE PATIENTS CAN ALSO HAVE SKIN RASH THAT'S CALLED -- THIS IS A REDDISH RAISED RASH THAT USUALLY OCCURS ON THE DORSUM OF THE FOOT OR ANKLE OR LOWER LEG. THE HISTOLOGIC FEATURES OF THE ATTACKS OF FMF ARE THAT THESE PATIENTS GET A MASSIVE ACCUMULATION OF POLYMORPH LEUKOCYTES IN THE AFFECTED AREA. WITH ARTHRITIS THERE'S LOTS OF POLYMORPH LEUKOCYTES IN THE SYNOVIAL FLUID AND AS A LONG TERM COMPLICATION OF FNF SOME PATIENTS WILL DEVELOP SYSTEMIC AM A LLOYDOSIS. A DEPOSITION OF CLEAVAGE PRODUCT OF ONE OF THE ACUTE PHASE REACTANT THAT IS MADE BY THE LIVER DURING THE INFLAMMATORY ATTACKS OF FMF. CLEAVAGE PRODUCT OF THIS PROTEIN, SERUM AMYLOID A CAN DEPOSIT IN THE KIDNEYS OR IN CERTAIN OTHER VITAL ORGANS, YOU CAN SEE HERE THIS IS THE GLOMERULAR WHICH HAD AMYLOID DEPOSITION, THE STAINED WITH RED LOOKED AT UNDER POLARIZING LIGHT YOU CAN SEE THE APPLE GREEN FRINGE. THESE PATIENTS SOMETIMES WOULD DEVELOP KIDNEY FAILURE, THIS IN THE DAYS BEFORE EVEN NOW PATIENTS WITH FMF WHO ARE UNTREATED SOMETIMES DEVELOP AM A LLOYDOSIS AND KIDNEY FAILURE. IT DO THE ME THINKING, THIS WAS REALLY SOMETHING THAT IF ONLY FIGURE OUT WHAT THE GENE IS. GOING AFTER THE GENE FOR CYSTIC FIBROSIS BY POSITIONAL CLONING BASICALLY THIS IS A APPROACH WHICH IF YOU FIND ENOUGH FAMILIES WHO ARE AFFECTED WITH THE PARTICULAR PHENOTYPE AND ONE TRACES INHERITANCE OF THE DISEASE IN THE FAMILIES COMPARES WITH IT DNA MARKERS OF KNOWN CHROMOSOMAL LOCATION YOU CAN FIGURE OUT WHAT CHROMOSOME THE GENE IS ON THEN WHAT THE BETWEEN IS. I THOUGHT WELL, GEE, IF FRANCIS COLLINS CAN GO AFTER THE GENE FOR CYSTIC FIBROSIS THEN WHY CAN'T I GO AFTER THE GENE FOR FAMILIAL MEDITERRANEAN FEVER. THAT'S WHAT I DID. SO I TOOK A FIELD TRIP TO ISREAL. ESSENTIALLY WHAT HAPPENED IS THAT I ESTABLISHED A COLLABORATION WITH THIS GUY HERE WHO HAD THAT TIME VERY LARGE CLINIC OF FMF PATIENTS NEAR TEL AVIV AND DURING THE SUMMER OF 1989 WE SAW LARGE NUMBER OF PATIENTS WITH FMF IN THE CLINIC BUT WE ALSO WENT OUT, SOME CASES THESE PATIENTS COULDN'T COME TO THE CLINIC AND SO WE WOULD GO TO THEM. WE WOULD VISIT THEM IN THEIR HOMES, THIS HAPPENS TO BE A FAMILY IN A NORTHERN PORT CITY IN ISREAL, FAMILY OF MOROCCAN-JEWISH ANCESTRY. IN FACT THE PARENTS IN THE FAMILY ARE FIRST COUSINS TO ONE ANOTHER YOU CAN NOTICE THE STRONG FAMILIAL RESEMBLANCE BETWEEN THE FATHER AND THE MOTHER IN THIS FAMILY. BUT IN ANY CASE, THERE WERE THREE IN THIS PICTURE. THREE INDIVIDUALS, THREE CHILDREN WHO WERE AFFECTED WITH FMF. ONE WHO WAS NOT. WE HAD NUMBER OF FAMILIES LIKE THIS. WHICH ALLOWED US TO DO THE LINKAGE STUDIES THAT ULTIMATELY LED TO THE MAPPING MUCH THE GENE TO THE CHROMOSOME 16 AS THEO HAD MENTIONED. THEN WE BASICALLY BECAME AT THAT TIME GENOME PROJECT FOR THAT PART OF CHROMOSOME 16 WE DEVELOPED A NUMBER OF MARKERS FOR THIS AREA WHICH WAS AT LEAST INITIALLY SOMETHING LIKE TEN MILLION BASE PAIRS AND SIZE, NARROWED THINGS DOWN OVER THE COURSE OF FOUR YEARS OR SO TO 200,000 BASE PAIR INTERVAL. AND WITHIN THAT INTERVAL THERE WERE TEN GENES THAT WE FIGURED OUT WERE ENCODED IN THAT REGION, THERE WASN'T A DATABASE BUT YOU COULD LOOK THEM UP SO WE ACTUALLY HAD TO FIGURE OUT WHAT GENES WERE ENCODED IN THAT REGION. AND AS LUCK WOULD HAVE IT, IT TURNED OUT THAT IT WAS THE TENTH OF THE TEN THAT WE LOOKED AT THAT MUTATIONS THAT WERE ASSOCIATED WITH INHERITANCE OF FMF THAT IS SHOWN HERE. MEFV WHICH STANDS FOR MEDITERRANEAN FEVER. IT ENCODED A PROTEIN THAT WAS A NOVEL PROTEIN THAT WE REASONED PROBABLY HAD SOMETHING TO DO WITH THE REGULATION OF INFLAMMATION. WE NAMED THE PROTEIN THAT'S ENCODED BY THAT GENE PIRAN AFTER PYREXIA A. A FRENCH GROUP WAS COMPETING WITH US MUCH MORE ERRUDITE THAN WE WHO NAMED THE PROTEIN NOSRA AND, WHICH WAS THE LATIN FOR THE MEDITERRANEAN SEA. WE CHOSE A SHORT EASY TO SPELL AND PRONOUNCE NAME IN THE HOPES THAT THAT WOULD CATCH ON. THE FRENCH CAME UP WITH THIS OTHER NAME. WE WERE DOING THIS INDEPENDENTLY. IT WASN'T LIKE WE WERE COMPARING NOTES. TURNED OUT OF COURSE WE BOTH FOUND THE SAME GENE AND SO, ANYWAY, THE GENE ENCODES THIS PROTEIN THERE'S A DOMAIN AT THE END TERMINUS OF THIS PROTEIN THAT WAS PREDICTED DOMAIN AT THAT TIME THAT'S TURNED OUT TO BE VERY IMPORTANT INTER-ACTION DOMAIN IN TERMS MUCH THE REGULATION OF INFLAMMATION AND APOPTOSIS IN HUMAN. AND THAT DOMAIN IS NOWADAYS CALLED THE PYRIN. NOT THE MARENOSTRIN DOMAIN. IT ASSUMES A SIX ALPHA HELIX STRUCTURE WHICH IS UP HERE. BASICALLY THAT ALLOWS FOR THE FORMATION OF A CHARGED DYE POLE THAT IS ILLUSTRATED HERE ON THE RIGHT HAND SIDE OF THE SLIDE. THERE FOR ALLOW FOR INTER-ACTIONS THAT ARE INVOLVED IN ACTIVATING CERTAIN PATHWAYS. IN THE CASE OF PYRIN ITSELF. IT IT HAS A CARD DOMAIN WHICH IS SIMILAR INSTRUCT TO PYRIN DOMAIN THAT IS C TERMINUS IT INTER-ACTS WITH C.A.T. BASE 1 WHICH IS MOLECULE THAT CATALYZES THE ACTIVATION OF PRO INTERLEUKIN ONE BETA. TO THE BIOLOGICALLY ACTIVE 17 KILL DALTON WHICH IS MAJOR MEDIATOR OF FEVER. IN FACT THERE ARE SOME 20 DIFFERENT PROTEINS IN HUMANS THAT HAVE PYRIN DOMAINS BUT IN ONE WAY OR ANOTHER ARE INVOLVED IN REGULATION OF INFLAMMATION. SO IN THIS CASE THIS IS A WILDTYPE MOUSE, THIS IS A MOUSE THAT HAS HAD GENETICALLY ENGINEERED THE V726A MUTATION. PREVAILING POSITION 726 THAT'S ONE OF THE HUMAN FMF MUTATIONS. YOU CAN SEE COMPARING THESE TWO MICE WILDTYPE MOUSE DOES NOT HAVE ARTHRITIS WHERE AS THE V726A KNOCK-IN MOUSE DOES HAVE. WITH THE KNOCK-IN MOUSE. ONE CAN SEE A LOT OF WHITE BLOOD CELLS. THEN SPEAKING TO THE QUESTION OF PATHOPHYSIOLOGY OF DISEASE WE HAVE BRED THESE MUTANTS ON TO VARIOUS GENETICALLY CHARACTERIZED BACKGROUNDS. EITHER ON TO WILDTYPE BACKGROUND, YOU CAN SEE THAT THIS IS A FLOW CYTOMETRY THAT SHOWS THERE'S A LOT OF GRANULAR SITES IN THE CIRCULATION OF THESE MICE WHERE AS IF YOU BREED ON TO A KNOCK OUT FOR THE IL1 RECEPTOR SO THAT IL1 SIGNALLING IS BLOCKED IN THESE MICE THAT LEUKOCYTOSIS GOES AWAY. ALL OF OF THE CLINICAL FINDINGS GO AWAY. THIS IS IN THESE MICE AN IL 1 DEPENDENT DISEASE. IN ANY EVENT WHAT ABOUT IN HUMANS. IN HUMANS ACTUALLY THE TREATMENT FOR MF -- FMF IS A DRUG, MANY OF YOU ARE FAMILIAR WITH IT A TREATMENT THAT IS OFTENTIMES USED IN GOUT IN THE EARLY 1907s IT WAS SHOWN TO BE EFFECTIVE IN PREVENTING THE ATTACKS OF FMF. QUITE A NUMBER OF PATIENTS MAJORITY OF PATIENTS WITH FMF BUT OCCASIONALLY PATIENTS THAT DO NOT RESPOND TO THE DRUG OR HAVE PROBLEMS WITH SIDE EFFECTS, IN FACT IN 2005 WE HAD HERE CLINICAL CENTER A PATIENT FROM BAGHDAD, IRAQ, WHO WAS 18 YEARS OLD AND WHO HAD FMF, COMPLICATED BY AMYLOID DOSES. WOULD HAD ANOTHER PATIENT, PLEASE MEET IF YOU WILL COME UP THIS IS PETE, ONE OF OUR PATIENTS WITH FMF THAT WE SEE HERE AT THE CLINICAL CENTER, HAVE A CHAIR, WE'RE GOING TO TALK A LITTLE BIT ABOUT JUST WHAT FMF IS LIKE AND SOME OF THE SYMPTOMS THAT YOU HAD WHEN YOU WERE ON CULTRACENE THEN WHEN YOU HAD TREATMENT WITH THE IL1 DRUG. PROBABLY FIRST THING THAT PERHAPS THE GROUP WOULD LIKE TO HEAR ABOUT IS JUST WHAT WERE SOME OF THE EARLY MANIFESTATIONS THAT YOU HAD OF FMF WHEN YOU WERE A CHILD. [ NOT AUDIBLE ] >> I HAD SEVERE CHEST PAIN, LIKE SHARP PAIN IN MY CHEST, IT WILL BE COMING AND GOING LIKE TWICE A YEAR. IT WOULD STAY FOR LIKE A WEEK. WITH HIGH FEVERS, THROWING UP AND ONCE IN AWHILE I WOULD HAVE LIKE STOMACH ATTACK GET LIKE SEVERE FLU. MAJOR STOMACH PAIN, HIGH, HIGH FEVER, CHILLS AND THROWING UP AGAIN. >> YOU HAD SURGERY AT ONE POINT. >> WHEN I WAS SIX YEARS OLD I DIDN'T KNOW WHAT IT IS SO THEY TOOK MY APPENDIX OUT. [LAUGHTER] >> DID IT HELP? >> NO. >> DID YOU EVER HAVE ANY PROBLEM WITH ARTHRITIS? >> WHEN I GREW UP ABOUT 16 YEARS OLD I WAS AN ATHLETE AND I PLAYED SOCCER AND I GUESS IT LIMITED ME BECAUSE ONCE I TRAINED A LITTLE BIT, A LITTLE TOO FAR MY KNEES WOULD SWELL. OR MY ANKLE WOULD SWELL. UNTIL THEN THEY DID NOT KNOW WHAT HAPPENS TO ME. I WAS HOSPITALIZED ALSO FOR LIKE THREE WEEKS IN THE HOSPITAL IN ISREAL THINKING I HAVE SOME SORT OF INFECTION IN MY KNEE. THEN AFTER WHEN I REACH ABOUT 17 YEARS OLD WAS WHEN THEY CONCLUDED I HAD FMF I MET WITH -- >> YOU WERE STARTED ON THE TREATMENT AT THAT TIME. >> I WAS ON I HAD TWICE A YEAR ATTACK THEN THEY GAVE ME INJECTION THEN 'A TAX GOT TO BE MUCH MORE SEVERE. GET ATTACKS EVERY TWO WEEKS, THREE WEEKS SO THEY RADDED. >> WHEN YOU CAME TO SEE US HERE AT THE NIH IT WAS SOMETHING LIKE 2004 OR SOMEWHERE IN THAT TIMEFRAME. YOU WERE STILL HAVING FAIRLY FREQUENT ATTACKS, RIGHT? >> THAT WOULD HAVE ATTACKS EVERY TWO TO THREE WEEKS. IN BETWEEN ATTACKS I'D HAVE FLARE, THE PAIN IN MY CHEST. I WOULD HAVE STOMACH ATTACKS. >> INITIALLY I HAD SUGGESTED BASED ON THAT PATIENT THAT I JUST MENTIONED WITH THE AMYLOIDOSIS THAT YOU MIGHT WANT TO CONSIDER TREATMENT WITH ANAKENDRA, WHAT WAS YOUR REACTION? >> I WAS NERVOUS. IT JUST CAME OUT I DIDN'T WANT TO BE A BUNNY. >> YOU DON'T LOOK LIKE A BUNNY. >> I SAID I'M GOING TO WAIT WITH THAT. I SUFFERED FOR ANOTHER THREE YEARS UNFORTUNATELY. >> THEN WHAT HAPPENED? >> THEN I CAME IN AGAIN AND YOU GUYS CONVINCED ME TO TAKE THE INJECTIONS THAT CHANGED MY WHOLE LIFE. >> FOUR YEARS THAT I'M ON -- I HAD MAYBE ONE AND A HALF ATTACKS. FOUR AND A HALF YEARS YOU GUYS SAVED MY LIFE. >> DO YOU HAVE ANY SIDE EFFECTS? >> NOT AT ALL. >> SOME PATIENTS DO GET SOME SORT OF SWELLING AROUND THE SITE WHERE THEY HAVE THE INJECTION, THAT DOESN'T HAPPEN IN YOUR CASE. >> NOT AT ALL. >> WE ARE IN TERRIFIC SHAPE. THANKS TO YOU GUYS. >> ALL RIGHT. THANK YOU VERY MUCH FOR COMING. WE REALLY APPRECIATE THAT. ROUND OF APPLAUSE FOR PETE. [APPLAUSE] >> OKAY. SO, ANYWAY, THAT'S AT LEAST A LITTLE BIT WITH REGARDS TO FMF. NOW WE'LL MOVE ON TO ANOTHER DISEASE, THIS IS ACTUALLY DISEASE THAT THEO ALSO ALLUDED TO. WE GOT INTERESTED IN THIS DISEASE AGAIN BECAUSE OF PATIENTS THAT PRESENTED HERE AT THE CLINICAL CENTER. AND THERE WAS ONE PATIENT THAT THEO REFERRED TO THAT WAS IRISH, I'LL TALK ABOUT HER IN A SECOND. BUT THERE WAS ACTUALLY ANOTHER PATIENT FROM LOUISIANA WHO CAME TO US IN ABOUT 1995 OR SO. SOMETHING LIKE THAT. IT WAS BEFORE WE HAD ACTUALLY FOUND THE GENE FOR FMF AND SO IT WAS A LITTLE BIT OF A MYSTERY. SO THERE WAS THIS LADY WHO CALLED ME FROM ACTUALLY SORT OF RURAL LOUISIANA SHE CALLED TO TELL ME THAT HER HUSBAND HAD JUST RECENTLY DIED IN A V.A. HOSPITAL IN LOUISIANA, I BELIEVE IN SHREVEPORT, LOUISIANA, OF DISEASE THAT THEY WERE CALLING FMF. HE HAD AMYLOIDOSIS HE DIED OF KIDNEY FAILURE, BASICALLY. THE HUSBAND WHO HAD JUST PASSED AWAY HAD HAD. SO SHE WANTED AN APPOINTMENT AT THE NIH TO TALK ABOUT THIS. SO, ANYWAY, I'M GOING TO JUST PLAY A LITTLE BIT OF AN A INTERVIEW WITH HER AND THE INTERESTING THING IS THAT SHE ACTUALLY RECOGNIZED THE VERY IMPORTANT CLINICAL FEATURE OF THE ILLNESS IN THEIR FAMILY, NAMELY THAT IT SEEMED TO HAVE A DOMINANT MODE OF INHERITANCE WHICH WAS AT ODDS WITH WHAT WAS PUBLISHED AT THE TIME WITH REGARD TO FMF. >> SIMILAR TO MEDITERRANEAN FEVER BUT MORE THAN I READ ABOUT IT IT'S A RECESSIVE GENE. THIS IS NOT RIGHT. THIS DOESN'T FIT WHAT OUR FAMILY WAS EXPERIENCING 'THIS IS DOMINANT GENE. MY SCOPE OF -- THAT WAS LIMITED I THOUGHT THIS IS A DOMINANT GENE THIS IS NOT MEDITERRANEAN FEVER. HE MIGHT GO A WEEK, OR TWO WEEKS AND HAVE FEVERS AND PAIN JUST SUFFER. WAKE UP ONE MORNING BE FINE. ALSO THERE WAS SERPENTINE RASH. NOT ALWAYS, THERE WASN'T ALWAYS A HIGH FEVER BUT THERE WOULD BE A RASH. IF YOU WOULD TOUCH WHEREVER THAT RED ENAREA WAS IT WOULD BE VERY HOT. SOME OTHER PLACE ON THEIR SKIN WOULD BE FINE, IT WOULD FEEL NORMAL. AND RACHEL WAS THE SAME WAY. ONLY THING RANDY ALWAYS SAID THAT RACHEL'S ATTACKS SEEM A LOT MORE VICIOUS. SHE WOULD HAVE ATTACKS. THE LONGEST WAS FIVE TO SIX WEEKS. EVERY DAY. 105 TEMP. FEVER, CHILLS, IF IT WAS IN HER ABDOMINAL AREA SHE WOULD JUST PANT CONSTANTLY. SHE WOULD GET IN HER EYES, HER EYE WOULD BULGE OUT. >> HER EYE WOULD BULGE OUT FROM BEING PUFFY. >> SOMETIMES. >> IN JAW AREA THAT WAS REALLY BAD. BECAUSE WHEN IT'S IN THAT AREA. >> STRESS, ANY KIND OF IN SHE HAD HER FIRST ATTACK SHE SAID, HONEY -- I WAS DEVASTATED. SAID, HONEY, IS THAT ARTHRITIS? YOU CAN'T DIE FROM IT, THOUGH. YOU MAY THINK YOU'RE GOING TO DIE FROM IT. BUT YOU CAN'T DIE FROM IT. THAT WAS WHEN SHE WAS THREE MONTHS OLD. THAT WAS ONE FAMILY F. THAT FAMILY WE GOT THE SENSE THAT THERE MIGHT BE SOMETHING ELSE GOING ON. THAT THERE MIGHT BE DISEASE IN WHICH THERE WAS -- THERE WERE MORE PROLONGED ATTACKS WHICH THE INDIVIDUAL SUFFERING FROM IT WERE NOT NECESSARILY OF MEDITERRANEAN ANCESTRY WHICH THERE WAS NOT A VERY DRAMATIC RESPONSE TO THE DRUG. IN WHICH THERE WERE SOME DIFFERENT CLINICAL MANIFESTATIONS. SIMILARLY, WE SAW ANOTHER PATIENT, THE ONE THAT'S SHOWN HERE WHO WAS THE WIFE OF AN EMPLOYEE OF THE IRISH EMBASSY HERE IN WASHINGTON. WITH WHO HAD A SIMILAR STORY OF VERY PROLONGED ATTACKS OF UNRESPONSIVENESS TO THE DRUG OF WHAT APPEARED TO BE DOMINANT PATTERN OF INHERITANCE IN THE FAMILY. SO WE AT LEAST PUT THAT IN THE BACK OF OUR MINDS. WE HADN'T FOUND THE GENE FOR FMF AT THAT POINT WE THOUGHT THAT PERHAPS IT WAS POSSIBLE THAT THIS WAS JUST SOME SORT OF 'DIFFERENT MUTATION. SO ANYWAY, MIKE MCDOOR 3409 WHO IS SHOWN HERE WAS A FORMER FELLOW OF MINE ACTUALLY TRACKED DOWN A LARGE FAMILY OF -- IN IRELAND, ENGLAND AND IRELAND WHO HAD THIS TYPE OF ILLNESS. AND MAPPED THE CAUSATIVE GENE TO THE CHROMOSOME 12. OF COURSE THE GENE FOR FMF IS ON CHROMOSOME 16 THAT PRETTY MUCH TELLS US THAT THAT CAN'T BE THE CAUSATIVE LOCUS. SO AT THAT POINT, MIKE CAME BACK TO THE LAB TO DO A SABBATICAL WAS WORKING WITH ANOTHER IN THE LAB TO TRY TO FIGURE OUT WHAT MIGHT BE THE CAUSATIVE GENE. AND IN THIS CANDIDATE INTERVAL ON CHROMOSOME 12 IT WAS FAIRLY LARGE INTERVAL. WE HAD NOT NARROWED IT UP TO THAT MUCH THERE WAS THE QUESTION OF WHAT POSSIBLY COULD WE LOOK AT AS CANDIDATE GENES WHILE WE WERE TRYING TO NARROW THE REGION NOW FURTHER. WE APPLIED WHAT WE SOMETIMES CALLED THE EMBARRASSMENT TEST WHICH IS THE TEST OF WHAT GENE WOULD BE THE MOST EMBARRASSING ONE THAT IF IT TURNED OUT TO BE THAT SPENT FIVE YEARS LOOKING FOR IT THAT WOULD REALLY BE BAD. SO THERE WAS ONE PARTICULAR GENE IN THAT INTERVAL WHICH ENCODES THE 55 KILODALTON RECEPTOR FOR TUMOR NECROSIS FACTOR. AS MANY KNOW THERE ARE THREE MAJOR MEDIATORS OF FEVER AND INFLAMMATION IN HUMANS. INTERLEUKIN ONE WHICH WE'VE TALKED ABOUT. TUMOR NECROSIS FACTOR AND INTERLEUKIN SIX. THIS SEEMED LIKE IT WAS MAYBE PRETTY GOOD CANDIDATE GENE AND SO IN FACT THE TWO LOOKED AT THIS GENE AS THEIR FIRST CANDIDATE AND ACTUALLY FOUND MUTATIONS ASSOCIATED WITH DISEASE IN SEVEN DIFFERENT FAMILIES FOUND SIX DIFFERENT MUTATIONS THAT WERE ASSOCIATED WITH DISEASE IN THOSE SEVEN FAMILIES. PROTEIN THAT'S ENCODED BY THIS GENE, AT LEAST PART IS SHOWN HERE. THE EXTRA CELLULAR PART OF THIS RECEPTOR COMPRISES FOUR CYCSTEINE RICH DOMAINS SHOWN HERE. THERE'S A TRANSMEMBRANE DOMAIN THEN A DEPTH DOMAIN WHICH IS SIMILAR IN STRUCTURE TO PYRIN. BASICALLY THE MUTATIONS THAT WE FOUND AT LEAST SEVERAL OF THEM ARE MUTATIONS THAT SUBSTITUTE SOMETHING ELSE FOR CYCSTEINE. BASICALLY THIS LOOP-D-LOOP IS HELD TOGETHER. IF YOU HAVE MUTATION SOMETHING ELSE FOR CYCSTEINE THEN DISULFIDE BOND DOESN'T FORM THEN YOU GET MISFOLDING OF THE PROTEIN. FOR VARIETY OF REASONS THAT ACTUALLY DOES LEAD TO INFLAMMATORY PHENOTYPE IN THIS FAMILY THAT MIKE HAD TRACKED DOWN IN THE BRITISH ISLE, IS THAT WAS OF IRISH ANCESTRY WAS ACTUALLY OF IRISH ANCESTRY ON ONE SIDE OF THE FAMILY AND SCOTTISH ON THE OTHER SIDE. IT ACTUALLY TURNED OUT, THIS IS DOMINANT DISEASE THE MUTATION CAME FROM THE SCOTTISH SIDE OF THE FAMILY NOT IRISH SIDE OF THE FAMILY. THIS DISEASE HAD BEEN CALLED BY SOME. WHAT WERE WE TO DO? WERE WE GOING TO RENAME IT SCATTISH FEVER? NO, THAT DIDN'T SEEM LIKE VERY GOOD THING. EVEN A FINNISH FAMILY THAT HAD A MUTATION. WELL, FINNISH FEVER, NO. WE SEE SIDED ULTIMATELY THAT WE'D COME UP WITH A NAME, AGAIN TRYING TO FIND NAMES THAT ARE SHORT, EASY TO PRONOUNCE, EASY TO REMEMBER WE CAME UP WITH THIS NAME TRAPS, WHICH STANDS FOR THE TNF RECEPTOR ASSOCIATED PERIODIC SYNDROME. HERE ARE SOME OF THE CLINICAL FEATURES OF TRAPS JUST VERY BRIEFLY, THIS WAS LAPAROSCOPIC VIEW OF THE PERITONEAL CAVITY OF SEVEN-YEAR-OLD GIRL THAT WE FOLLOW HERE AT THE NIH. YOU CAN SEE ADHESION, IS THAT HAVE ALREADY FORMED FROM REPEATED EPISODES OF STERILE INFLAMMATION. THICKENING. THERE'S A RASH, MIGRATORY RASH THAT PATIENTS CAN DEVELOP THAT STARTS PROXIMALLY. IF YOU LOOK AT THE MAGNETIC RESONANCE IMAGING YOU CAN SEE THAT THE INFLAMMATION GOES DOWN IN TO THE MUSCLE COMPARTMENT IN FACT MORE FASCIITIS. YOU'LL REMEMBER IN THE VIDEO CLIP THE BULGING OF THE EYES. IT'S ACTUALLY SORT OF A PERI ORBITAL EDEMA THAT THEY CAN DEVELOP. THIS IS ACTUALLY AMYLOIDOSIS IN THE KIDNEY THIS IS FROM THE AUTOPSY OF RACHEL'S FATHER, THE GUY WHO DIED THAT WAS SORT OF THE BEGINNING OF THE SEARCH IN THE CASE. FAMILY FROM LOUISIANA. PROBABLY RELATED TO THE FACT THAT ORDINARILY TNF SIGNALS BY INDUCING A TRIMER OF TNF TO FORM. THERE'S A TRIMER OF TNF THAT WILL BIND TO INDIVIDUAL CHAINS OF THE TNF RECEPTOR AND ORGANIZE TRIMMIZATION WHICH ALLOWS FOR SIGNALLING COMPLEX TRAIN CELLULARLY WHICH LEADS TO CTYOKINE ACTIVATION. MISFOLDING CAUSES -- ACTIVATION OF THIS SIGNALLING COMPLEX AND FOR THAT REASON INFLAMMATION. IN ANY CASE WE'LL NOW MOVE ON TO ANOTHER DISEASE JUST BRIEFLY. AGAIN DISEASE THAT OUR GROUP GOT INTERESTED IN BECAUSE OF A PATIENT WHO WAS REFERRED TO MY COLLEAGUE, IN THE ARTHRITIS INSTITUTE IN NIAMF. THIS YOUNG MAN FROM NORTH CAROLINA WHICH WAS REFERRED TO THE POSSIBILITY OF SYSTEMIC ONSET JEW FALL IDIOPATHIC ARTHRITIS. TURNED OUT THAT HE HAD CLINICAL FEATURES THAT WERE ATYPICAL THAT DISEASE NAMELY HIVES-LIKE SKIN RASH. HE HAD EVIDENCE FOR PAP LLOYD EDEMA, SWELLING OF THE CEREBRAL VENTRICLES HE HAD DEFORMITIES OF HIS KNEES WHICH ARE NOT TYPICAL FOR SYSTEMIC ONSET JIA. AND RAFAELA CORRECTLY DEFUSED DID HE NOT HAVE SYSTEMIC ONSET BUT DISEASE CALLED NEONATAL ONSET MULTI-SYSTEM INFLAMMATORY DISEASE. IT IS A DISORDER THAT IS CHARACTERIZED BY THIS TRIAD OF AND CHRONIC ASEPTIC MENINGITIS, INFLAMMATION OF THE WHICH CAN LEAD TO NUMBER OF COMPLICATIONS INCLUDING BLINDNESS, DEAFNESS AND MENTAL DISABILITY. SO IN ANY CASE, BASED ON THAT THE FACT THAT THE FELLA WHO HAD SEEN THIS PATIENT FROM NORTH CAROLINA ALSO HAPPENED TO HAVE SEEN PATIENT OF MINE WHO HAD DISEASE WHICH HAD JUST BEEN SHOWN TO BE CAUSED BY MUTATIONS IN THE GENES, ANOTHER GENE THAT'S INVOLVED IN IL1 ACTIVATION. FELLOW SAID, THOSE PATIENTS LOOK A LITTLE BIT SIMILAR. YOU GUYS OUGHT TO THINK ABOUT WHETHER IT'S THE SAME GENE THAT CAUSES BOTH DISEASES. IN ANY CASE, THEY SET OUT TO DO JUST THAT AND THEY DISCOVERED THAT IN FACT THERE WAS A MUTATION IN THAT GENE, IN THAT PATIENT THAT WAS ASSOCIATED WITH DISEASE AND THEN THEY FOUND AT LEAST IN A NUMBER OF OTHER PATIENTS, NOT IN ALL OF THEM BUT IN A NUMBER OF OTHER PATIENTS THAT THERE ARE IN FACT DISEASES LOCATED MU SITUATIONS AND THIS PROTEIN SOMETIMES CALLED -- BECAUSE IT'S A PROTEIN THAT HAS PYRIN DOMAIN THAT RELATED TO THE GENE THAT CAUSES FMF AND CRYO, BECAUSE AT LEAST PATIENTS THAT HAVE MILDER END OF THE SPECTRUM OF DISEASE HAVE COLD-INDUCED FEVERS. CRYOPYRIN. IN ANY CASE ONE CAN SEE THAT THE MUTATIONS THAT HAVE BEEN IDENTIFIED IN THIS PROTEIN FOR BOTH NOMI DISHES AND COLD-INDUCED FORM OF THE DISEASE ARE ALL IN A COMMON AREA OF A CERTAIN DOMAIN OF THE PROTEIN. THEY REASONED THAT IT MIGHT BE WORTHWHILE TO TRY THAT SAME DRUG THAT WE TALKED TO PETE ABOUT, NAMELY -- IN THESE PATIENTS WHO HAVE THIS DISEASE. GIVEN THE SEVERE CLINICAL MANIFESTATIONS OF THIS DISEASE SEEMED LIKE IT WAS REALLY AN IMPORTANT THING TO DO. THIS SLIDE, LEFT HAND SLIDE DEPICTS HOW SIGNALLING THROUGH IL1 ORDINARILY OCCURS. YOU CAN SEE OF THE BLUE BUBBLES HERE AT BEING IL1 MOLECULES. WHAT HAPPENED THAT IL 1 HAS TO BIND TO TWO CHAINS. THE TYPE TWO SHOWN IN GREEN AND ACCESSORY PROTEIN SHOWN IN PURPLE. IN ORDER TO GET A SIGNAL, YOU HAVE TO HAVE BOTH OF THOSE CHAINS ENGAGED. THERE IS IN ALL OF US AN IL1 RECEPTOR ANTAGONIST WHICH COMBINE TYPE ONE RECEPTOR BUT NOT TO THE ACCESSORY PROTEIN. IT COMPETES WITH DAMAGE -- BASICALLY THAT HOW IT WORKS IS THAT IT BINDS TO THE IL ONE RECEPTOR WITHOUT INDUCING SIGNALLING. IN ANY CASE THAT'S WHAT WE TRIED WAS ANAKENDRA IN THE PATIENTS THIS IS JUST TESTIMONY TO THE POWER OF MOLECULAR MEDICINE. SO, IF YOU COMPARE THE PATIENTS BEFORE TREATMENT WITH THOSE AFTER TREATMENT WITHIN TWO OR THREE DAYS, THE RASH GOES AWAY. CONJUNCTIVITIS GOES AWAY, THESE ARE MRI OF THE BRAIN DONE HERE AT THE CLINICAL CENTER YOU CAN SEE THE WHITE REPRESENTS INFLAMMATION THAT IS BASICALLY THE MENINGITIS. YOU CAN SEE OF A II THREE MONTHS THAT GOES AWAY. THE ARROW POINTS TO INFLAMMATION IN THE COCHLEA, THAT GOES AWAY. IN ANY EVENT IT'S REALLY GRATIFYING AND DRAMATIC CLINICAL RESPONSE. SIMILARLY ON THEIR OWN FOUND ANOTHER DISEASE THAT THEY CALLED -- FOR DEFICIENCY OF THE IL1 RESOP FOR. SOME PEOPLE THEY DON'T MAKE THIS ENDOGENOUS PROTEIN THAT IS SUPPOSED TO TURN OFF SIGNALLING BY IL1. IN THAT CASE YOU CAN SEE THAT THERE ARE SEVERE INFLAMMATORY AFFECTS OF PUSTULAR RASH ALL OVER THE BODY. ANYWAY, WE WILL NOW TURN TO YET ANOTHER DISEASE. ANOTHER DISEASE WHICH WAS PROMPTED BY A CLINICAL CLUE BY INTER-ACTION WITH A PATIENT. THAT'S DISEASE CALLED PAPA SYSTEM, THIS IS DISEASE, THERE'S PHOTOGRAPH OF ONE OF OUR PATIENTS FROM KANSAS CITY WHO HAS THIS DISEASE. THEY DEVELOP PYODERMA. THE SKIN IS BROKEN DOWN THERE'S BLOOD AND PUS IN THAT AREA. THEY ALSO CAN DEVELOP ARTHRITIS THAT IS A PURE LENT ARTHRITIS. AT THIS POINT WE'LL JUST WATCH BRIEF FILM CLIP, ACTUALLY FROM THE PATIENT WHO IS -- >> WHEN I WAS ABOUT THREE I WAS MAULED BY A DOG AND I HAD TO GO TO THE DOCTOR THEY WANTED TO GIVE ME A TETANUS SHOT. WELL, MY MOM KNEW RIGHT OFF THAT I CAN'T TAKE SHOTS OTHERWISE I WOULD GET A BIG ABSCESS. THE DOCTOR DIDN'T LISTEN, I ENDED UP GETTING THE SHOT AND MY WHOLE RIGHT BOTTOM WAS REALLY BIG. AND EVER SINCE THEN THE DOCTOR JUST -- >> THEY HAD TO DRAIN IT, IS THAT RIGHT? >> THE DRAINED IT. THE DOCTOR APOLOGIZED THEN HE BASICALLY LISTENS TO US NOW WHEN WE SAY THAT WE CAN'T DO THIS, WE NEED SOMETHING ELSE. >> I THINK ONE OF THE DIFFERENCES WE'RE HEARING ALREADY BETWEEN THE PATIENTS IS THAT NATHAN'S MOM KNEW, THE ROBE NATHAN'S MOM KNEW IS THAT HE HAS A BIG FAMILY HISTORY. COULD YOU TELL US ABOUT THAT? >> I GUESS. MY GRANDPA HAD IT FIRST, NONE OF HIS SIBLINGS HAD IT NOR HIS PARENTS. HE HAD FIVE KIDS AND ONLY ONE OUT OF THE FIVE DIDN'T SHOW ANY SIGNS. MY MOTHER WAS ONE OF THE ONES THAT SHOWED THE THE MOST. SHE GOT REALLY BIG ARTHRITIS IN HER ELBOW AND HER KNEE. HER, ALONG WITH MY OLDER SISTER AND I WE CAN'T HAVE SHOTS. I'VE GOT SEVEN SIBLINGS AND TWO OF THEM DON'T SHOW ANY SIGNS. >> SO THIS WAS A MYSTERY DISEASE, AT LEAST AT THE OUTSET, THE PAPA LESIONS SOMETIMES ARTHRITIS, SOMETIMES ABSCESSES FORMING WITH INJECTIONS. THEN OF COURSE THERE WAS ALL THE QUESTIONS WHAT IT MIGHT BE, THIS IS JUST FROM THE SAME INTERVIEW. BASICALLY THE PERSON THAT'S INTERVIEWING THESE PATIENTS IS LYNN, FROM TEXAS SCOTTISH RITE HOSPITAL ENODAL WHICH IS ONE OF THE PLACES THAT DID SOME OF THE GENETIC STUDIES ON THIS DISEASE. SHE'S GOING TO BE ASKING ANOTHER PATIENT, ACTUALLY ONE OF OUR PATIENTS FROM HERE AT THE NIH ABOUT SOME OF THE PROBLEMS THAT HE'S EXPERIENCED THAT HE HAD EXPERIENCE WITH REGARD TO MISDIAGNOSIS. >> PEOPLE WOULD SAY, IT WAS OSTEOMYELITIS, ALL SORTS OF DIFFERENT THINGS, THEN THEY SAY, IT REALLY ISN'T. YOU GET A LOT OF UNPRODUCTIVE THERAPIES. I'VE HAD A LOT OF PLASMA FER RECESS. EVERY ANTIBIOTIC. >> ANYWAY WHAT THIS TURNED OUT TO BE ULTIMATELY THE GROUP IN DALLAS DID STUDIES ON COUPLE OF FAMILIES WITH THIS PHENOTYPE. ACTUALLY FOUND THAT THE CAUSATIVE GENE IS A GENE THAT IS PSTPIP1. IN ANY CASE, AT ABOUT THE SAME TIME THAT THE GROUP IN DALLAS WAS DOING THAT, WE WERE LOOKING WITH THESE TWO HYBRID APPROACHES AT WHAT WERE THE PROTEINS WITH INTER-ACT WITH PYRIN. LO AND BEHOLD WHAT WE FOUND IS THAT ONE OF THE TWO PROTEINS THAT CAME UP AS POSITIVE IN THOSE ASSAYS FOR PYRIN INTER-ACTION WAS THIS PROTEIN. IN FACT THE MUTATION, IS THAT ARE ASSOCIATED WITH DISEASE WHEN YOU COMPARE THE INTER-ACTION WITH THE WILDTYPE PROTEINS WITH THE INTER-ACTION OF MUTANT PROTEIN WITH PYRIN IS MUCH INCREASED IT ACTUALLY LEADS TO THE ACTIVATION OF IL1 SIGNALLING PROBABLY OTHER CTYOKINE SIGNALLING PATHWAYS AS WELL. IN ANY CASE MAYBE JUST TO SUMMARIZE WHAT I'VE TOLD YOU SO FAR THERE ARE SEVERAL DISEASES THAT ARE CAUSED BY MUTATIONS IN GENES THAT ARE INVOLVED IN REGULATION OF IL1 IN THE CASE OF FAMILIAL MEDITERRANEAN FEVER THE PROTEIN THAT'S INVOLVED WITH PYRIN YOU GET THIS KIND OF SKIN RASH IN THE CASE OF PAPA SYNDROME WHICH WE TALKED ABOUT YOU CAN GET -- IN THE CASE OF PYROPYRIN PROTEIN YOU GET HIGH SKIN RASH IN THE CASE OF DIRA YOU GET THIS PUSTULAR RASH. INFLAMMATION IN ALL CASES BUT DIFFERENT KINDS. WE DON'T UNDERSTAND EXACTLY WHY YOU GET ONE KIND OF INFLAMMATION WITH ONE OF THESE DISEASES AND ANOTHER KIND. BUT I DO WANT TO EMPHASIZE TO YOU THAT THIS IS NOT JUST THE STUDY OF RARE DISEASES. ALTHOUGH THE DISEASES THAT I'VE TOLD YOU ABOUT THAT -- AT LEAST IN SOME SETTINGS ARE RELATIVELY RARE. IN POINT OF FACT THIS INVOLVEMENT OF THE INTERLEUKIN ONE IN TERMS OF PATHOPHYSIOLOGY IS IMPORTANT AND A MORE COMMON DISEASES. ONE OF THE COMMON DISEASES THAT RIGHT NOW IS BEING STUDIED AT GREAT LENGTH IS ATHEROSCLEROSIS. IF YOU LOOK AT MOUSE MODELS OF ATHEROSCLEROSIS, FOR EXAMPLE, IF YOU LOOK AT LDL RECEPTOR INCOME OUT MICE THAT HAVE BEEN BRED ON TO A CRY COPYRIN KNOCK OUT BACKGROUND THEY DON'T GET ATHEROSCLEROSIS. THOSE THAT ARE BRED ON TO WILDTYPE DO. THIS IS ACTUALLY LED TO A STUDY THAT'S ONGOING RIGHT NOW BY NOVA ARTIS, WHICH IS A MONOCLONAL ANTIBODY COMPARING PLACEBO WITH THREE DIFFERENT DOSES OF THIS IL1 ANTIBODY. IN PATIENTS THAT HAVE HAD MYOCARDIAL INFARCTION NOT UNDER STANDARD THERAPY NORMALIZED THEIR REACTION. BASICALLY LOOKING TO SEE WHETHER OR NOT THEY CAN REDUCE FREQUENCY OF SECONDARY CARDIAC EVENT. JUST TO GIVE YOU SOME SENSE OF AT IS THE INVESTMENT IN IL1 INFLAMMATION IN COMMON DISEASES, JUST THE DRUG FOR EACH PATIENT FOR A YEAR'S TREATMENT FOR THIS IS SIMILAR -- SOMEWHERE AROUND $100,. THIS IS AROUND A BILLION DOLLAR STUDY LOOKING TO SEE WHETHER OR NOT INHIBITION OF IL1 HAS ROLE IN COMMON DISEASES. FINALLY, AS A SET UP FOR OUR NEXT PATIENT I DO WANT TO TELL YOU ABOUT SOME LINKAGE STUDIES JUST VERY BRIEFLY THAT WERE AGAIN PROMPTED BY A PATIENT THAT WAS COLLABORATION BETWEEN JOSH MILNER AND NIAID AND MIKE IN MY LAB THIS ALL CAME ABOUT BECAUSE OF A PATIENT THAT PRESENTED TO JOSH WITH HISTORY OF VERY DIFFUSE GRANULOMA LESIONS, CUTANEOUS AS A WELL AS -- BECAUSE OF THE FACT THAT THERE WAS THIS COLD-INDUCED COMPONENT WE GOT INVOLVED IN TRYING TO FIGURE OUT WHAT WAS GOING ON, TURNED OUT THAT THERE WAS NOT A MUTATION IN CRYOPYRIN, ULTIMATELY JOSH AND MIKE WERE ABLE TO IDENTIFY THREE FAMILIES WITH THIS KIND OF CONDITION, MAPPED THE GENE TO THE LONG ARM OF CHROMOSOME 16 FIGURED THAT THERE WERE MUTATIONS IN A SIGNALLING MOLECULE TLC GAMMA 2 THAT WERE ASSOCIATED WITH THE DISEASE. THIS PLC GAMMA 2 ACTUALLY MUTATION GET RID OF AN AUTO INHIBITORY DOMAIN BUT ACTUALLY LEAD TO DESENSITIZATION IN A WAY OF LEUKOCYTES FROM PATIENTS THAT HAVE THIS DISEASE. SO THAT IN THIS PARTICULAR CALCIUM ASSAY YOU CAN SEE THAT THE WILDTYPE RESPONSE IS HERE WHERE AS THE PATIENTS HAVE REDUCED RESPONSE. THEN FINALLY IF ONE LOOKS IN THE COLD, THIS WAS AFTER COLD-INDUCED ONE CAN SEE WITH A CONTROLLED TEMPERATURE STAGE, MICROSCOPE STAGE THAT IN FACT WHERE AS CONTROL INDIVIDUAL DOES NOT DEGRANULATE DOES NOT HAVE CALCIUM FLUX INTRACELLULARLY. THEY DO DEGRANULATE. IN ANY CASE TO MOVE ON TO THE SORT OF THE NEXT PATIENT I SHOULD JUST POINT OUT TO YOU THAT IN FACT SEQUENCING TECHNOLOGY HAS REALLY ADVANCED DRAMATICALLY. IN THE LAST SEVERAL YEARS, THIS SLIDE DEPICTS MOORE'S LAW WHICH IS A LAW THAT WAS PROPOSED ACTUALLY BY, I GUESS IT WAS THE GUY WHO WAS THE HEAD OF INTEL AT ONE TIME. THE IDEA IS THAT FOR COMPUTING THAT THE POWER OF CHIPS IMPROVES BY A FACTOR OF TWO ROUGHLY AFTER 18 MONTHS TO TWO YEARS. DEFISH SEE OF SEQUENCING ALSO WAS IMPROVING MORE OR LESS ALONG THE LINE OF MOORE'S LAW UP UNTIL SOMEWHERE AROUND 2007-2008 WHEN THERE WERE DRAMATIC ADVANCES IN SEQUENCING TECHNOLOGY THAT LED TO MUCH GREATER EFFICIENCY IN TERMS OF THE IMPROVEMENT OF SEQUENCING TECHNOLOGIES AT THAT TIME THESE ARE THE BEFORE. SO THAT ALLOWED US ESSENTIALLY TO LOOK AT CASES BY USING SEQUENCING STRATEGIES THAT WE WOULDN'T HAVE CONSIDERED LOOKING AT BEFORE. THERE WAS A PATIENT, ACTUALLY A FATHER AND DAUGHTER WHOM I HAVE FOLLOWED FROM NEW YORK FOR THE LAST EIGHT OR SO YEARS WHO WERE REFERRED TO US I GUESS AT LEAST INITIALLY WITH THE THOUGHT THAT MAYBE THEY MIGHT HAVE FMF. THAT WAS JUST SORT OF THE TEASE, I GUESS TO, GET US INTERESTED IN THE CASE. SO, ANYWAY, THEY ENDED UPCOMING, WE CONFIRMED THAT THEY DID NOT HAVE MUTATIONS IN THE FMF LOCUS WE REALLY LOOKED AT JUST ABOUT EVERYTHING THAT WE COULD THINK OF IN TERMS OF INFLAMMATORY GENES THAT MIGHT CAUSE THEIR ILLNESS TO NO AFFECT UNTIL THE SEQUENCING TECHNOLOGY. STEVEN, IF YOU WOULD, COULD YOU PLEASE COME UP TO THE CHAIR, WE WON'T ACTIVATE THE TRAP DOOR AT LEAST YET. AND PERHAPS WE CAN TALK A LITTLE BIT ABOUT YOUR AND YOUR DAUGHTER'S ILLNESS. CAN YOU TELL THE GROUP ABOUT KINDS OF THINGS THAT YOU EXPERIENCE MAYBE STARTING WITH YOUR SKIN? >> RIGHT AT BIRTH WE WERE BORN WITH BOTH OF US WITH RASHES. OVER THE YEARS ANYTHING MY MOM HAD PUT ON ME THAT HAD A SNAP OR BUTTON OR TIE OR SOMETHING WOULD FORM A BLOOD BLISTER AT THE TIME THEY THOUGHT I HAD EPIDERMLIZES. ANY KIND OF TRAUMA WOULD CAUSE BLISTERING OF SOME SORT BUT NOT ALWAYS. >> WERE THERE OTHER THINGS THAT THE TWO OF YOU NOTE THAT WERE MANIFESTATIONS OF THIS ILLNESS? >> CONSTANT RESPIRATORY INFECTIONS SINCE I WAS A BABY. LATER ON FOR ME MY EYES GOT INVOLVED WITH SOME, WHAT THEY CALL -- ERUPTIONS AND E OCEANS IN MY EYES. VICTORIA'S EYES GOT INVOLVED RIGHT AWAY. SHE SEEMED TO GET MORE OF THE PROBLEMS EARLIER IN HER LIFE THAN I DID. >> ANYTHING WITH THE GASTRO INTESTINAL TRACT? >> IN MY TEENS, I HAD MAJOR STOMACH PAINS AND I HAD MY APPENDIX REMOVED. IT WASN'T MY APPENDIX. IT TURNEDDED OUT TO BE SOME INFLAMMATION IN MY ILIUM WHICH SOUNDED VERY FAMILIAR. >> THAT WENT ON FOR YEARS, VICTORIA'S STOMACH PROBLEMS STARTED WHEN SHE WAS -- WHEN SHE WAS A BABY. >> TRYING TO READ MY WIFE'S LIPS. >> IN ANY CASE SINCE YOU'VE BEEN HERE SINCE WE'VE BEEN AT LEAST APPROACHING YOUR ILLNESS IN VARIETY OF WAYS THAT WE'LL TALK ABOUT IN A COUPLE OF MINUTES, HOW ARE THINGS GOING? >> AT THIS POINT I FEEL GREAT. A MONTH AGO I WAS FILLING OUT DISABILITY PAPERS. I HADN'T WORKED SINCE PAPER, I WAS USING OXYGEN 24/7. WE STARTED EXERCISING, WE STARTED -- I WENT BACK TO WORK TWO WEEKS AGO. I HAVE BEEN GOING SHOPPING WITH MY LIFE, I'M NOT DRAGGING THE OXYGEN AROUND AS MUCH I HAVE MOBILITY SCOOTER AT WORK WHICH I'M NOT USING MOST OF THE TIME. PEOPLE DIDN'T KNOW I WAS THIS TALL. BIG CHANGE. MY WHOLE OUT LOOK ON EVERYTHING IS A LOT DIFFERENT. >> I THINK WE'LL CALL THIS TO A CLOSE SO I CAN TELL THEM A LITTLE BIT ABOUT WHAT WE FOUND. ANYWAY, THANK YOU VERY MUCH. [APPLAUSE] >> IN ANY CASE, AS IT WOULD HAPPEN WE DID ACTUALLY EMBARK ON WHAT IS KNOWN AS HAUL SEQUENCING. WE SEQUENCED MOST OF THE CODING REGIONS, THE EXOME OF THE GENOME OF STEVEN AND HIS DAUGHTER AND HIS WIFE WHO ARE NOT AFFECTED. LOOKING FOR VARIANTS THAT WE WOULD SEE IN COMMON BETWEEN STEVEN AND HIS DAUGHTER, NOT PRESENT IN STEVEN'S WIFE, VICTORIA'S MOTHER ALSO GIVEN THE FACT THAT ACTUALLY STEVEN'S PARENTS WERE NOT AFFECTED EITHER. WE WERE LOOKING FOR SOMETHING THAT MIGHT TURN OUT TO BE DE NOVO IN STEVEN THAT WE COULD CONFIRM. IN ANY EVENT, ONE OF OUR OUTSTANDING POST DOCS IN THE LAB UNDERTOOK THIS PROJECT OF SEQUENCING AND WHEN SHE DID THIS AND SCREENED THE VARIOUS VARIANTS THAT WERE IDENTIFIED WITH REGARD TO WHETHER OR NOT THEY WOULD BE PREDICTED. WHETHER OR NOT THEY WOULD BE DOMINANTLY INHERITED, WHETHER OR NOT THEY WERE DE NOVO SHE CAME UP WITH ONLY ONE GENE, THIS WAS REALLY INCREDIBLE. ONLY ONE GENE THAT HAD A VARIANT THAT WAS ASSOCIATED WITH IT AND IT WAS PLC GAMMA 2 WHICH MIKE AND JOSH HAD JUST FIGURED OUT CAUSED THIS OTHER ILLNESS. IN FACT IT WAS -- IT WAS NOT AS MIKE AND JOSH HAD FOUND AN ACTUAL DELETION OF PART OF THE GENE BUT INSTEAD IT WAS A CHANGE, THE SUBSTITUTION OF TRYOSINE FOR SERIN AT POSITION 707 WHICH IS ACTUALLY IN THAT SAME DOUGH MAIM THAT IS DELETED IN PATIENTS. THIS IS HIGHLY CONSERVED IN EVOLUTION. IT'S IN THE SAME DOMAIN SHOWN HERE BY MOLECULAR MODELING AS DELETIONS THAT WERE SEEN. BUT IT'S NOT QUITE AS STRONG A MUTATION AS YOU WILL. YOU CAN SEE HERE WHEN WE LOOKED AT PERIPHERAL BLOOD LEUKOCYTES, BOTH FROM STEVEN AND HIS DAUGHTER THAT IN FACT THEY PRODUCE INCREASED AMOUNTS OF IP1 WHICH IS A SURROGATE FOR IP3 WHICH IS ONE OF THE PRODUCTS OF PLC GAMMA TWO. THEY HAVE INCREASED CALCIUM FLUXES RELATIVE TO CONTROL AND IF YOU LOOK AT CONTROLS WITH. THE PATIENTS, IN ANY CASE JUST THINKING ABOUT HOW PERHAPS APPROACH THE IN TERMS. WE DON'T RIGHT NOW HAVE PHARMACOLOGIC INTERVENTION THAT WOULD ADDRESS THE PLC GAMMA 2 SIGNALLING BUT WE DID THINK ABOUT WHETHER PERHAPS OUR OLD FRIEND IL1 MIGHT PLAY A ROLE. THESE ARE -- THIS IS RELATIVELY NEW DATA THAT OUR LAB HAS DEVELOPED. BASICALLY COMPARING CONTROLS WITH STEVEN WITH REGARD TO BOTH PRODUCTION OF PRO-IL 1 BETA STIMULATED BY LPS AND THEN MATURE IL1 BETA. YOU CAN SEE THAT IN THE CASE OF STEVEN THAT IN FACT HE PRODUCES IF YOU LOOK HERE -- GO UP UNDER IT SO I CAN SEE LINES UP WITH WHAT SO THAT YOU CAN SEE THAT IN STEVEN'S CASE HE'S PRODUCING IL1 BETA WHERE AS CONTROL DOES NOT PRODUCE IL1 BETA WHICH SUGGESTS THEN THE TREATMENT WITH AN IL1 BLOCKING AGENT WOULD HELP. THAT'S ACTUALLY WHAT WE'RE DOING AT THIS POINT IN THE HOPE TO TARGET HIS AND VICTORIA'S SYMPTOMS. SO IN ANY CASE, THIS SLIDE HERE JUST DEPICTS A PIE DIAGRAM OF THE PATIENTS THAT WE'VE DONE GENETIC TESTING ON IN OUR GROUP OVER THE LAST SEVERAL YEARS THAT HAVE VARIOUS UNDIAGNOSED INFLAMMATORY DISEASES. YOU CAN SEE THE TOTAL NUMBER OF INDIVIDUALS AROUND 1900. THERE IS REALLY A LOT YET TO BE DONE. I'M NOT SAYING THAT ALL OF THEM HAVE MENDELIAN DISEASES. NOT SAYING ALL OF THEM WE'LL FIND GENETIC EXPLANATION. CLEARLY THERE IS A LOT LEFT TO BE DONE. I SEE THAT I HAVE GONE A LITTLE BIT OVER MY TIME. STILL HAVE NOT GOTTEN TO ANOTHER DISEASE. MAYBE JUST SO THAT WE CAN AT LEAST TALK ABOUT THE SUMMARY AND MAYBE HAVE A LITTLE BIT OF TIME FOR QUESTIONS WE COULD FORGO THAT DISEASE THIS TIME. THIS WILL BE OF COURSE GOOD REASON FOR THEO OR SOMEONE TO INVITE ME BACK FOR ANOTHER LECTURE SOME TIME IN THE FUTURE. YOU WON'T HEAR ABOUT THIS DISEASE TODAY. BUT MAYBE JUST TO SUMMARIZE WHAT WE HAVE TALKED ABOUT MINUS B BEHCET'S DISEASE. HAVE HAD PROFOUND IMPACT ON DIAGNOSIS AND TREATMENT PROVIDED IMPORTANT NEW INSIGHTS IN TO THE REGULATION OF THE INNATE IMMUNITY. ADVANCES IN SEQUENCING TECHNOLOGY FOR DISORDERS THAT SEEMED INSCRUTABLE ONLY SHORT TIME AGO. THIS WAS THE BECET'S PART. AND SORT OF SOME BIG PICTURE CONCLUSIONS HERE, I THINK THAT WE'VE REALLY SEEN THAT ADVANCES IN TECHNOLOGY HAVE DRAMATICALLY ENHANCED OUR ABILITY TO UNDERSTAND THE GENETIC BASIS OF HOST OF HUMAN DISEASES THAT CLINICAL INVESTIGATION REALLY IS A TEAM SPORT, THAT THIS IS SOMETHING WHERE WE HAVE TO ENGAGE PEOPLE ON THE CLINIC SIDE OF THINGS AS WELL AS IN THE LABORATORY AND IT'S CONSTANT INTER-ACTION OF THE CLINIC AND THE LABORATORY THAT MAKES THESE KINDS OF THINGS POSSIBLE. THEN FINALLY TO QUOTE OUR PATIENT FROM THE VIDEO CLIP, LISTEN TO YOUR PATIENTS, LISTEN TO THEIR MOMS. OUR PATIENTS PROVIDE THE QUESTIONS AND PROVIDE THE MOST STRINGENT TEST OF OUR HYPOTHESESW THAT, I'LL JUST SHOW YOU THE SLIDE OF ALL OF THE PEOPLE THAT CONTRIBUTED TO THIS WORK I'M HIGHLIGHTING THE INDIVIDUALS JUST FOR SAKE OF TIME. I WON'T NAME THEM ALL. THEY'RE SHOWN HERE THEN NUMBER OF COLLABORATORS, MY FAMILY, MY WIFE WHO PUTS UP WITH THESE SHENANIGANS, OUR SONS BEN AND NATHAN AND OUR DOG HERSHEY WHO IS IN CONTROL OF IT ALL. THE CLINICAL CENTER OF THE NIH WHERE OF COURSE ALL THIS HAPPENS AND WITHOUT WHICH WE WOULDN'T BE ABLE TO DO ANY OF THIS. ANYWAY, WITH THAT, I'LL CALL IT TO A CLOSE. THANKS A LOT. [APPLAUSE]