TODAY WE HAVE ANOTHER DAY OF EXCITING TALKS TO LOOK FORWARD TO AND THANK YOU ALL FOR COMING BACK. THANK YOU ALSO FOR YOUR SUPPORT. IT'S IMPORTANT TO REMIND YOU TO FILL OUT THE ASSESSMENT FORMS. IT'S IMPORTANT AS TO HOW TO PLAN THE NEXT YEAR'S PROGRAM, WHAT YOU LIKE AND WHAT YOU THINK ARE TOPICAL AND ALSO TO GIVE US INCENTIVE TO CONTINUE THIS EVENT EVENT. AND I HAVE GREAT PLEASURE IN INTRODUCING DR. GARY GIBBONS, DIRECTOR OF THE NHLBI, WHO HAS ALWAYS BEEN A VERY STRONG SUPPORTER IN ADVOCATING SICKLE CELL DISEASE SINCE I HAVE BEEN HERE AND BEFORE. DR. GIBBONS SPEARHEADED THE CURE SICKLE CELL INITIATION. SO IT'S REALLY VERY GENEROUS OF HIM TO MAKE SOME TIME TO COME AND OPEN THE SECOND DAY OF OUR CONFERENCE. THANK YOU VERY MUCH, GARY. [ APPLAUSE ] >> GARY GIBBONS: GOOD MORNING AND THANK YOU FOR THAT INTRODUCTION. IT IS A PLEASURE TO BE PART OF THE WELCOME TO THIS CONFERENCE. WE CERTAINLY ARE EXCITED BY THE PRESENCE AND THE AGENDA THAT YOU HAVE MAPPED OUT HERE THAT IS TRYING TO ADDRESS HOW WE CAN BETTER CARE FOR INDIVIDUALS LIVING WITH SICKLE CELL DISEASE. I'M A CARDIOLOGIST BY TRAINING, SO I'M NOT A HEMATOLOGIST OR EXPERT IN SICKLE CELL. BUT IT'S HARD TO BE TRAINED IN AN INNER CITY HOSPITAL SETTING WITHOUT ENGAGING THESE PATIENTS. AND THAT SPEAKS VOLUMES IN AND OF ITSELF, BECAUSE SO MANY OF US WHO ARE NON-HEMATOLOGISTS ARE INTRODUCED TO THE CARE OF THESE PATIENTS IN AN EMERGENCY ROOM AS RESIDENTS. WHEN THEY ARE COMING IN WITH CRISIS. WHEN I THINK ABOUT THAT, THAT'S A HORRIBLE WAY TO INTRODUCE TO A CHRONIC DISEASE. AND THAT SPEAKS VOLUMES FOR SOME OF THE CHALLENGES WE ARE FACING WHEN CARING FOR THESE PATIENTS. I WAS ALSO STRUCK BY, AS AGAIN, ADULT CARDIOLOGIST, TO ENCOUNTER CHILDREN WHO ALREADY HAD A STROKE BY THE AGE OF 5. AND SO, AS ALLUDED TO, I'VE ALWAYS FELT THAT IT'S TOTALLY UNACCEPTABLE FOR A CHILD OF 5 TO HAVE A STROKE. AS SOMEONE WHO CARED FOR A 75-YEAR-OLD WITH A STROKE, THIS SEEMS LIKE SOMETHING WE SHOULD BE ABLE TO PREVENT. AND SO WHEN I STARTED IN MY FIRST YEAR IN THIS POSITION, ACTUALLY THE FIRST PLENARY SESSION INVITATION I HAD AT THE AMERICAN SOCIETY OF HEMATOLOGY, I WANTED TO CHALLENGE OUR INSTITUTE AND OUR COMMUNITY TO CONSIDER A STROKE-FREE GENERATION OF CHILDREN BORN WITH SICKLE CELL DISEASE. AND I THOUGHT THAT WAS KIND OF EDGY AT THE TIME, FIVE YEARS AGO, BUT THEN I WAS CHIDED, IN PART BY DR. TISDALE, THAT THAT WASN'T BOLD ENOUGH; AND THAT OUR VISION OUGHT TO BE THAT CHILDREN BORN WITH SICKLE CELL DISEASE SHOULD HAVE A NORMAL LIFESPAN, A NORMAL PAIN-FREE LIFESPAN. THAT SHOULD BE OUR GOAL. IN THAT REGARD, OUR INSTITUTE IS COMMITTED TO A FULL-COURT PRESS ON SICKLE CELL DISEASE. WE ARE COMMITTED TO THE DEVELOPMENT OF NEW THERAPEUTICS, WHETHER SMALL MOLECULES OR CELL-BASED, GENETIC THERAPIES, ANYTHING WE CAN DO TO IMPROVE THE LIVES OF PATIENTS LIVING WITH SICKLE CELL DISEASE. WE ARE HOPEFUL AS A RESEARCH ORGANIZATION TO WORK IN PARTNERSHIP WITH PATIENTS AND PROVIDERS, THE WHOLE COMMUNITY OF US AS A COLLECTIVE, TO MAKE THAT VISION WORK AND THAT MEANS WE HAVE A PORTFOLIO THAT SPANS THE SPECTRUM OF BASIC SCIENCE, TRANSLATIONAL RESEARCH, FIRST-IN-HUMAN RESEARCH, CLINICAL TRIALS THAT ARE CONTINUING TO ADVANCE BETTER TREATMENTS, WORK DONE IN WHAT WE CALL, IMPLEMENTATION SCIENCE, ENSURING THAT WHAT WE KNOW ACTUALLY PENETRATES THE HEALTH CARE SYSTEM TO PROVIDERS IN REAL-WORLD CONTEXT TO AFFECT PATIENTS. WE WANT TO ENSURE THAT WE ARE CREATING THE EVIDENCE BASE WHERE CELL PATIENTS CAN THINK ABOUT WAKING UP IN THE MORNING AND NOT BE SO ANXIOUS ABOUT WHETHER THIS IS GOING TO BE A PAIN-FILLED DAY OR NOT. THAT'S OUR TASK COLLECTIVELY AND WE LOOK FORWARD TO THE DIALOGUE, THE INFORMATION, THE INSIGHTS, THE GUIDANCE ON UNANSWERED QUESTIONS THAT WILL COME FROM THIS CONFERENCE TO ENSURE THAT WE ARE MOVING TOWARDS THAT VISION AS A COLLECTIVE COMMUNITY WITH THE PATIENTS AT THE CENTER OF THAT COMMITMENT. WITH THAT, AGAIN, I WELCOME YOU. THANK YOU FOR YOUR ACTIVE PARTICIPATION. WE LOOK FORWARD TO YOUR INPUT AND DELIBERATIONS AND PARTNERING WITH US AS WE TRY TO MAKE THAT VISION A REALITY FOR THIS COMMUNITY. THANK YOU VERY MUCH. >> GOOD MORNING. I'D LIKE TO START OUR FOURTH SESSION OF THE SICKLE CELL FOCUS CONFERENCE ON UNANSWERS QUESTIONS AND NEW FRONTIERS IN CURATIVE THERAPIES. OUR FIRST SPEAKER IS DR. MARK WALTERS, DIRECTOR OF BONE AND MARROW TRANSPLANT AT CHILDREN'S HOSPITAL OF OAKLAND, AND HE WILL BE SPEAKING TODAY ABOUT ALLOGENEIC HEMATOPOIETIC SICKLE CELL TRANSPLANT, MATCH RELATED, MATCH UNRELATED, CORD BLOOD. DR. WALTERS. >> MARK WALTERS: THANK YOU. WE ARE STARTING 10 MINUTES LATE. I'D JUST LIKE TO SAY THAT. THANKS, JOHN FOR INVITING ME TO THIS 12th ANNUAL OR BIANNUAL SICKLE CELL AND FOCUS SYMPOSIUM. IT'S A PLEASURE TO PARTICIPATE. AND I RENAMED THE TITLE A LITTLE BIT JUST TO DEMONSTRATE HOW DAUNTING THIS TASK IS. LET'S BEGIN. AND HERE ARE MY DISCLOSURES. NONE OF THESE DISCLOSURES, I THINK, IMPACT IN ANY WAY THE TALK I'M GIVING TODAY. SO, I'M FROM UCSF CHILDREN'S HOSPITAL OAKLAND, AND THIS REPRESENTS OUR TRANSPLANT EXPERIENCE OVER THE PAST 18 YEARS OR SO. TREATED 26 PATIENTS. MOST WERE CHILDREN BUT THE SMATTERING OF UNRELATED HAPLOID IDENTICAL DONOR, AND MISMATCH DONOR, ET CETERA. AND THESE ARE RESULTS, ALL 26 PATIENTS SURVIVING AFTER THE PROCEDURE EXCEPT FOR ONE CASE SURVIVING FREE OF SICKLE CELL DISEASE. SO I THINK THAT IS A PRETTY GOOD RESULT AND IT'S A SINGLE-CENTER EXPERIENCE. WHY NOT SEND ALL YOUR PATIENTS TO ME IN OAKLAND TO GET CURED OF SICKLE CELL DISEASE. WELL, THERE ARE LIMITATIONS WITH SINGLE-CENTER TRIALS, OR EXPERIENCES, BUT THE REASON WHY YOU SHOULDN'T SEND THEM TO OAKLAND IS BECAUSE IT'S NOT NECESSARY. SO THESE ARE SIX CENTERS REPORTED RESULTS IN THE LAST DECADE OR SO BETWEEN 10-50 PATIENTS TREATED WITH SICKLE CELL DISEASE, ALL OF WHOM RECEIVED A REGIMEN. VERY FEW DEATHS OCCURRED AFTER THESE IDENTICAL SIBLING BONE MARROW TRANSPLANTS AND ACUTE AND CHRONIC GVHD, MANAGEABLE. PRETTY GOOD FOLLOW-UP. AND SO WHEN I ADDED UP ALL THESE CASES, NEARLY 200 CASES IN SEVEN U.S. AND EUROPEAN CENTERS, 96% SURVIVING 92% SURVIVING FREE OF THE SICKLE CELL DISEASE AND REALLY ONLY A SMALL FRACTION STILL RECEIVING IMMUNOSUPPRESSIVE THERAPY TO TREAT CHRONIC GRAPH VERSUS HOST DISEASE. AND THEN THIS EXPERIENCE WAS FURTHER EXPANDED LAST SUMMER WHEN THIS EXPERIENCE WAS REPORTED OF 1000 PATIENTS WORLDWIDE TREATED BY IDENTICAL SIBLING STEM CELL TRANSPLANTATION, EITHER MOBIDES PERIPHERAL BLOOD STEM CELLS, MARROW OR CORD BLOOD AS THE STEM CELL SOURCE. AGAIN, CORD BLOOD, 100% SURVIVAL AFTER THE TRANSPLANT DECLINING TO ABOUT 75% IF MOBILIZED PERIPHERAL BLOOD STEM CELLS WERE UTILIZED. THE UPPER GRAPH ALSO SHOWS THE AFFECT OF AGE ON DEVELOPING CHRONIC GVHD AND THIS IS IMPORTANT BECAUSE GRAPH VERSUS HOST DISEASE IS THE LEADING CAUSE OF DEATH AFTER THE BONE MARROW TRANSPLANTATION AFTER SICKLE CELL DISEASE. SO A COUPLE OF LESSONS FROM THIS. ONE, BETTER TO BE YOUNGER RATHER THAN OLDER BEFORE YOU GET THE TRANSPLANT FOR THE REASONS OF CHRONIC GVHD AND ALSO SUGGESTING THERE MAY BE OPTIMAL STEM CELL SOURCE SUGGESTED HERE THAT MARROW AND CORD BLOOD MIGHT BE BETTER THAN MOBILIZED PERIPHERAL BLOOD STEM CELLS USED IN THIS WAY. SO, AND WE ARE AT THE NIH SO I HAVE TO POINT OUT THAT THERE IS AN IMPORTANT ALTERNATIVE WAY TO DO A TRANSPLANT THAT DOESN'T RELY ON MYELO ABLATIVE SULF IN LIKE THESE OTHER CASES, WHICH IS A NONMYELOA LITTLE BITTIVE IMMUNOTHERAPY DIRECTED AT DEPLETING T-CELLS BEFORE AND AFTER THE TRANSPLANT WITH A SINGLE TOTAL BODY IRRADIATION. YOU CAN TREAT MUCH OLDER PATIENTS WHO ARE MUCH MORE ILL THAN THE HEALTHY CHILDREN WE SEE IN OAKLAND. SO 48 PATIENTS BY MY COUNT LAST TREATED WITH THE RANGE IN AGE SHOWN. 94% SURVIVAL, TWO PATIENTS DIED AND 87% EVENT-FREE SURVIVAL WITH 10% OF PATIENTS REJECTING THE GRAFT. AND THE AIM HERE IN THE TOP PANEL GRAPH IS TO INDUCE STABLE MIXED CHIMERISM. SO A MIXTURE OF DONOR AND HOST CELLS AFTER THIS PROCEDURE WITH SELECTIVE ENRICHMENT OF THE DONOR ARITHROID CELLS IN THE BLOODSTREAM TO ILLICIT THE AFFECT. THIS IS SHOWN NICELY IN THE MIDDLE GRAPH WHICH SHOWS THE TOTAL HEMOGLOBIN INCREASING FROM EIGHT TO MORE THAN 12 AFTER THE TRANSPLANT BY ONE YEAR AFTER TRANSPLANT. AND THEN ELIMINATION OF HOMOLYSIS EXPRESSED AS CORD AND NORMALIZED COUNT TOTAL BILL I RUBIN AND LDH IN THE BLOOD. AND THEN AN IMPORTANT OBSERVATION IN THIS STUDY WAS THAT THERE WERE NO SIGNIFICANT GRAFT-VERSUS-HOST DISEASE PRESUMABLY AS A CONSEQUENCE OF THIS CONDITIONING REGIMEN. SO THIS HAS BEEN PIONEERED AT THE NIH HERE BY JOHN TISDALE AND MATT SHAY AND COURTNEY AND THE TEAM. AND ALSO DUPLICATED IN SMALL SERIES AT UNIVERSITY OF ILLINOIS AND EVEN IN CHILDREN NOW IN ALBERTA. SO ANOTHER TRANSPLANTATION WITH SIBLING DONOR. THE CHALLENGE IS THAT WITH THAT BACKGROUND, THE EUROPEAN BONE MARROW TRANSPLANT SOCIETIES RECOMMEND THAT YOUNG PATIENTS WITH SYMPTOMATIC SICKLE CELL DISEASE WHO HAVE AN HLA MATCH SIBLING DONOR SHOULD BE TRANSPLANTED AS EARLY AS POSSIBLE, PREFERABLY AT PRESCHOOL AGE AND UNMANIPULATED BONE MARROW OR CORD BLOOD, WHENEVER AVAILABLE FROM SIBLINGS, ARE RECOMMENDED AS STEM CELL SOURCE. SO FOLLOWS FROM THIS EXPERIENCE THAT I JUST SHARED. IN THE UNITED STATES, THERE IS A DIFFERENT RECOMMENDATION. THIS IS FROM THE EVIDENCE-BASED MANAGEMENT OF SICKLE CELL DISEASE MANUAL THAT WAS PUBLISHED IN 2014. AND THE RECOMMENDATIONS FROM THIS PANEL ARE THAT ADDITIONAL RESEARCH IS STILL NEEDED THAT ADDRESSES THE POTENTIAL RISK OF THIS THERAPY. FOR EXAMPLE, THE FAILURE OF ENGRAFTMENT AND GRAFT-VERSUS-HOST DISEASE BEFORE TRANSPLANTATION CAN BE A WIDELY-USED THERAPY. REALLY QUITE AT ODDS WITH EUROPEAN RECOMMENDATIONS. AND I THINK THE PUBLISHED EXPERIENCE TO DATE. SO, WHAT REALLY ARE THE ISSUES OF STEM CELL TRANSPLANTATION USING THESE CONVENTIONAL MEANS IN THE FUTURE? SO, WHILE THERE ARE IMPORTANT BARRIERS, ONLY 18% OF PATIENTS WILL HAVE A SIBLING DONOR THAT IS IDENTICAL AND IF WE LOOK ON THE DONOR REGISTRY, WE'LL PICK UP ANOTHER 19%. SO EVEN IF WE WANTED TO TREAT EVERYONE WE COULD BY A WELL-MATCHED TRANSPLANTATION FOR SICKLE CELL DISEASE, WE COULD ONLY DO SO ABOUT A THIRD OF THE TIME. AND I THINK THERE IS THIS WELL-SUPPORTED CONCERN OF GRAFT-VERSUS-HOST DISEASE AND THE RISKS OF DYING OF THE TRANSPLANT ITSELF AND LONG-TERM TOXICITY. MANY ARE INCOMPLETELY CHARACTERIZED. AND THEN THIS PROBLEM OF GRAFT REJECTION RECURRENT SICKLE CELL DISEASE HAS NOT BEEN ELIMINATED ESPECIALLY IN MISMATCHED DONOR TRANSPLANTATION. AND THIS IS ILLUSTRATED NICELY IN ANOTHER STUDY FROM THE NIH. THIS IS COURTNEY'S WORK LOOKING AT HLA HAPLO IDENTICAL TRANSPLANTATION USING THAT SAME REGIMEN THAT LOOKED SO GOOD WHEN AN HLA SI SIBLING DONOR WAS UTILIZED. SO AIMED AT DEPLETING T-CELLS. AND USING THAT APPROACH ALONE, THEY HAD NO EVENT-FREE SURVIVORS AND THEN ADDING SEQUENTIALLY HIGH-DOSE PSYCHE LOW PHOS MIDE AFTER THE INFUSION TO PROMOTE TOLERANCE AND GET THE DONOR CELLS, ULTIMATELY ACHIEVED EVENT FREE SURVIVAL RATE OF 50%. SO NOT THE 87 OR 90% WE SEEN IN THE OTHER TRIALS. SO WHEN WE DO A MISMATCHED DONOR TRANSPLANTATION AS AN ATTEMPT TO EXPAND THE AVAILABILITY OF BONE MARROW TRANSPLANTATION, WE HAVE TO DEAL WITH THIS PROBLEM OF REJECTION. THE OTHER PROBLEM, AND THEN THIS IS ILLUSTRATED TOO IN A PAPER THAT WAS PUBLISHED IN THE LAST YEAR OR SO. THESE ARE DATA FROM 95 PATIENTS TREATED IN THE LAST 15 YEARS OR SO FOR WHOM WE HAD MIXED CHIMERISM DATA. SO THIS COMBINATION OF DONOR AND RECIPIENT HEME PIECEIS AFTER THE BONE MARROW TRANSPLANT. THIS HAPPENS AFTER A MILE ABLATIVE TRANSPLANT BUT MOST COMMON AFTER THE REGIMEN LIKE THE ONE USED AT THE NIH AND ALL THE REJECTIONS OCCURRED IN PATIENTS RECEIVED THAT REDUCED INTENSITY CONDITIONING REGIMEN. NONE OF THE BU SULF IN-BASED PATIENTS HAD GRAFT REJECTION. AND IT ALSO TENDED TO HAPPEN WHEN THERE WAS DONOR MISMATCHING. SO AGAIN, HIGHLIGHTS THIS PROBLEM OF WHAT DO WE DO WHILE WE ARE TRYING TO MAKE TRANSPLANTS SAFER BUT USING A MISMATCHED OR UNRELATED DONOR? AND THE OTHER ISSUE FOR ME, AND THIS WAS REALLY ILLUMINATING. THESE ARE CIBMTR DATA SO THE CENTER FOR INTERNATIONAL BONE MARROW TRANSPLANT RESEARCH, RETROSPECTIVE DATA. IT'S VERY GOOD AT LOOKING AND TRANSAND TRANSPLANTATION. SO IN THIS REGISTRY, NEARLY 1000 PATIENTS TREATED IN THE LAST DECADE. AND THE 1-2 YEAR SURVIVAL RATES ARE GOOD AS WE EXPECTED, 95 PLUS PERCENT. BUT WHAT WAS SURPRISING WAS THAT THERE IS THIS ANNUAL DECKRAMENT IN SURVIVAL AT FIVE YEARS AT 86%. THAT WAS SURPRISING. BECAUSE WE THINK TRANSPLANT AS HAVING A FIXED MORTALITY IN THE FIRST YEARS AFTER TRANSPLANT AFTER WHICH THOSE CURVES SEEM TO PLATEAU. SO THERE ARE DEATHS STILL OCCUR EVEN THROUGH FIVE YEARS AFTER THE TRANSPLANT. THAT HAS TO BE ACCOUNTED FOR AND WE NEED TO DO A BETTER JOB OF UNDERSTANDING WHY THOSE PATIENTS ARE DYING. AND THEN THIS ILLUSTRATES -- IT'S A BUSY SLIDE -- BUT FROM THE SAME DATASET, THE CHALLENGE OF USING HLA-MISMATCHED OR MATCHED UNRELATED DONORS. SO THE PROBLES HAVE TO DO WITH GRAFT FAILURE, THAT REACHES 25-40%. AGAIN NOT NECESSARILY PLATEAUING IN THE FIRST YEARS AFTER TRANSPLANT SO THAT IS A CHALLENGE THAT NEEDS TO BE OVERCOME AND THIS PROBLEM OF GRAFT-VERSUS-HOST DISEASE, CHRONIC GVHD SIGNIFICANTLY DURING ABOUT A THIRD OF THE PATIENTS THAT EXTENDING THROUGH THREE YEARS POST TRANSPLANT AFTER UNRELATED DONOR TRANSPLANTS. THOSE ARE ARE THE TWO ISSUES THAT NEED TO BE TACKLED SIGNIFICANT ISSUES THAT NEED TO BE TACKLED GOING FORTH IF WE ARE GOING TO EXPAND THIS THERAPY TO MORE INDIVIDUALS WITH SEVERE SICKLE CELL DISEASE. AND THIS IS A SLIDE THAT WE PRESENTED JUST LAST WEEK IN A JOINT AMERICAN HEMATOLOGY FDA MEETING TO LOOK AT LONG-TERM FOLLOW-UP STUDIES THAT WE MIGHT CONSIDER DOING. AND NOTICE THAT WE HAVE EXTENDED HERE THE TIMELINE OUT TO 15 YEARS. WE ARE LOOKING AT VITAL ORGAN FUNCTION IN THE LONG TERM AS WELL AS HEALTH-RELATED QUALITY OF LIFE TRANSFUSION EXPOSURES AND ENDOCRINOPATHYS AS A CONSEQUENCE OF THE THERAPY. SO, WITH THAT, I'M GOING TO TRANSITION IN THE LAST PORTION OF THE TALK TO WHAT I THINK IS THE GOLD STANDARD, WHICH IS TO CONDUCT MULTI-CENTER TRIALS PROSPECTIVELY, LOOKING AT OTHER NOVEL THERAPIES. I WAS GOING TO START WITH THIS STUDY THIS WAS UNRELATED BONE MARROW TRANSPLANT TRIAL IN CHILDREN WITH SEVERE DISEASE. THE 061 MEANS IT STARTED IN 2006. THIS WAS A 10-YEAR STUDY BEFORE RESULTS WERE PUBLISHED. SO SICKLE CELL DISEASE MULTI-CENTER BONE MARROW TRANSPLANT TRIALS TAKE TIME AND IT'S VERY CHALLENGING TO COMPLETE THEM IN 2-3 YEARS TIME PARTICULARLY IF WE ARE GOING TO ENCOMPASS SOME OF THE LONG TERM EFFECTS OF THE THERAPY THAT WE'D LIKE TO CAPTURE AND ILLUMINATE. SO THIS WAS A PHASE II STUDY IN CHILDREN 3-20 YEARS OF AGE, AND THE GOAL WAS TO ESTABLISH A ONE-YEAR DISEASE-FREE SURVIVAL OF 75%, IN COMBINATION OF CHEMOTHERAPY DRUGS, INCLUDING THE ANTISERUM THERAPY TO DEPLETE T-CELLS MAINLY BEFORE THE TRANSPLANT IN THIS PARTICULAR STUDY. SO THIS WORKS REALLY WELL IN THE SETTING OF SIBLING DONORS. THESE ARE RESULTS FROM WASH U A FEW YEARS AGO. OVERALL EVENT-FREE SURVIVAL OF 90-93%, QUITE IMPRESSIVE WHEN IDENTICAL SIBLING DONOR IS USED. BUT WHEN THE STUDY TEST THE UNRELATED UMBILICAL CORD TRANSPLANTATION, THE RESULTS WERE NOT NEARLY AS GOOD EVEN THOUGH THE CELL DOSES LOOKED GOOD AND APPEARED TO BE SUITABLE MATCHING BETWEEN THE DONOR RECIPIENT PAIRS, 5-8 PATIENTS HAD GRAFT REJECTIONS, TWO OF 8 HAD SEVERE GVHD THAT WAS FATAL AND 25% OF THE PATIENTS SURVIVED DISEASE-FREE. FOR THAT REASON, THIS PARTICULAR ARM IN THE STUDY WAS CLOSED EARLY AND THIS CONTINUES TO BE A CHALLENGE. EACH THOUGH UMBILICAL CORD BLOOD WOULD BE A NATURAL STEM CELL SOURCE TO UTILIZE FROM UNRELATED DONOR BECAUSE OF THE NAIVETY OF IMMUNE SYSTEM WHICH SHOULD MODULATE RISK, IT'S STILL A PROBLEM, PARTICULARLY IN SICKLE CELL DISEASE. SO THE PRIMARY OBJECTIVE WAS ACHIEVED IN THE STUDY. EVENT FREE SURVIVAL OF ONE YEAR AT 95%, BUT BECAUSE OF ONGOING TOXICITIES OF THE TRANSPLANT, EVENT-FREE SURVIVAL PLATEAUED AT 67-68% AND THE REASON WHY WAS CHRONIC GVHD. THIS SHOWS ACCUMULATIVE INCIDENTS, ACUTE, SEVERE ACUTE, 17% AND THEN EXTENSIVE CHRONIC GVHD OCCURRING IN ALMOST 40% OF THE PATIENTS. SO UNFORTUNATELY, THIS APPROACH PROBABLY IS NOT GOING TO BE DOABLE, PARTICULARLY IF A MISMATCHED OR PARTIALLY MATCHED UNRELATED DONOR IS UTILIZED. SO, IF WE CAN'T USE AN UNRELATED DONOR AND UNDERSTANDING OF COURSE THAT ONLY 19% OF PATIENTS WILL HAVE SUCH A DONOR, AT LEAST USING THAT REGIMEN, WHAT ABOUT HAPLO IDENTICAL BONE MARROW TRANSPLANTATION? THIS IS THE TYPE OF TRANSPLANT WHERE ONE CAN USE 50% MATCHED AND STILL GET A SUCCESSFUL GRAFT. SO THIS IS AN ONGOING STUDY, BONE MARROW TRANSPLANT CLINICAL TRIALS NETWORK, STARTED IN 2015, JUST OPENED FOR LESS THAN A YEAR NOW. AND LED BY THE COLLEAGUES SHOWN HERE, PIONEERED BY THE TEAM AT JOHNS HOPKINS UNIVERSITY. BECAUSE THIS IS A NON-TRANSPLANT AUDIENCE, I THOUGHT I WOULD GO THROUGH THE RATIONAL FOR HOW THIS WORKS. IT BEGINS WITH A PROFESSIONAL ANTIGEN PRESENTING CELL GROATING A T-CELL AND PRESENTING AN ANTIGEN WHICH THROUGH ALL THE INTERACTIONS HIGHLIGHTED WITH THE PURPLE LINES, LIST TWO IMPORTANT RESPONSES, SECRETION OF INTERLEUKIN 2 AND THEN A SIGNAL FOR T-CELL PROLIFERATION. SO BY THE THIRD DAY AFTER BONE MARROW TRANSPLANT USING A 50% MISMATCHED DONOR, THERE SHOULD BE LOTS OF DONOR T-CELLS ACTIVATED TO CAUSE GRAFT-VERSUS-HOST DISEASE. AND THE OTHER SIDE OF THE EQUATION, LOTS OF PERSISTING HOST T-CELLS ACTIVATED AND PROLIFERATING TO REJECT THAT. SO THE TEAM AT HOPKINS DISCOVERED THAT GIVING HIGH-DOSE CYCLOPHOSPHAMIDE TARGETS THOSE CELLS ACTIVATED AND DESTROYS THEM. AND THERE IS A WHOLE ANOTHER GROUP OF T-REG TORY CELLS THAT ARE NECESSARY TO ESTABLISH TOLERANCE THAT IS BIDIRECTIONAL AND ALSO THE HEMATOPOIETIC STEM CELL ITSELF THAT EITHER IS QUIESCENT OR BY EXPRESSION OF DEHYDROGENASE IN THE MILL YOU OR THE STEM CELLS RESIDE ARE PROTECTED FROM THE ADVERSE AFFECT OF CYCLOPHOSPHAMIDE EXPOSURE ON DAY THREE. SO THEY EMERGE LARGELY UNSCATHE FRIDAY THIS APPROACH. SO WE CALL THIS IN-VIVO T-CELL DEPLETION AND IT IS NOT PARTICULARLY SELECTIVE BUT IT'S QUITE EFFECTIVE. SO THIS IS THE REGIMEN THAT IS BEING TESTED IN THE TRIAL. IT'S A REDUCED INTENSITY COMBINATION OF CHEMOTHERAPY AND IN THE ITALICS IS A DRUG THAT WAS ADDED TO BETTER ENSURE ENGRAFTMENT OF THE DONOR CELLS BY CREATING MORE SPACE IN THE MARROW FOR ENGRAFTMENT. IT RELIES ON A DONOR BONE MARROW HARVEST AND THEN HIGH-DOSE CYCLOPHOSPHAMIDE ADMINISTERED ON THE THIRD AND FOURTH DAYS AFTER THE STEM CELL INFUSION AND THEN THIS COMBINATION OF MEDICINES CALLED MMF AND -- TO PREVENT GVHD AND ALSO TO PROMOTE ENGRAFTMENT OF THE DONOR CELLS. SO TWO STRATA IN THIS STUDY, ONE OF CHILDREN WHO HAD A CEREBRAL INFARCTION LESS THAN 6 YEARS OF AGE AND THEN 16-45 YEARS OF AGE WHO HAVE SEVERE DISEASE. THESE TWO STRATA WILL BE ANALYZED SEPARATELY AND THE GOAL IS TO ENROLL 40 ON EACH ARM. SO THERE IS SOME PRELIMINARY EXPERIENCE WITH THIS REVISED REGIMEN, THE ADDITION OF -- THESE ARE SMALL BUT IMPRESSIVE EXPERIENCES AT VANDERBILT AND ST. MARY'S IN LONDON SHOWING VERY GOOD ENGRAFTMENT RATES AND SURVIVAL RATES USING THIS REGIMEN. SO WE WERE ENCOURAGED TO TEST IT IN THIS MULTI-CENTER SETTING. AND THESE ARE DATA FROM JOHNS HOPKINS, IT'S A BUSY TABLE AND INCLUDES 17 PATIENTS WITH SICKLE CELL DISEASE BUT IN LIEU OF THIGH PEPPA THEY USED A HIGHER DOSE OF TOTAL BODY RADIATION, 400 CENTER GRADE AND I HAVE SEEN SIMILAR RESULTS, VERY GOOD ENGRAFTMENT, ALL BUT ONE ENGRAFTED WITH LOW RATES OF GVHD. SO WE THINK WE ARE ON TO SOMETHING WITH THIS MODIFICATION. AND HERE WE ARE IN THE THIRD QUARTER OF THIS YEAR AND THIS STUDY IS ACTUALLY EXCEEDING THE ACCRUAL TARGET. SO HOPEFULLY INFORMATION WILL BE FORTHCOMING IN THE NEXT SEVERAL YEARS. THE LAST STUDY I WANTED TO PRESENT ANOTHER BONE MARROW TRANSPLANT CLINICAL TRIALS NETWORK, MULTI-CENTER PROSPECTIVE TRIAL, THIS IS CALLED 1503 AND I THINK THIS IS THE MOST IMPORTANT EVEN THOUGH IT'S THE MOST DIFFICULT TO DO ARE ACTUALLY PAIRING, BASED ON- BIOLOGICAL RANDOMIZATION, BONE MARROW TRANSPLANTATION USING THIS STANDARD MILE ABLATIVE REGIMEN COMPARED TO BEST SUPPORTIVE CARE. IF A PATIENT DOESN'T HAVE A DONOR. SO THOSE WHO HAVE A WELL-MATCHED DONOR GET ASSIGNED TO A TRANSPLANT AND THOSE WHO LACK A DONOR ARE FOLLOWED FOR BASICALLY THE NATURAL HISTORY SEVERE SICKLE CELL DISEASE IN THE CURRENT ERA. SO HERE ARE THE PILOT DATA THAT WE ESTABLISHED TREATED 22 PATIENTS WITH THE REGIMEN. EVENT-FREE SURVIVAL SETTLING OUT AT 86%. AND BECAUSE THESE ARE IN ADULTS WITH SEVERE SICKLE CELL DISEASE OUR COLLEAGUES IN INTERIM MEDICINE TWO TAKE CARE OF THESE PATIENTS TOLD US THAT IS A PERFECTLY-ACCEPTABLE OUTCOME IN THIS COHORT OF PATIENTS. SO WITH THAT, WE MOVED AHEAD WITH A COMPARATIVE TRIAL. SO IT'S TO COOM COMPARE THE SURVIVAL IN YOUNG ADULTS WITH SEVERE SICKLE CELL DISEASE WHO RECEIVE TRANSPLANT COMPARED TO STANDARD OF CARE BUT ALSO INTENT TO TREAT ANALYSIS. SO, ACCOUNT FOR INDIVIDUALS WHO HAVE A DONOR AND DON'T GO TO TRANSPLANT FOR ONE REASON OR ANOTHER AND THOSE WHO LACK A WELL-MATCHED DONOR BUT MAYBE DRIBBLE OFF TO GET ALTERNATE DONOR TRANSPLANT OR GENE THERAPY. SO IT'S A REAL-WORLD ANALYSIS. THE OTHER THING THAT IS IMPORTANT ABOUT THIS IS WE KNOW IN THE SHORT-TERM THERE IS A HIGH RISK OF DYING OF A TRANSPLANT TWO YEARS THAN THERE IS OF DYING OF SICKLE CELL DISEASE, 19ADULTS WITH SEVERE DISEASE. SO THE IDEA IS THAT WE CAN EXTEND THIS COMPARISON THROUGH 10 YEARS AND MAYBE EVEN LONGER AT WHICH POINT AT SOME POINT THERE WILL BE A CROSSOVER, WE THINK, IN SURVIVAL WITH TRANSPLANT BEING SEVERE. SO HERE ARE THE ELIGIBILITY CRITERIA. THEY SHOULD LOOK FAMILIAR. 15-40 YEARS OF AGE WITH SEVERE SICKLE CELL DISEASE AS DEFINED HERE EITHER SURROGATES FOR AT RISK FOR EARLY OR SUDDEN DEATH OR EARLY MORTALITY OR ONGOING EVENTS THAT ADVERSELY AFFECT QUALITY OF LIFE. SO, VERY WELL MATCHED UNRELATED DONORS ALL DONATING BONE MARROW ONLY, NO MOBILIZED PERIPHERAL STEM CELLS, AND THEN AT THE FAIRLY STANDARD REGIMEN THE THERAPY. SO, THIS ONE IS STRUGGLING WITH ACCRUAL FOR A LOT OF OBVIOUS REASONS IT'S A COMPARISON. PATIENTS COME TO A TRANSPLANT TRIAL TO GET A TRANSPLANT, USUALLY, AND IN THIS CASE, TWO-THIRDS OF THE TIME THEY ARE NOT GOING TO HAVE A DONOR. SO WE ARE ONLY AT 55% PROJECT THE ACCRUAL. 10 PATIENTS ASSIGNED TO A TRANSPLANT ASSIGNED TO THE COMPARISON ARM AND WHILE WE DESIGNED IT AS A 4-YEAR TRIAL, I DON'T THINK THAT'S VERY LIKELY AT ALL. I THINK THIS IS GOING TO BE ANOTHER IN THE SERIES OF 10-YEAR TRIALS, MULTICENTER PROSPECTIVE CLINICAL TRIALS TO ESTABLISH WHETHER OR NOT THIS IS A USEFUL STUDY. WE PUSHED THE SPONSOR TO EXTEND THE TRIAL EVEN THOUGH WE ARE DOING BADLY WITH ACCRUAL BECAUSE IT'S SUCH AN IMPORTANT ONE. IF WE DON'T SUCCEED THIS TIME, I DON'T KNOW WHEN WE'LL HAVE AN OPPORTUNITY TO DO A WELL-CONTROLLED COMPARATIVE ANALYSIS OF BONE MARROW TRANSPLANTATION. SO WE ARE PUSHING HARD TO LET US KEEP AT IT. SO IN SUMMARY, BONE MARROW TRANSPLANT TRIALS IN SICKLE CELL DISEASE ARE ONGOING AND WHAT WE ARE TRYING TO DO SPECIFICALLY IS DEFINE THE PRESENCE OR ABSENCE OF THE CLINICAL BENEFIT IN ADULTS AND IN HAPLO IDENTICAL BONE MARROW TRANSPLANTATION. BOTH MYELO ABLATIVE AND NON MYOABLATIVE REGIMENS GENERATE SHORT-TERM RESULTS AFTER BONE MARROW TRANSPLANTATION IN ADULTS AND CHILDREN. BUT THE NONMYELOABLATIVE REGIMENS DO NOT GENERATE EQUIVALENT RESULTS IN THE LONG TERM, AT LEAST WITH MISMATCHED DONOR BECAUSE OF THE HIGHER RISK OF GRAFT REJECTION AND THAT IS SOMETHING THAT WE ARE ATTEMPTING TO TACKLE WITH MODIFICATION OF HOW WE DO THE TRANSPLANTS. AND THEN I WOULD ARGUE EVEN THOUGH WE HAVE REALLY NICE SINGLE-CENTER OUTCOME DATA FROM A NUMBER AROUND THE COUNTRY, THE WAY WE ADVANCE THE FIELD, THE WAY WE HAVE A TRANSFORMATIVE AFFECT IS TO WORK TOGETHER AND TO DO A MULTI-CENTER TRIAL EVEN THOUGH IT'S SO HARD TO GET UNIVERSAL AGREEMENT ABOUT ANY STUDY DESIGN. SO WE HAVE TO BE WILLING TO COMPROMISE, WHICH WE HAVE DONE THAT. THAT IS HOW WE ARE GOING TO ADVANCE THE FIELD. SO I WOULD ARGUE THE PARTICIPATION IN WELL-DESIGNED PROSPECTIVE MULTI-CENTER CLINICAL TRIALS IS NEEDED TO EXTEND THE BROADER APPLICATION OF TRANSPLANTATION USING THESE ALTERNATE DONORS FOR TRANSPLANTATION. THANK YOU VERY MUCH. [ APPLAUSE ] >> WE CAN TAKE ONE QUICK QUESTION. >> HI DR. WALTERS, I'M A TRANSPLANT -- 1503 IS OPEN AND YOU INDICATED THAT MISMATCHED RELATED AND MISMATCHED UNRELATED DONORS HAVE POORER OUTCOMES BUT FOR THE PURPOSES OF SICKLE CELL DISEASE WHAT WOULD YOU DEFINE AS A MISMATCHED DONOR? >> FOR THESE TRIALS IT'S DEFINED AS A HLA DONOR, SO NOT EVEN 10 OF 10 OR 12 OF 12 ALLELES. SO IF YOUR POINT IS MAYBE WE NEED TO GO FURTHER IN THE MATCHING, THAT IS A GOOD POINT. IT IS INCREDIBLY CHALLENGING TO DO, THOUGH, TO FIND THOSE PERFECT DONORS. >> YES, SO ONE OF THE PATIENTS ON THE DONOR HAS A MISMATCHED 9-10 BUT 8 ON 8. SO CURIOUS TO SEE WHAT OUTCOMES I SHOULD -- >> IF YOU LOOK AT THE REGISTRY DATA HAVING A SINGLE MATCH OF DQB1, SHOULDN'T ADVERSELY AFFECT OUTCOME BUT I'M NOT SURE THAT IS TRUE IN SICKLE CELL DISEASE. >> OKAY. >> THANK YOU DR. WALTERS. [ APPLAUSE ] OUR NEXT SPEAKER IS DR. JOHN TISDALE WHO IS THE SENIOR INVESTIGATOR AND CHIEF OF CELLULAR AND MOLECULAR THERAPEUTICS HERE AT THE NHLB I AND ONE OF THE PROGRAM DIRECTORS FOR THE CONFERENCE AND HE WILL BE TALKING TODAY ABOUT COLLECTING HEMATOPOIETIC STEM CELLS, NOT A TRIVIAL BUSINESS. DR. TISDALE. >> JOHN TISDALE: THANK YOU. SO MY JOB IS TO TALK TO YOU ABOUT HOW TO GET HEMATOPOIETIC STEM CELLS FOR GENE THERAPY APPLICATIONS SORT OF THE NEXT FRONTIER BEYOND ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION AND SICKLE CELL DISEASE. AND IT TURNS OUT THIS IS NOT A TRIVIAL. I WANTED TO START OFF BY REITERATING THAT A FEW POINTS THAT MARK MADE AND SO WE CAN SET THE STAGE FOR GENE THERAPY APPLICATIONS IN THIS DISEASE. AND AS WE SAID, WE INITIATED THE TRIAL SOME TIME AGO TESTING A NON MYOABLATIVE APPROACH. IN THIS CHEMOTHERAPY-FREE CONDITIONING WAS WELL TOLERATED, GAVE US ABOUT A 90% EVENT-FREE SURVIVAL IN THE INITIAL AND SUBSEQUENT TRIAL. WITHOUT GRAFT-VERSUS-HOST DISEASE, BUT ONE OF THE THINGS THAT WAS INTERESTING ABOUT THIS TRIAL AND WHY IT IS RELEVANT TO GENE THERAPY APPLICATIONS IS THAT ALL PATIENTS EXPERIENCED MIXED HEMATOPOIETIC CHIMERISM. SO THEY HAD SOME PERCENTAGE OF THEIR OWN CELLS, SOME PERCENTAGE OF THEIR DONOR CELLS IN THE CIRCULATION, AND AT LEAST INITIALLY, ALL OF THOSE PATIENTS WITH MIXED CHIMERISM HAD FULL DONOR ARITHROID. SO IF THEY HAD A SICKLE TRAIT DONOR, THEIR CELLS WERE A SICKLE TRAIT OR IF A NORMAL DONOR, ALL THE HEMOGLOBIN IN THE PERIPHERY WAS NORMAL. AND THIS ALLOWED US TO ASK THE QUESTION, HOW WELL DO WE HAVE TO DO WITH THE GENE THERAPY APPLICATION TO FIX THIS DISEASE? SO WE ASKED A QUESTION, WHAT LEVEL OF DONOR CHIMERISM IS ENOUGH TO FIX SICKLE CELL DISEASE? SO BY THE TIME WE PERFORMED THIS ANALYSIS, WE PERFORMED OVER TRANSPLANTS IN OVER 100 PATIENTS AT THE NIH CLINICAL CENTER WITH SICKLE CELL DISEASE AND THAT WAS A MIX OF MATCH-RELATED DONORS AND HAPLO IDENTICAL DONORS LIKE MARK JUST SHOWED. AND WE HAD 67 PATIENTS WITH LONG-TERM FOLLOW-UP AVAILABLE. AND WE HAD MEASURED MYELOID CHIMERISM, SO WE GET NEUTROPHILS FROM THESE PATIENTS AND ACCESS WHAT PERCENTAGE IS DONOR. LYMPHOID CHIMERISM, THESE ARE CD3 CELLS AND WE CAN LOOK AT HEMOGLOBIN ELECTROPHORESIES, HEMOGLOBIN S LEVELS AND MONITOR SYMPTOMS AT REGULAR INTERVALS. AND WE IDENTIFIED THREE SUBJECTS WHO HAD EXPERIENCED DECLINING DONOR ENGRAFTMENT AS MEASURED OVER TIME DESPITE HAVING INITIAL ROBUST LEVEL WITH REVERSION OF THEIR DISEASE. ONE WAS MATCHED SIBLING DONORS AND THE OTHER TWO WERE ON THE HAPLOPROTOCOL. AND ALL THREE OF THESE PATIENTS DEVELOPED A RISE IN THEIR HEMOGLOBIN S OVER 50%, SEVERE ANEMIA IN RECURRENT SICKLE CELL DISEASE SYMPTOMS WHEN THEIR DONOR MYELOID CHIMERISM DROPPED BELOW 20%. AND THESE PATIENTS HAD SPENT SOME TIME AROUND THE 20-25% LEVEL AND ALWAYS HAD NORMAL HEMOGLOBIN FROM DONOR, BUT ONCE THEY GOT LESS THAN 20, THEY HAD RECURRENT SYMPTOMS. AND SO I WAS ROUNDING WITH ONE OF THE FELLOWS WHO USED TO BE A QUANT GUY. HE WORKED AS A MATHEMATICIAN AN AND WENT BACK TO TRAIN OR GET HIS MEDICAL DEGREE AND TRAINED IN HEMEATOLOGIY AND WE WERE ROUNDING ORCH THE WEEKEND AND HE ASKED A QUESTION, WHY DOES THIS PATIENT WITH 30-40% MYELOID CHIMERISM HAD COMPLETE REPLACEMENT OF ARITHROID COMPARTMENT WITH NORMAL CELLS? MY THOUGHT WAS IT WAS JUST RELATED TO DIFFERENCES IN RED BLOOD CELL LIFESPAN BETWEEN SICKLE CELL DISEASE, RED CELLS AND NORMAL RED CELLS. BUT THERE COULD HAVE BEEN OTHER REASONS LIKE SENSITIVITY TO ARITHPIT IN FOR EXAMPLE, PERHAPS THESE SICKLE CELLS WERE NOW LESS SENSITIVE TO OPENO AND THUS THE NORMAL CELLS GET AN ADVANTAGE WHEN THEY GO IN. HE CAME UP WITH A MATHEMATICAL MODEL THAT ONLY TAKES INTO ACCOUNT RED CELL LIFESPAN AS SHOWN HERE. AND THEN TRIED TO PREDICT WITH THAT MATHEMATICAL MODEL, WHAT WE HAD OBSERVED IN OUR PATIENTS. HERE SHOWS THE DATA FROM THESE THREE PATIENTS. THIS IS CHIMERISM IN RED, DROPPING FROM AROUND 60%, YOU CAN SEE HERE THE 20% MARK GOING DOWN TO ABOUT 10. AND AT THIS 20% MARK, YOU SEE HEMOGLOBIN S START TO TICK UP ABOVE 50%. AND THIS IS WHERE THEY HAD REOCCURRENCE OF THEIR SYMPTOMS. AND THIS WAS WHAT THE MODEL PREDICTS HERE. SO IF IT'S ONLY LIFESPAN OF RED CELLS THAT ACCOUNTS FOR THIS REPLACEMENT, THEN YOU WOULD PREDICT THIS LINE WITH THE MODEL AND IT DOES EXACTLY THAT. SO IT SAYS THAT 20% IS INDEED THE MARK BECAUSE OF THESE VAST DIFFERENCES IN LIFESPAN BETWEEN RED CELLS THAT ARE NORMAL AND SICKLE RED BLOOD CELLS. THE OTHER THING THAT WE DID WITH THE MODEL WAS TO LOOK AT WHETHER SHORTENED RED CELL HALF-LIFE OR LENT END RED CELL HALF-LIFE WOULD AFFECT THIS. SO IF YOU HAD A PATIENT WHO HAS A VERY SHORT RED CELL HALF-LIFE, PERHAPS SOME OTHER ABNORMALITY THAT AFFECTS THEIR LIFESPAN, THEN YOU COULD GET BY WITH A MUCH LOWER LEVEL OF DONOR CHIMERISM IN THIS MODEL. AND IF FOR EXAMPLE THEY HAVE ALPHA THAT WILLASEMIA AS WELL AND HAVE A LITTLE BIT LONGER RED CELL HALF WILL LIFE, IT MAY TAKE MORE CHIMERISM TO FIX THEM. BUT IN GENERAL, AND IN THESE THREE PATIENTS, 20% IS THE MARK. SO WE CAN CURE THE DISEASES AS MARK SHOWED WITH CHEMOTHERAPY-FREE APPROACH NOW IN ADULTS, WHICH ALLOWS US TO DO TRANSPLANTS IN SICKER PATIENTS WITH END-ORGAN DAMAGE. 20% IS ENOUGH BUT AS MARK SAID, MOST LACK THE AVAILABILITY OF A SUITABLE SIBLING MATCH DONOR TO GET THE GREAT RESULTS THAT MARK SHOWED EARLIER. AND AS HE ALSO SHOWED, UNRELATED AND CORD BLOOD DONORS ARE SIMILARLY LIMITED AND HAVE LIMITED BENEFIT. AND WE HAVE BEEN NOW LOOKING TO USE GENE TRANSFERS AS A STRATEGY TO GET AROUND THIS LIMITATION AND DONOR AVAILABILITY, AND WE CAN NOW ROUTINELY ACHIEVE WITH VIRAL VECTORS, 20% OR MUCH HIGHER NOW TRANSDUNK EFFICIENCY IN CELLS FROM PATIENTS -- TRANSDUCTION -- AND THIS WOULD BE A STRATEGY THAT COULD RESULT AND CURE THE DISEASE. BUT ALL OF THE STUDIES PRIOR TO NOW HAVE USED GCSF AS THE WAY TO COLLECT HEMATOPOIETIC STEM CELLS. SO GCSF MOBILIZATION AND ALL THE OTHER APPLICATIONS OF GENE THERAPY. AND THIS IS NOT FEASIBLE IN SICKLE CELL DISEASE AND I'LL SHOW YOU SOME OF THE REASONS WHY. SO THIS IS AN EARLY REPORT IN 1998 FROM MIGUEL ABUD IN SEATTLE AT THE TIME, AND THEY TRIED MOBILIZING AN INDIVIDUAL WITH SICKLE CELL DISEASE WITH GCSF AND THIS WAS WANT MET WITH A SEVERE -- THIS WAS MET WITH A SEVERE CRISIS. A SUBSEQUENT REPORT IN 2001 IN BLOOD, MULTI-ORGAN FAILURE. THIS PATIENT SPENT EIGHT WEEKS IN THE ICU AFTER TCSF MOBILIZATION FOR STEM CELL COLLECTION. THERE WAS ANOTHER REPORT IN THAT SAME YEAR IN BLOOD, A FATAL CRISIS AFTER MOBILIZATION WITH GCSF IN AN INDIVIDUAL WHO WAS DONATING FOR HER SISTER'S TRANSPLANT WHO DID NOT EVEN KNOW SHE HAD SICKLE CELL DISEASE BEFORE THIS MOBILIZATION. SO THIS WAS A VERY BENIGN COURSE UP 2348 TH UNTIL THE COURSE OF GCSF. AND THAT THE POINT, COURTNEY AND I WROTE AN EDITORIAL, IT WAS TIME TO STOP USING GCSF IN SICKLE CELL DISEASE, GIVEN THESE AND OTHER PUBLICATIONS AT THE TIME, SUGGESTING IT IS REALLY TOO TOXIC TO ALLOW FOR ITS USE FOR COLLECTING STEM CELLS. AND WE PUT A QUESTION MARK HERE AND I'M NOT SURE WHY WE HAD THIS QUESTION MARK. I THINK IT PROBABLY SHOULD HAVE BEEN AN EXCLAMATION POINT. SO, WE HAD BEEN WORKING IN THE NON-HUMAN PRIMATE FOR MANY YEARS TO OPTIMIZE GENE TRANSFER TECHNIQUES AND WE SAID, WHAT IS OUR ALTERNATIVE? IT'S STEADY-STATE BONE MARROW. AND WE HAD AT THE TIME BEEN USING THE ONCORETROVIRAL VECTORS TO TRANSFER GENES AND DO MARKING STUDIES N THIS STUDY WE DECIDED TO COMPARE STEADY STAYED BONE MARRY TO MOBILIZED PERIPHERAL BLOOD WITH GCSF OR MORE COMMONLY, GCSF PLUS STEM CELL FACTOR. AND IN THIS EXPERIMENT, WE HAD SIX ANIMALS WHERE WE FIRST COLLECTED UNPRIMED BONE MARROW, DID CD34 ENRICHMENT, TRANSDUCED WITH ONE VIRAL VECTOR AND THEN FROZE THAT PRODUCT. AND THEN WE DID A BONE MARROW HARVEST ON THE SAME ANIMAL, GCSF MOBILIZATION, CD34 ENRICHMENT AGAIN TRANSDUCTION WITH A DIFFERENT RETROVIRAL VECTOR, AND THEN WOULD FREEZE THIS, RADIATE THE ANIMAL, AND INFUSE AND LOOK TO SEE WHAT THE CONTRIBUTION BY BONE MARROW WAS VERSUS PERIPHERAL BLOOD. AND WE TOOK EVERYTHING THAT WE GOT AND IN GENERAL, WE GOT A HIGHER DOSE OF CD34s FROM THIS MOBILIZATION. HERE YOU CAN SEE BONE MARROW COMPARED TO GCSF FAVORABLY HIGHER MARKING IN ALL THREE ANIMALS FROM THE STEADY STATE BONE MARROW. THAT THE TIME WE WERE GETTING ANYWHERE FROM 1-10% LONG TERM MARKING WITH THE TECHNIQUES WE HAD AVAILABLE TO US AT THAT TIME. SO THAT SAID, STEADY STATE BONE MARROW SHOULD BE FINE. BUT THESE ONCORETROVIRAL VECTORS PROVED INCAPABLE OF TRANSFERRING BAIT'S GLOBIN GENE AND THERE WERE OTHER PROBLEMS -- BETA GLOBIN GENE -- INCLUDING INSERTION OF MUTAGENESISES IN SEVERE COMBINED IMMUNODEFICIENCY. SO WE WENT BACK ON DEVELOPING LENTIVIRAL VECTORS. AGAINY TRANSDUCING WITH LENTIVIRAL VECTOR, FREEZING OR DOING THE SAME THING GCSF MOBILIZATION AND THEN PUTTING BOTH OF THESE PRODUCTS BACK INTO THE ERADIATED ANIMAL AND YOU CAN SEE IN THIS PAIR OF ANIMALS, AGAIN BONE MARROW AT STEADY STATE COMPARES FAVORABLY TO MOBILIZED PERIPHERAL BLOOD OVER TIME IN THESE ANIMALS. SO THAT SAID, OKAY, WITH THESE NEW LENTIVIRAL VECTORS, STEADY STATE BONE MARROW LOOKS FINE. AND WE ALSO LOOKED IN SUBJECTS WITH SICKLE CELL DISEASE AT THEIR CD34 CELL COUNT AND BOTH THE PERIPHERAL BLOOD AND THE MARROW AND COMPARED TO HEALTHY DONORS AND YOU CAN SEE HERE THAT THE CD34 CONTENT IN THE MARROW OR THE PERIPHERAL BLOOD IN SICKLE CELL DISEASE SUBJECTS IS AS GOOD IF NOT BETTER THAN HEALTHY DONORS, BUT IT'S PROBLEMATIC IF THESE INDIVIDUALS ARE CONCURRENTLY ON HYDROXYUREA THERAPY. SO WE REASONED THAT STEADY STATE BONE MARROW, AFTER DISCONTINUATION OF HYDROXYUREA, SHOULD BE A GOOD SOURCE OF HEMATOPOIETIC STEM CELLS FOR MOVING INTO THE CLINIC. SO AT THIS POINT, WE JOINED THE HGB206 STUDY THAT ALEXIS WILL TALK ABOUT DURING THIS SESSION. THIS IS OPEN-LABEL MULTICENTER PHASE I TRIAL OF HEMATOPOIETIC STEM CELL GENE THERAPY FOR SEVERE SICKLE CELL DISEASE AND THIS HAS GONE THROUGH AN EVOLUTION OVER TIME. IN GROUP A BASED IN PART OF THE RESULTS THAT I JUST SHOWED AND OTHER DATA, WE COLLECTED BONE MARROW AS HEMATOPOIETIC STEM CELL SOURCE. THERE WAS AN OPTIONAL FREE COLLECTION TRANSFUSION REGIMEN, AND THERE WAS AN ORIGINAL MANUFACTURING PROCESS WHICH WAS THE STATE-OF-THE-ART AT THE TIME N GROUP B, BECAUSE THERE WERE RESULTS IN GROUP A, WE REQUIRED A RUN-IN PERIOD OF PRE-COLLECTION TRANSFUSIONS TO SETTLE THINGS DOWN. AGAIN BONE MARROW WAS THE SOURCE BUT WE MOVED TO MOBILIZATION WITH A SINGLE AGENT FOR COLLECTION OF HSCs FOR THEIR BACKUP AND WE COULD STEP WHETHER OR NOT IT WAS FEASIBLE -- ESTABLISH -- AND SAFE AND WHETHER WE GOT A SUFFICIENT CELL GOES THIS SINGLE DOSE OF MEDICINE AND MOVED FROM AN ORIGINAL TO REFINED MANUFACTURING PROCESS. AND THEN IN GROUP C, WE MOVED EXCLUSIVELY TO MOBILIZATION AS THE SOURCE. SO THESE CELLS ARE TRANSDUCED WITH LENTIVIRAL VECTOR. THE PATIENT COMES IN AND GETS INFUSION. SO IN CONTRA TO THE WHAT WE SAW IN THE NON-HUMAN PRIMATE, WE SAW PRECIPITOUS DECLINE IN THE PERIPHERAL BLOOD VECTOR COPY NUMBER. SO VECTOR COPY NUMBER IS THE AVERAGE NUMBER OF VECTOR INTEGRATED PER CELL IN THE PERIPHERAL BLOOD OR IN THE PRODUCT BEFORE INFUSION. SO YOU CAN SEE MOST OF THESE HAD ABOUT ONE COPY OF THE VECTOR ON AVERAGE PER CELL. BUT THIS DROPPED TO POINT 1 TO POINT 4 AT THEIR MORE RECENT FOLLOW-UP. SO A PRETTY SIGNIFICANT DECLINE IN THEIR VECTOR COPY NUMBER WHICH WAS DISAPPOINTING IN THIS GROUP A OF THE PROTOCOL. WITH THE HIGHEST VECTOR COPY NUMBER BEING ALMOST .25. SO THIS IS NOT ENOUGH TO CURE THIS DISEASE. WE PREDICTED IN OUR ANNUAL MODELS, AND INDEED, THERE WAS ONLY A MODEST INCREASE IN THEIR VECTOR-Y DO ARRIVED HEMOGLOBIN OVER TIME. ON THE Y AXIS YOU CAN SEE THE T87Q HEMOGLOBIN THAT IS ENCODED BY THIS VECTOR, QUANTITATED BY HPLC OVER THE FIRST YEAR POST-TRANSPLANT. AND YOU CAN SEE A MODEST INCREASE UP TO ABOUT AT MOST, TWO GRAMS PER DECILITER COMING FROM VECTOR. SO THIS WAS NOT ENOUGH TO FIX THESE PATIENTS, AND THIS JUST SHOWS THE RESULTS OF GROUP A OVER TIME WITH PINK SHOWING THE PERCENTAGE OF HEMOGLOBIN COMING FROM VECTOR OVER TIME WITH THEIR TOTAL HEMOGLOBIN ON THE Y AXIS. SO AGAIN, NOT ENOUGH USING STEADY STATE BONE MARROW TO FIX THIS DISEASE. SO ABOUT THIS TIME, ALEXIS LEONARD JOINED OUR GROUP AND WAS FACED WITH THIS PROBLEM OF RECONCILING THE DIFFERENCE BETWEEN WHAT WE PREDICTED IN THE STEADY STATE BONE MARROW OF OUR NON-HUMAN PRIMATE MODEL AND WHATY WE SAW IN OUR PATIENTS. AND SO WHAT WE WERE EXPERIENCING ON THE CLINICAL TRIAL WAS BOTH A POOR CELL DOSE COMING FROM THE MARROW AND FAILURE OF ROBUST ENGRAFTMENT OF THOSE CELLS WITH THE LOW VECTOR COPY NUMBER OVER TIME, AND FAILURE TO PRODUCE A SIGNIFICANT AMOUNT OF THIS CORRECTIVE BETA GLOBIN TO MELIORATE THE DISEASE. SO, SHE THEN BEGAN TO COLLECT BONE MARROW FROM SUBJECTS WITH SICKLE CELL DISEASE. AND COMPARED COLLECTION BECAUSE WE HAD THIS IDEA OF COLLECTING IN ACDA. SHE LOOKED AT THE MONONUCLEAR LAYER AFTER DENSITY GRADIENT FOR MARKERS OF INFLAMMATION, ADHESION, CONTAMINATION WITH OTHER CELLS THAT SHOULDN'T BE IN THIS LAYER AT BOTH DAY 0, SO FRESHLY-ISOLATED CELLS, AND A DAY AFTER BECAUSE MOST OF THESE TECHNIQUES THAT YOU'LL HEAR ABOUT IN THE COMING TWO TALKS REQUIRE SENDING YOUR CELLS TO SOME OFF-SITE LOCATION FOR MANIPULATION. SO WE WANTED TO SEE WHAT HAPPENED OVER TIME. SHE ALSO LOOKED AT IMAGE STREAM AT CELLS AND DID THE SELECTION EFFICIENCY BOTH AT DAY 0 AND DAY ONE. THIS SHOWS PATIENTS DEMOGRAPHICS AND BLOOD AND HOMOLOGIC PARAMETERS. YOU CAN SEE SICKLE CELL SUBJECTS HAD HIGHER WHITE COUNTS AND LOWER HEMOGLOBIN. HIGHER HEMOGLOBIN S. ONE OF THE DISAPPOINTING THINGS WE OFTEN SEE WHEN EVALUATING PATIENTS WITH SICKLE CELL DISEASE ON SPECIFIC THERAPY IS THAT WE DON'T SEE A LOT OF EVIDENCE OF THAT SPECIFIC THERAPY. SO OFF HYDROXYUREA, ON HYDROXYUREA, PERCENT S WAS PRETTY MUCH THE SAME. MCD WAS VERY SIMILAR. HEMOGLOBIN WAS NOT THAT DIFFERENT. AND PATIENTS ON CHRONIC TRANSFUSION AGAIN THERE WEREN'T THAT BIG OF A DIFFERENCE BETWEEN THEIR CLINICAL PARAMETERS EXCEPT THE FACT THAT THOSE ON CHRONIC TRANSFUSIONS HAD A LOWER S FRACTION LESS THAN 30%. SO THE FIRST THING THAT SHE NOTED WAS THAT MARKERS OF INFLAMMATION AND CONTAMINATION WITH OTHER CELL FRACTIONS ARE MUCH HIGHER IN SICKLE CELL DISEASE MARROW COMPARED TO NON SICKLE CELL DISEASE MARROW, WHETHER YOU LOOK ON THE DAY 0 OR DAY 1. SO THE SICKLE CELL DISEASE BONE MARROW ON DAY 0 AND DAY 1 WITH THE HIGH FRACTION OF GPA, FOR EXAMPLE, NOT SO MUCH SO FOR NON SICKLE CELL DISEASE MARROW AND THAT WAS TRUE ACROSS-THE-BOARD FOR THESE MARKSERS THAT SHE MEASURED. AND THESE MARKERS OF INFLAMMATION AND CONTAMINATION ARE ELEVATED REGARDLESS OF THE ANTICOAGULANT USED OR THE DAY OF PROCESSING. SO, WE HAD REALLY HOPED THAT ACDA WOULD IMPROVE THINGS. IT DID NOT. AND THAT IF WE DID THINGS QUICKLY, WE MIGHT BE ABLE TO AVOID ALL OF THIS CONTAMINATION, AND IT DID NOT. AND A PICTURE IS WORTH A THOUSAND WORDS. YOU CAN SEE IN SICKLE CELL DISEASE IN HEPARIN OR ACD, THIS WHITE CELL MONOLAYER WHICH IS SO NICE AND WHITE HERE ON THE NON-SICKLE CELL DISEASE MARROW, IS IN FACT RED. SO WE WERE WONDERING ARE THESE RED CELLS THAT ARE STUCK TO THE WHITE CELLS THERE? ARE THESE COMMITTED PROGENITORS THAT ARE ALREADY DOWN THE RYTH ROID PATHWAY? WHAT IS EXPLAINING THIS RED MONOLAYER, WHICH IS SUPPOSED TO BE WHITE? SO SHE LOOKED BY IMAGE STREAM AND YOU CAN SEE HERE STAINING FOR A GPA, SO THESE ARE COMMITTED PROGENITORS ALONG THE RYTH ROID PATHWAY. THIS IS CD34. YOU CAN SEE THIS CELL IN THE STREAM STAINING FOR BOTH. SO THIS IS A CD34 CELL NOW THAT HAS GONE ON TO BECOME A RED CELL AND IS REALLY NO LONGER A STEM CELL BUT IS BEING CAPTURED BY THE CD34 SELECTION AS IF IT IS A STEM CELL. BUT WE ALSO SEE GPA-POSITIVE CELLS STUCK TO CD34 POSITIVE CELLS COMING THROUGH IMAGE STREAM AS WELL. SHE QUANTITATED THAT AND THE MAJORITY OF THE PROBLEM IS THAT THESE CD34 CELLS IN THE MARROW OF SICKLE CELL DISEASE SUBJECTS ARE ALREADY DOWN THE COMMITMENT PATHWAY. SO 20% HERE WITH ONLY ABOUT 5% STUCK TO WHITE CELLS. AND AGAIN NOT THE CASE FOR NORMAL STEADY STATE BONE MARROW AND IT HAPPENS IN BOTH HEPARIN AND ACD AND IT HAPPENS AT BOTH DAY 0 AND DAY 1. SO ANY COAGULANT USED DOESN'T AFFECT THINGS TIME TO PROCESSING DOESN'T REALLY AFFECT THINGS. AND THIS REALLY SHOWS THE PROBLEM. SO CD34 CELLS THAT ARE BRIGHT IN THEIR EXPRESSION OF CD34 ARE THE MORE PRIMITIVE OF THE CD34 FRACTION. AND YOU CAN SEE HERE IN A NORMAL MARROW, MOST OF THE CD34 CELLS ARE VERY BRIGHTLY EXPRESSING THAT ANTIGEN. BUT IN THE SICKLE CELL MARROW IT'S ABOUT 50/50. AND AGAIN, IT DOESN'T MATTER THE ANTICOAGULANT OR THE DAY OF COLLECTION. IT'S MUCH WORSE IN SICKLE CELL DISEASE MARROW WITH ONLY ABOUT HALF OF THEM LOOKING LIKE REAL CD34 CELLS. SO COMPARED TO NON-SICKLE CELL DISEASE SUBJECTS BONE MARROW FROM SUBJECTS FROM SICKLE CELL DISEASE ARE CHARACTERIZED BY INFLAMMATORY MARKERS, HIGHER CONTAMINATION WITH OTHER CELLS, LOWER TOTAL CD34 COUNT AFTER SELECTION, WHICH I DIDN'T SHOW YOU BUT IS INDEED THE CASE. CD34 CELL SIGNAL INTENSITY THAT IS MAJORITY DIM ACCIDENT SUGGESTING THESE ARE ON THE COMMITMENT PATHWAY AND SO THESE PROGENITORS ARE PROBABLY IN PART, AT FAULT FOR THE DROP IN VECTOR COPY NUMBER THAT WE ORIGINALLY SAW IN GROUP A PATIENTS ON THIS GENE THERAPY TRIAL. ADDITIONALLY, THERE WERE AGGREGATES OF CD34 POSITIVE CELLS ATTACHED ERYTHROCYTES THAT COMPLICATE THE DOWNSTREAM PROCESSING. SO THE MORE THE RED CELLS THAT WERE IN THE MIX, THE MORE DIFFICULT IT WAS TO CULTURE THESE CELLS. SO THEN WE MOVED ON TO GROUP C BASED ON ONLY TWO IN GROUP B FOR WHICH WE DID MOBILIZATION FOR BACKUP. BOTH PATIENTS HAD SUCH ROBUST MOBILIZATION AND THE PROCESSING WAS SO MUCH SIMPLER THAN BONE MARROW. WE JUST STARTED COLLECTING BACKUP ON GROUP C UNTIL WE HAD ENOUGH SAFETY DATA TO MOVE COMPLETELY TO USING THIS AS A SOURCE. SO THIS SHOWS SAFETIY WITH BONE MARROW HARVEST VERSUS MOBILIZATION IN APHORESIES. I THINK IT IS IMPORTANT TO CONTEXTUALIZE WHAT WE ARE SEEING BECAUSE MOBILIZATION IN GENERAL MAY CAUSE MISCHIEF IN SICKLE CELL DISEASE BUT WHEN WE ARE COLLECTING THESE ON A CLINICAL PROTOCOL FOR WHICH THERE IS A POTENTIAL OF BENEFIT TO SUBJECTS, WE CAN TOLERATE A LITTLE BIT MORE IN TERMS OF TOXICITY. SO IN 9 PATIENTS ON THE ORIGINAL GROUP A AND GROUP B, WE HAD TO DO 26 BONE MARROW HARVESTS TO GET ENOUGH CELLS TO MOVE AHEAD. SO THAT IS MULTIPLE HARVESTS PER PATIENT, ONE PATIENT HAD TO HAVE FOUR BONE MARROW HARVESTS TO GET ENOUGH CELLS. WITH THAT, WE HAD 17 GREATER THAN OR EQUAL TO GRADE, THREE ADVERSE EVENTS IN FIVE PATIENTS. THESE WERE PAIN, ANEMIA, AND FULL-BLOWN CRISIS. WHEREAS IN THE SEVEN PATIENTS WHO UNDERWENT MOBILIZATION IN APHORESIES, THERE WERE 5 GRADE III AEs REPORTED IN THREE PATIENTS. SO AS A FRACTION OF THE TOTAL PATIENTS, THE NUMBER OF GRADE THREE OR HIGHER ADVERSE EVENTS IS IN FACT LOWER WITH FLOR EXFOREMOBILIZATION. AND THIS INCLUDED THREE PAIN EVENTS THAT LOOKED LIKE SICKLE CELL CRISIS AND SOME PATIENTS STARTED BEFORE GIVING PLOR EXFORE. THIS SHOWS A WHITE COUNT AFTER MEREXA FOREMOBILIZATION SO INCREASE IN WHITE BLOOD CELL COUNT AND NEUTROPHIL COUNT AFTER LYRICS FORECOUNT. A COUPLE OF PATIENTS REQUIRED A SECOND DOSE TO MEET THE NECESSARY NUMBER FOR MOVING FORWARD WITH THE PROCESSING. THIS SHOWS CD34 CELL COUNT AFTER MOBILIZATION AND IN CONTRAST TO THE NORMALS WHERE THE CD34 COUNT GOES TO 30-40, YOU CAN SEE HERE 50 TO OVER 200CD34 CELLS PER MICROLITER IN SUBJECTS WITH SICKLE CELL DISEASE. SOUPLE EXFOREBY ITSELF WORKS WELL IN THIS DISEASE. IN PART THE BASELINE IS HIGHER IN SICKLE CELL DISEASE. SO THIS IS WHAT YOU NORMALLY REACH WITH LYRICS FOREIN NORMALS BUT IN SICKLE CELL DISEASE THEY START THERE. SO THEY GET ROBUST MOBILIZATION. WITH MOBILIZATION WE GOT A MEDIAN OF 10 MILLION CD34 CELLS PER KG RECIPIENT. AND THIS SHOWS CD34 DIM AND BRIGHT POPULATIONS IN THE PATIENTS. SO YOU CAN SEE IN THE BONE MARROW HARVEST, WE HAD IN OUR PATIENTS ON THE PROTOCOL, ABOUT 40% CD34 DIM. THAT'S AROUND 8% IN THE APHORESIES PRODUCT AND YOU CAN SEE THE CD34 BRIGHT COMPARES FAVORABLY IN PATIENTS WITH SICKLE CELL DISEASE TO THOSE ON THE THALASSEMIA TRIAL AND IN HEALTHY DONORS MOBILIZED WITH PLERIXAFORE AND IT IS BETTER THAN WHAT WE OBSERVED IN THE PRIOR NINE PATIENTS WITH BONE MARROW HARVESTING. VECTOR COPY NUMBER WAS IMPROVED IN GROUP B BECAUSE OF THE IMPROVED MANUFACTURING PROCESS AND YOU CAN SEE THAT APPLIES WELL TO MOBILIZED PERIPHERAL BLOOD AS WELL SO VECTOR COPY NUMBER OF 4 AND TRANSDUCTION EFFICIENCY 80-90% AND IMPORTANTLY, THE CD34 CELL COUNT IN THE PRODUCT AT THE END WAS THE HIGHEST IN THOSE WHO UNDERWENT PLERIXAFORE MOBILIZATION. SO THIS IS JUST A GRAPH OF WHAT WE THINK YOU NEED TO MAKE THIS WORK. THE DRUG PRODUCT CELL DOSE, TIMES OF PERCENT, CD34 BRIGHT. SO THE ONES WE THINK ARE THE GOOD HEMATOPOIETIC STEM CELLS TIMES THE PERCENT VECTOR POSITIVE. YOU CAN SEE IT IS HIGHEST IN THOSE INDIVIDUALS WHO UNDERWENT PLERIXAFORE MOBILIZATION AND ALEXIS WILL SHARE WITH YOU THE CLINICAL RESULTS IN THOSE PATIENTS DURING THE LATTER PART OF THIS SESSION. YOU DON'T HAVE TO TAKE MY WORD FOR IT THAT PLERIXAFORE WORKS IN SICKLE CELL DISEASE BECAUSE THERE NOW HAS BEEN SEVERAL PUBLICATIONS, ONE WHERE THEY DID MOBILIZATION OF 15 SUBJECTS A DOSE ESCALATION JUST LOOKING AT CD34s. THEY DIDN'T DO EXCHANGE OR DISCONTINUED HYDROXYUREA, AND THEY REACHED THE CD34 COUNT OF GREATER THAN 30 IN ONLY EIGHT OF THE 15 AND I THINK THIS MIGHT BE PART OF THAT, THE FACT THAT MANY OF THOSE SUBJECTS WERE ON HYDROXYUREA. THEY HAD TWO EPISODES OF PAIN THAT COULD HAVE BEEN RELATED TO THIS MOBILIZATION. ANOTHER PUBLISHED THREE SUBJECTS IN THIS SAME WHERE THEY DID EXCHANGE TRANSFUSIONS TO GET THE S DOWN AND STOP HYDROXYUREA. THEY HAD PEAK CD34s LIKE WHAT I SHOWED YOU WITH ROBUST COLLECTION. NO PAIN AND JUST RECENTLY, SIX SUBJECTS REPORTED BY DAVID WILLIAMS GROUP WITH THE DOSE ESCALATION, 180-240. EXCHANGED TRANSFUSIONS WITH HYDROXYUREA BEING DISCONTINUED. PEAK CD34 CELLS 27-290. WITH ROBUST COLLECTION AND NO SAEs. SO STEADY STATE BONE MARROW IN SICKLE CELL DISEASE IS CHARACTERIZED BY INCREASED INFLAMMATORY MARKERS, LOWER CD34 PURITY, A SIGNAL INTENSITY THAT IS MAJORITIY DIM FOR CD34, HIGHER FRACTION OF COMMITTED PROGENITORS AND AGGREGATES OF CELLS WITH RED CELLS ATTACHED THAT COMPLICATE THE DOWNSTREAM PROCESSING. THIS PLERIXAFORE MOBILIZATION TO COLLECT BONE MARROW STEM CELLS HAS A SAFETY PROFILE THAT IS FAVORABLE WHEN COMPARED TO BONE MARROW HARVESTING AND LYRICS AFOREYIELDS PRODUCTS WITH A HIGHER CD34 CELL DOSE AND INTENSITY ALLOWING FOR IMPROVED OUTCOMES. SO I ACKNOWLEDGE THE CREW. THERE ARE MANY INVESTIGATORS IN THE STUDY THAT HAVE ACCRUED PATIENTS THUS FAR. MY GROUP HERE, THE ANIMAL CARE STAFF, COURTNEY WHO DID THE WORK IN THE HAPLO IDENTICAL SETTING, AND I'M GOING TO POINT OUT ALEXIS HERE HIDING IN THE BACK WHO DID ALL OF THE BONE MARROW WORK. I SEE HER OVER THERE. I'LL TAKE ANY QUESTIONS. [ APPLAUSE ] >> WE ARE OPEN FOR QUESTIONS. >> I COULD HAVE CUT IT SHORT BY SAYING, USE PLERIXAFORE. >> THANKS. I HAVE A GENERAL QUESTION. SO I THOUGHT THAT THE DATA YOU WERE SHOWING LOOKING AT THE MINIMUM PERCENT ANNUAL OF THE DONOR CELLS -- PERCENTAGE OF THE -- WAS A CRITICAL QUESTION. IS THERE A WAY FOR US TO ACTUALLY, AT THE STEM CELL LEVEL TO CREATE CIRCUMTANCES WHERE THEY ACTUALLY HAVE A SURVIVAL OF MANAGEMENT? IT'S FAIRLY CLEAR THE RED CELLS IN CIRCULATION OBVIOUSLY HAVE ADVANTAGE, BUT CAN WE -- IS THERE SOMETHING THAT CAN BE DONE TO -- >> YES, SO WE ARE WORKING ON JUST THAT. SO THERE ARE PEOPLE THAT ARE BORN WITH A TRUNCATED ERYTHOPOIETIN RECEPTOR THAT WIND UP ACROSS COUNTRIES, GOLD MEDALIST BECAUSE THEY HAVE HIGHER HEMOGLOBIN THAN THE REST OF US. THAT TRUNCATION MAKES THEIR RYTH ROID PROGENY MORE SENSITIVE TO ARITHPIT IN. SO WE HAVE OR RE-CREATED THAT TRUNCATION IN THE ERYTH PIT IN RECEPTOR AND EXPRESS TODAY IN A LENTIVIRAL VECTOR WITH A MARKER GENE AND IN-VITRO, WE CAN GET OUTGROWTH OF CELLS WITH THE GENE BY CULTURING RYTH PIT IN. WE ARE GETTING READY TO TRY THOSE STUDIES IN THE NON-HUMAN PRIMATE AND IF WE EXPRESS THAT WITH THE RYTH ROID-SPECIFIC PROMOTOR, THEN WE SHOULD BE ABLE TO GET SELECTION OF THOSE CORRECTED CELLS OR THOSE CELLS WITH THE VECTOR. AND THEN TURN BACK DOWN ONCE THE HEMOGLOBIN GETS TO NORMAL BY THE NORMAL MECHANISM OF SUPPRESSION OF OPENO THROUGH A NORMAL HEMOGLOBIN. SO THAT IS ONE WAY THAT WE ARE TRYING. THAT WOULD NOT WORK FOR GENE EDITING TECHNIQUES BECAUSE YOU'D HAVE TO CO-EDIT THE EPO RECEPTOR AND THE ARITHROID ENHANCER YOU'LL HEAR ABOUT NEXT. AT FLEET A GENE TRANSFER SETTING WE COULD DO THAT. >> ONE FINAL QUESTION. >> GREAT, WONDERFUL TALK. AT THE END YOU SHOWED THE STUDIES OF OTHER GROUPS OF PLERIXAFORE IN DIFFERENT CIRCUMSTANCES SO SOMETIMES THE PATIENTS WERE TRANSFUSED BEFOREHAND, SOMETIMES HYDROXYUREA WAS STOPPED BEFOREHAND. DO YOU KNOW IF SOME OF THESE LEADING UP TO THE ACTUAL HARVEST EVENTS HOW THEY MIGHT IMPACT THIS CENTRAL ISSUE OF THE PROPORTION OF THE CD34 CELLS WHICH ARE BRIGHT? TRULY PRIMITIVE? FOR EXAMPLE, THE EXCHANGE TRANSFUSING FOR A MONTH BEFOREHAND WILL THAT ENABLE YOU TO ENRICH EVEN MORE FOR CD34 BRIGHT? >> DO YOU MEAN FOR THE BONE MARROW? OR PERIPHERAL BLOOD? BECAUSE SO BOTH THINGS WERE DONE IN THESE STUDIES THAT GOT REALLY GOOD MOBILIZATION, BOTH TRANSFUSIONS AND HYDROXYUREA DISCONTINUATION. SO IT'S HARD TO KNOW WHICH MATTERED BUT WE HAVE LOOKED WITH HIGH FOR EXAMPLEY RIA, WITHOUT HYDROXYUREA AND WHAT I SHOWED AND BEFORE THAT, IN BOTH CASES HYDROXYUREA DIMINISHED CD34 COUNT IN THE BONE MARROW AND THE PERIPHERAL BLOOD. SO I THINK THAT MIGHT BE THE MORE IMPORTANT OF THE TWO. HOWEVER, THE TWO PATIENTS IN GROUP B HAD PRETTY DECENT HARVESTS AFTER WE REQUIRED CHRONIC TRANSFUSION BEFOREHAND, WHETHER THAT WAS RELATED IS HARD TO SAY, BUT IT WAS IN FACT BETTER. >> THANK YOU DR. TISDALE. [ APPLAUSE ] OUR NEXT SPEAKER IS DR. DAN BAUER WHO IS PRINCIPAL FACULTY AT HARVARD MEDICAL SCHOOL BOSTON CHILDREN'S WHO WILL BE SPEAKING TO US ABOUT GENE THERAPY, ADDICTION, CORRECTION AND SOME INDUCTION AS WELL. DR. BAUER. >> DAN BAUER: THANK YOU FOR THE OPPORTUNITY TO PRESENT TODAY. YOU CAN SEE THE TITLE INCLUDES SOME OF THE SPECTRUM OF OPTIONS THAT ARE BECOMING FEASIBLE TO CONTEMPLATE FOR GENE THERAPY FOR ADDITION WE'LL HEAR MORE FROM DR. THOMPSON NEXT AND THERE IS ACTUALLY SOME EMERGING CLINICAL DATA FOR SOME OF THE OTHER APPROACHES, I'LL FOCUS ON PRE-CLINICAL RATIONAL BUT HOPEFULLY, AT FUTURE MEETINGS WE CAN BEGIN TO REVIEW SOME CLINICAL RESULTS. HERE ARE MY DISCLOSURES. WE ALREADY HEARD FROM JOHN TISDALE ABOUT THE EXISTING CURATIVE APPROACHES FOR SICKLE CELL DISEASE, WHICH REFLECT ALLOGENEIC OPTIONS FOR HEMATOPOIETIC CELL TRANSPLANT, WHICH ALTHOUGH HAVE IMMENSE PROMISE, HAVE SOME LIMITATIONS, INCLUDING DONOR AVAILABILITY AND IMMUNE INCOM PATTABILITY AND MORBIDITY AND MORTALITY OF THE APPROACHES. AND ALTERNATIVE VISION IS TO COLLECT THE HEMATOPOIETIC STEM CELLS FROM THE PATIENT AND THEN PERFORM AN EX-VIVO MODIFICATION AND THEN THE CELLS CAN BE REINFUSED FOR A DURABLE THERAPEUTIC AFFECT. SO WITHIN THESE AUTOLOGOUS APPROACHES, THERE IS SEVERAL POSSIBLE IDEAS TO EXPLORE. ONE GENE ADDITION WHERE A NON-SICKLING, ANTI-SICKLING GLOBIN GENE CAN BE ADDED EVEN IN THE PRESENCE OF AN UNMODIFIED SICKLE BETA GLOBIN GENE LOCUS, AND WE'LL HEAR MORE FROM ALEXIS. SO I'M NOT GOING TO FOCUS ON THAT FOR THE REMAINDER OF THE TALK. ALTERNATIVELY, ONE CAN THINK ABOUT GENE CORRECTION WHERE THE SICKLE MUTANT BAIT GLOBIN IS ACTUALLY CHANGED BACK TO A NORMAL SEQUENCE AT BETA GLOBIN AND THAT CLEARLY WOULD BE A DEFINITIVE THERAPY FOR SICKLE CELL DISEASE. AND THEN ALSO THERE IS A NUMBER OF THERAPIES THAT REFLECT INDUCTION OF FETAL HEMOGLOBIN WHERE THE SICKLE BETA GLOBIN IS LEFT INTACT BUT THE ENDOGENOUS GENE FETAL GLOBIN GENE PARALOGUES ARE TURNED ON AND THERE IS A NUMBER OF APPROACHES WITHIN THIS THAT INCLUDE SHRNA APPROACHES AND FORCED CHROMATIN LOOPING AND THEN GENE EDITING APPROACHES SUCH AS DISRUPTION OF B-CELL ENHANCER AND I'LL FOCUS A LITTLE BIT MORE ON THESE. SO THESE APPROACHES RELY ON GENE EDITING AND GENE EDITING IS MADE POSSIBLE BY THESE BIFUNCTIONAL MOLECULES THAT HAVE TWO -- THE FIRST BEING DNA TARGETING THAT CAN BE PROGRAMMABLE IN A SEQUENCE-SPECIFIC MANNER TO ALLOW IDENTIFICATION OF VERY PARTICULAR LOCI IN THE GENOME, AND THEN COUPLED WITH AN EFFECTOR, TYPICALLY AN END NUCLEASE THAT CAN CREATE A DOUBLE STRAND BREAK AT THE SITE OF TARGETING. SO WITHIN ARE A NUMBER OF SPECIFIC MOLECULES AND ON THE LEFT ARE THE OLDER GENERATION WHERE THEY RELY ON PROTEIN DNA INTERACTIONS FOR THE DNA SPECIFICITY, AND ALTHOUGH THOSE CAN BE VERY EFFECTIVE GENE EDITING NUCLEASES THEY ARE CHALLENGING TO REPROGRAM TO NEW SITES IN THE GENOME. SO OVER THE LAST 5 PLUS YEARS WITH THE ADVENT OF CRISPR GENADEITING AND RNA PROGRAMMABLE NUCLEASES LIKE CAS9, HAS OPENED THE FIELD UP SO THAT MANY INVESTIGATORS CAN STUDY THE EFFECTS OF THESE MOLECULES AND THEN BEGIN TO CONSIDER THEM AS THERAPEUTICS. SO HERE IS AN ARTISTIC DEPICTION OF HOW GENE EDITING MIGHT HAPPEN. THIS IS AN IMAGE FROM JENNIFER WHERE YOU CAN SEE WITHIN THE GENOME THERE ARE THESE LITTLE YELLOW MOTIFS THAT ARE THE RESTRICTION SITES FOR CAS9 AND NGG MOTIFS. SO THIS CAS9 MODULE CAN SCAN THE GENOME AND THEN IN THE PRESENCE OF A GUIDE RNA, WHICH HAS WATSON SEQUENCE COMPITATORY TO TARGET SEQUENCES, FIND PRECISE SEQUENCES IN THE GENOME AND THEN EFFECTORS NUCLEASE MIGHTEES CAN CREATE A DOUBLE STRAND BREAK. AFTER THIS DOUBLE STABBED BREAK OCCURS, IT DEPENDS ON THE CELLS ENDOGENOUS REPAIR MECHANISMS TO DEFINE WHAT THE FINAL OUTCOME. AND ONE CAN CONSIDER TWO MAIN CLASSES OF OUTCOME. ON THE LEFT IS THE NON-HOMOLOGOUS END JOINING WHERE THERE IS SOME AND ERROR GENERATED AT THE CLEAVAGE SITE WHERE THERE IS SMALL INCISIONS OR DELETIONS THAT FORM LIKE A SCAR AT THE SITE OF THE DOUBLE STRAND BREAK. SO THIS IS KIND OF LIKE THE DELETE MODE OF GENOME EDITING. ON THE RIGHT IS THE HO MOLOGIY DIRECTED REPAIR MODE WHERE IN THE PRESENCE OF EXTRACHROMOSOMAL TEMPLATE, A SEQUENCE CAN BE USED TO REPAIR THE ENDOGENOUS SEQUENCE. SO, THIS CAN LEAD TO A PRECISE INSERTION. NOW THIS IS VERY APPEALING BUT TURNS OUT THAT IN MANY CELLULAR CONTEXT, ESPECIALLY IN THE HEMATOPOIETIC STEM CELLS, THIS REPAIR MODE ON THE RIGHT MAY BE LESS ACTIVE AS COMPARED TO THE NON-HOMOLOGUES END JOINING DELETE MODE. AND SO, ON THE RIGHT ONE CAN IMAGINE HARNESSING THIS APPROACH FOR DIRECTORY PAIR OF THE SICKLE MUTATION, WHICH AS I STATED, HAS GREAT PROMISE BUT SOME CHALLENGES OF THE LOWER EFFICIENCY OF THE APPROACH AND THE CONCURRENT NON HOMOLOGOUS END JOINING MEDIATED INSERTIONS AND DELETIONS THAT OCCUR. ALTERNATIVELY, IF ONE CAN FIND DELETIONS THAT HAVE A BENEFICIAL AFFECT SUCH AS INDUCTION OF FEELS HEMOGLOBIN, THOSE DELETIONS THEMSELVES COULD BE -- FETAL -- HARNESSED THEMSELVES AS A THERAPEUTIC. AND SO, THE PROMISE OF FETAL HEMOGLOBIN HAS BEEN LONG APPRECIATED IN HEMATOLOGY, STEMMING BACK TO THE 1940s WHEN JANET WATSON MADE THE CLINICAL OBSERVATION THAT THE ERYTHROCYTES FROM NEWBORNS WITH SICKLE CELL DISEASE WERE PROTECTED FROM SICKLING DUE TO THE HIGH LEVELINGS OF FETAL HEMOGLOBIN AND ONLY IN THE FIRST YEAR OF LIFE AS THE FETAL HEMOGLOBIN LEVELS DECLINE DO THE CLINICAL MANIFESTATIONS OF SICKLE CELL DISEASE EMERGE. AND WE HAVE LEARNED THAT THIS IS A TRANSCRIPTIONAL PROCESS THAT DEPENDS ON SILENCING OF THE FETAL GAMMA GLOBIN GENES SO A MAIN GOAL IN HEMATOLOGY HAS BEEN TO UNDERSTAND HOW IS IT THAT THESE ALTERNATIVE FETAL GLOBIN GENES GET SILENCED AND HOW COULD WE TURN THEM BACK ON IN SICKLE CELL DISEASE TO TRANSITION AWAY FROM SICKLE HEMOGLOBIN TOWARDS BENEFICIAL FETAL HEMOGLOBIN? AND THERE IS LOTS OF DATA FOR THIS BENEFICIAL AFFECT IN SICKLE CELL DISEASE INCLUDING EPIDEMIOLOGIC STUDIES SUCH AS THIS ONE FROM COLLEAGUES DEMONSTRATING THAT INDIVIDUALS WITH SICKLE CELL DISEASE WITH THE HIGHEST QUARTILE OF HIGHLIGHT FETAL HEMOGLOBIN HAD SUBSTANTIAL INCREASE IN THEIR OVERALL SURVIVAL. SO, REALLY THE ADVANCES CAME FROM HUMAN GENETICS IN UNDERSTANDING HOW IS IT THAT FETAL HEMOGLOBIN IS REGULATED? AND THESE ARE GENOME-WIDE ASSOCIATION STUDIES RESULTS THAT BEGAN TO BE REPORTED MORE THAN A DECADE AGO BY MANY THAT IDENTIFIED JUST A SMALL NUMBER OF LOCI THAT WERE CRITICALLY IMPORTANT IN DETERMINING FETAL HEMOGLOBIN LEVEL IN SICKLE CELL DISEASE SEVERITY, AND WHAT WAS NOVEL ABOUT THESE STUDIES WAS THE IDENTIFICATION OF THIS GENE AS A CRITICAL REGULATOR OF FETAL HEMOGLOBIN. AND THIS IS THE WORK OF A NUMBER OF LABS, INCLUDING THAT OF MY POSTDOCTORAL MENTOR, DEMONSTRATING THE KEY ROLE OF B-CELL AS A SILENCER OF FETAL HEMOGLOBIN. I THINK THIS IS AN EXPERIMENT WHERE A SICKLE CELL DISEASE MOUSE IS CROSSED TO ANIMAL CONDITIONALLY EFFICIENT IN RYTH ROID CELLS TO CREATE A DOUBLE MUTANT ANIMAL AND IN THE ABSENCE OF BCL11A, THE APPEARANCE OF SICKLE CELLS FROM THE PERIPHERAL SMEAR AND ON THE BOTTOM RIGHT, ESSENTIALLY INDUCTION OF FETAL HEMOGLOBIN ASSOCIATED WITH REVERSAL OF THE HOMOLOGIC AND PATHOLOGIC MANIFESTATIONS SICKLE CELL DISEASE. AND IT'S NOT JUST FROM ANIMAL GENETICS OR COMMON GENETICS BUT EVEN IN FORMATIVE RARE HUMANS SUBSTANTIATE THIS QUANTITATIVE ROLE OF BCL11A IN SILENCING HEMOGLOBIN. THERE ARE INDIVIDUALS THAT CARRY HAPLOINSUFFICIENCY FOR BC11A WHO ARE ASCERTAINED IN NEURODEVELOPMENTAL CLINICS WHO PRESENT WITH AUTISM SPECTRUM DISORDER. YOU YOU CAN SEE THAT 50% LEVEL OF BCL11A LEADS TO DRAMATIC REDUCTION OF HEMOGLOBIN RANGING FROM 16-29%. JUST REDUCING THIS BY A LITTLE BIT LEADS TO DRAMATIC INDUCTION OF FETAL HEMOGLOBIN. YET, CLEARLY BCL11A PLAYS ROLES IN THE DEVELOPMENT OF THE CENTRAL NERVOUS SYSTEM. PREVIOUSLY IDENTIFIED AS A LYMPHOCYTE MATURATION AND IN FACT, IT PLAYS IMPORTANT ROLLS IN HEMATOPOIETIC STEM CELLS. THIS IS DATA FROM STEWART ORKIN SHOWING IN A IS DOSE DEPENDENT MANNER THAT BCL11A IS REQUIRED FOR HEMATOPOIETIC STEM CELL FUNCTION SO THESE ARE TRANSPLANT EXPERIMENTS DONE IN BCL11A, HETEROZYGOUS AND KNOCKOUT MICE TRANSPLANTED TO PRIMARY AND SECONDARY RECIPIENTS AND ON THE BOTTOM IN A DOSE-DEPENDENT MANNER, A FAILURE OF HEMAPOIESIS DUE TO A LACK OF RENEWAL OF STEM CELLS. THIS RAISES THE QUESTION HOW IS IT THAT COMMON GENETIC VARIATION IS BENEFICIAL, THAT PATIENTS WITH SICKLE CELL DISEASE WHO CARRY THESE COMMON VARIANTS HAVE MILDER SICKLE CELL DISEASE? THEY DON'T APPEAR TO HAVE ANY DELETERIOUS CONSEQUENCES IN THE BRAIN OR THE B LYMPHOCYTES OR IN THE HEMAPOIESIS? AND LIKE MANY GENOME-WIDE ASSOCIATION STUDIES, THE COMMON VARIANTS ARE NOT IN THE CODING SEQUENCES BUT ARE IN NON-CODING SEQUENCES SHOWN HERE CLUSTERING MORE THAN 50,000 BASE PAIRS AWAY FROM THE TRANSCRIPTION START SITE IN THIS LARGE SECOND INTRON. AND IT TURNS OUT THAT THESE SEQUENCES OVERLAP SEQUENCES THAT ARE SHOWING DNA SENSITIVITY IN ARITHROID CELLS WHICH INDICATES SITES OF THE GENOME WITH REGULATORY POTENTIAL. YOU CAN SEE THERE IS THREE OF THESE DNA SENSITIVE SITES IN RYTH ROID CELLS, 55, 58 AND 62, EACH OF WHICH HAS OVERLYING TRAIT ASSOCIATED COMMON GENETIC VARIANTS. AND WHEN ONE LOOKS AT OTHER CELL TYPES FROM HUMANS THAT HAVE HIGH LEVELS OF BCL11A, THERE IS A POSITIVITY THIS NIECE REGIONS INDICATING THESE ARE SEQUENCES THAT CAN CARRY RYTH ROID-SPECIFIC REGULATORY POTENTIAL. I DON'T HAVE TIME TO GO THROUGH ALL OF THE DATA BUT SUFFICE IT TO SAY FROM BIOCHEMICAL CORRELATION OR GAIN-OF-FUNCTION ANALYSIS, THESE SEQUENCES BEHAVE LIKE ERYTH ROID ENHANCERS. I THINK THE MOST STRIKING DATA COME FROM KNOCKOUT RESULTS WHERE WE HAD GENERATED MICE THAT HAD DELETION OF THE ORTHOLOGOUS INTRONNIC RYTH ROID ENHANCER, BC11A AND TO A MOUSE CARRYING A HUMAN BETA GLOBIN TRANSGENE TO EVALUATE THE EFFECTSFUL DEVELOPMENTAL GENE REGULATION. YOU CAN SEE ON THE BOTTOM LEFT, THE NORMAL PATTERN OF GENE REGULATION IN THESE TRANSGENIC MICE IS THAT TURN EMBRYOGENESIS, THEY TURN OFF THE FETAL GAMMA GLOBE IN AND TURN ON THE ADULT BETA GLOBIN AND IN A DOSE-DEPENDENT MANUALER IN THE ABSENCE OF THE BCLA ENHANCER, THEY FAILED TO SILENCE THE FETAL GAMMA GLOBIN AND THIS PHENOCOPIES THE AFFECT OF KNOCKING OUT BCL11A WHERE THE WITH RESPECT TO HEMOGLOBIN SWITCHING BUT LACKS THE ADVERSE EFFECTS. SO THE CONVENTIONAL EN HANGSER, THE BCL11A GENE KNOCKOUT MICE ARE CARRYING LETHAL, IMPAIRED CENTRAL NERVOUS SYSTEM AND WITH THE FUNCTIONAL B LYMPHOCYTES. AND THEY HAVE FAILURE HEMAPOIESIS. BUT THE MICE WHERE THE BCLA ENHANCER KNOCKED OUT HAVE ONLY LOST IF IN RYTH ROID CELLS BUT THEY PRESERVE IN THE B-CELLS AND THE BRAIN AND STEM CELLS ARE CAPABLE OF ENGRAFTMENT AS SHOWN ON THE BOTTOM RIGHT. SO THIS LED TO THE THERAPEUTIC STRATEGY WHERE WE COULD COLLECT THE STEM CELLS FROM PATIENTS WITH SICKLE CELL DISEASE DISRUPT BY GENE EDITING, THE RYTH ROID ENHANCER AND AUTOLOGOUSLY REIN FUSE THOSE CELLS. THIS DEPEND ENDED ON IDENTIFYING CRITICAL, MINIMAL CORE SEQUENCES WITHIN THE ENHANCER, THAT WOULD BE SENSITIVE TO DISRUPTION AND WE DID THIS EXPERIMENT WHERE WE TOOK AGNOSTIC APPROACH WHERE WE TESTED MANY OR ALL POSSIBLE GUIDE RNAs AS RESTRICTED BY THE CAS9 NUCLEASE, DELIVERED THEM AS A POOL TO RYTH ROID CELLS AND ASKED WHAT WERE THE CRITICAL SEQUENCES IF ANY WITHIN THE RYTH ROID ENHANCER? AND SO HERE FROM LEFT TO RIGHT ARE THE PERFORMS ON THE LEFT IS A SET OF NEGATIVE CONTROL GUIDE RNAs AND THE SECOND PANEL AXON TARGETING GUIDE RNAs THAT DISRUPT THE CODING SEQUENCE WHICH LEAD TO THIS HIGH FETAL HEMOGLOBIN ENRICHMENT AND THEN THE RESULTS OF THE THREE RYTH ROID ENHANCERS OF BCL11A. AND THE CONCLUSION OF THIS WAS THAT MOST GUIDE RNAs HAD NO EFFECT ON REGULATION OF FETAL HEMOGLOBIN BUT THERE WAS A NARROW SET OF GUIDE RNAs SUCH AS THIS STRIKE WITH THE PLUS 58 ENHANCER WHERE WE OBSERVED 10 GUIDE RNAs WHOSE CLEAVAGES WERE IN ABOUT 40 BASE PAIRS WHERE WE SAW INDUCTION OF FETAL HEMOGLOBIN. SO ESSENTIALLY, WE HAD IDENTIFIED BASED ON THE NATURALLY-OCCURRING MELIORATING COMMON GENETIC VARIATIONS, RYTH ROID ENHANCER AND THEN USING THIS CRISPR SCREENING APPROACH, IDENTIFIED CRITICAL MINIMAL SEQUENCES. AND IT TURNS OUT THESE MINIMAL SEQUENCES AS IDENTIFIED BY INTRODUCING SINGLE GUIDE RNAs INTO RYTH ROID PRECURSORS AND ASKING WHAT WERE THE SEQUENCES WHOSE DISRUPTION WAS MOST POTENT IN TERMS OF INDUCED HEMOGLOBIN, THESE MINIMAL SEQUENCES REFLECT A BINDING SITE FOR THE KEY RYTH ROID TRANSCRIPTION FACTOR. SO IT BINDS TO THE 68 TURNS ON BCL AVENUE A AND THEN IT TURNS OFF FETAL HEMOGLOBIN. SO WORK IN MY LAB AMONG OTHERS HAS INVESTIGATED HOW CAN WE OPTIMIZE THE BCL11A ENHANCER EDITING APPROACH AS A POTENTIAL THERAPEUTIC FOR SICKLE CELL DISEASE? WHAT WE HAVE FOUND IS THE MOST POTENT WAY TO DELIVER THESE EDITING MATERIALS TO CD34 CELLS IS BY MEANS OF ELECTROOPERATION OF CAS9 AS A PROTEIN IN COMPLEX WITH A GUIDE RNA. IN THIS CASE, A CHEMICALLY SYNTHESIZED AND MODIFIED GUIDE RNA. AND IN WORK WITH THE COLLABORATOR, SCOTT WOLF AT THE UNIVERSITY OF MAGS CHOOSEETS, WE FOUND ALTERING THE NUCLEAR LOCALIZATION SEQUENCES THAT WERE APPENDED TO THIS CAS9 COULD FURTHER ENHANCE THE EDITING SHOWN IN THE UPPER RIGHT IN BLUE WHERE WE CAN NOW GET MORE THAN 95% ALLELE MODIFICATION IN PRIMARY CD34 POSITIVE HEMATOPOIETIC STEM AND PROGENITOR CELLS. ON THE BOTTOM IT IS A TYPICAL SEQUENCE RESULT WE GET AFTER PERFORMING THIS EDITING AND BLOCKS THE GAMMA MOTIF IN RED AND YOU CAN SEE THAT BY PLACING THE GUIDE RNA SO IT DIRECTS CLEAVAGE DIRECTLY ON THE MOTIF, EVERY EDITED ALLELE DISRUPTS THE MOTIF. YOU CAN SEE MIDWAY THROUGH THIS TABLE THE UNEDITED ALLELES IS 2% OF THE REMAINING. 98% OF THE ALLELES ARE EDITED. WE WANTED TO SEE ARE THESE CELLS STILL COMPETENT FOR HEMATOPOIETIC STEM CELL FUNCTION SINCE OBVIOUSLY THE CD34 CELLS ARE A GROUP OF CELLS THAT WILL COMPARE THE PERFORMS OF MOCK NON-ELECTROOPERATED AND NON-MANIPULATED CELLS, JEAN EDITED CELLS AND THEN TRANSFERRED THEM TO IMMUNODEFICIENT MICE, WAITED FOUR MONTHS, 16 WEEKS, AND THEN LOOKED IN THE BONE MARROW AT THE FRACTION OF HUMAN ENGRAFTING CELLS. WE SAW NO DIFFERENCE WHEN WE EITHER DID OR DID NOT PERFORM THE EDITING ON THE BOTTOM LEFT. WE SAW SIMILAR DISTRIBUTION OF BLOOD CELL OUTPUT IN TERMS OF LYMPHOID, MYELOID AND RYTH ROID OUTPUT. AND THAT THE ENGRAFTING CELLS SHOWN ON THE RIGHT PANEL MAINTAIN THESE EDITS IN A VERY HIGH FREQUENCY GREATER THAN 90% ALLELE MODIFICATION FOUR MONTHS AFTER THE INITIAL EDITING IN THE RECIPIENT BONE MARROW. SO WHAT WAS THE IMPACT OF THIS EDITING? WHEN WE SORTED OUT B-CELLS FROM THESE RECIPIENT ANIMALS, THERE WAS NO CHANGE IN THE EXPRESSION OF BCL11A AS WE HAD PREDICTED GIVEN THAT THIS WAS AN RYTH ROID-SPECIFIC REGULATOR BUT WHEN WE SORTED OUT RYTH ROID CELLS, YOU COULD SEE 80% REDUCTION IN BCL11A LEVELS AND CONCOMITANT WITH REDUCTION OF THIS AS EXPECTED IN THE BOTTOM RIGHT, WE SAW SUBSTANTIAL INDUCTION OF FETAL GAMMA GLOBIN. WE ASKED ABOUT THE SPECIFICITY OF THIS APPROACH. WE DID AN ASSAY CALLED CIRCLE SEQ WHICH ASKS WHAT ARE ALL THE POSSIBLE SITES OF GENOMIC CLEAVAGE IN-VITRO? WE IDENTIFIED 20 POSSIBLE SITES. WE IDENTIFIED ADDITIONAL SITES BY COMPUTATIONAL ANALYSIS AND THEN WE SEQUENCED OUR EDITED CELLS TO SEE IF THEY HAD OFF TARGET MUTATIONS AT ANY SITES. SO UNDER CONDITIONS WHERE WE HAD EXTREMELY POTENT ON-TARGET EDITING OF 90%, WE DIDN'T SEE ANY OFF TARGETS AT A LEVEL OF DETECTION OF DEEP SEQUENCING, WHICH IN OUR CASE WAS 0.1%. SO THIS IS A VERY SPECIFIC GENE EDITING APPROACH. FURTHERMORE WE PERFORMED SOME TARGETED DEEP SEQUENCING OF RECURRENT HEMATOLOGIC MALIGNANCY ASSOCIATED GENE MUTATIONS AND FOUND NO MUTATIONS IN SAIDITTED CELLS SUGGESTING THE GENE EDITING IS EXTREMELY SPECIFIC IN TERMS OF TARGETING THE BCL11A ENHANCER. NEXT WE TURNED TO SICKLE CELL DISEASE CELLS AS JOHN JUST INDICATED. PLERIXAFORE MOBILIZATION IS EXTREMELY PROMISING IN TERMS OF THE ABILITY TO GET HEMATOPOIETIC STEM CELL ENRICHED MATERIAL FROM PATIENTS WE HAD EXPRESS TO THAT MATERIAL WITH COLLABORATION WITH OTHERS AND WE FOUND OUR SAME PROTOCOL WORKED JUST THE SAME IN SICKLE CELL MATERIAL. WE COULD GET 95% EDITS OF THE BCL11A ENHANCER. THESE CELLS AS ASSAYED BY ENGRAFTMENT POTENTIAL OF 16 WEEKS AND THERE WAS NO DIFFERENCE IN ABILITY TO GRAFT COMPARED TO UNMODIFIED CELLS AND THE ENGRAFTED CELLS MAINTAINED 95% EDITS OF THE BCL11A ENHANCER. WE COULD PERFORM SECONDARY TRANSPLANTS AND THESE AGAIN PERFORMED IDENTICALLY ON MANIPULATED CELLS AND THE SECONDARY TRANSPLANTING CELLS ALSO RETAINED EXTREMELY HIGH ALLELE MODIFICATION. WE SAW 80% DECKRAMENT IN THESE CELLS SELECTIVELY ACCOMPANIED BY POTENT INDUCTION OF FETAL GAMMA GLOBIN ON THE BOTTOM RIGHT. WE COULD DO FETAL HEMOGLOBIN ASSAY TAKING THIS ENGRAFTING MATERIAL DURING A 2-WEEK IN-VITRO CULTURE TO GENERATE SICKINOUSLY MATUREY RYTH ROID CELLS AND YOU CAN SEE THAT WE OBSERVED IN THE RANGE OF 35-50% FETAL HEMOGLOBIN AFTER PERFORMING THIS GENE EDITING. FROM THE SICKLE CELL DONOR, WE ASKED THE ABILITY OF THE CELLS TO SICKLE, EXPOSING THE CELLS TO SULFITE AND NOT SURPRISINGLY, GIVEN THEIR HIGH EXPRESSION OF FETAL HEMOGLOBIN, THE EDITED CELLS FAILED TO SICKLE. IT SHOWED IN THE MIDDLE IN CONTRAST TO THE PARALLEL UNEDITED CELLS FROM THE SAME DONOR, AND THIS IS QUANTIFIED ON THE RIGHT. IN THE FINAL MINUTES, I WANT TO JUST REFLECT ON THE LANDSCAPE OF GENE EDITING AND GENE THERAPY OPTIONS. I HAD SIMPLIFIED THE GENE REPAIR ALLELES AS INCLUDING HOMOLOGY REPAIR AND NON HOMOLOGUES END JOINING. THERE IS A THIRD TYPE OF OUTCOME WHICH IS A MICROHOMMOLOGY OUTCOME, A HYBRID, BETWEEN NON HO HOL GUS REPAIR WHERE, LIKE HOMOLOGY REPAIR IT IS TEMP LATED BUT USES MATERIAL ON EITHER SIDE OF THE DOUBLE STRAND BREAK TO GENERATE A MICROHOMMOLOGY REPAIR. LIKE HOMOLOGY DIRECTED REPAIR, THIS REQUIRES FACTORS THAT ARE RESTRICTED TO CERTAIN PHASES OF THE CELL CYCLE UNLIKE NON HOMOLOGUES END JOINING WHICH IS ACTIVE IN ALL THE CELLS. AND ONE THING WE HAVE HAD OBSERVED WAS WHEN WE DID THE DCL11A ENHANCING WE HAD A PLUS ONE INSERTION AND WE HAD THESE LARGER DELETIONS MINUS 13 AND MINUS 15 THAT COMPRISED ABOUT 25% OF OUR ALLELES AND IT TURNED OUT THESE WERE MICROHOMMOLOGY-TYPE REPAIRS. BUT WHEN WE LOOKED IN THE ENGRAFTING BONE MARROW CELLS, ALTHOUGH THE SMALL DELETIONS WERE ABUNDANT, WE ALMOST COMPLETELY LOST THESE MICROHOMOLOGY REPAIR ALLELES. SO WE LOOKED AT OUR 10 TRANSPLANTS, 33 RECIPIENT MICE, TWO TARGET LOCI AND OUR CONTROLS AND WE SAW ALMOST COMPLETE LOSS OF THESE MICROHOMMOLOGY ALLELES IN THE LONG TERM ENGRAFTING MATERIALS SUGGESTING THAT THE TRUE ENGRAFTING STEM CELLS IN THESE EXPERIMENTS GREATLY PREFERRED TO REPAIR BY NON HO HOL GUS END JOINING. I THINK WILL SKIP OVER THIS DATA AND GIVE YOU THE SUMMARY THAT WE COULD VERIFY THAT BY SORTING OUT CELLS AND THAT THE CELLS THAT WE SORTED OUT WITH OUR IMMUNE OL PHENOTYPE OF HEMATOPOIETIC STEM CELLS ARE QUIESCENT IN THIS PHASE, EXCLUSIVELY PERFORMED THIS NON HOMOLOGY-BASED REPAIR AND THE MICROHOMMOLOGY WAS RESTRICTED TO THE ACTIVELY CYCLING CELLS AND GREATLY ENRICHED IN THE PROGENITORS OVER THE STEM CELLS. THIS EDITING WAS EXTREMELY POTENT. WE COULD DO BY CLONAL ANALYSIS ASK WHAT WERE THE ALLELES REQUIRED FOR HIGH FETAL HEMOGLOBIN. THESE ARE LIST FRIDAY SMALLER TO LARGER AND WE FOUND THAT EVEN SINGLE BASE PAIR INSERTIONS WERE POTENT IN INDUCING JAMA GLOBIN. ONE OF THE OTHER APPROACHES THAT IS BEING EXPLORED IS GENERATION OF NATURALLY OCCURRING HEREDITARY PERSISTENCE OF FETAL HEMOGLOBIN ALLELES. AND THERE IS THIS NATURALLY OCCURRING 13 BASE PARODY LESION IN THE GAMMA GLOBIN PROMOTOR WHICH IS ACTUALLY THE RESULT OF MICROHOMMOLOGY AND BY TARGETING CAS9 CLEAVAGE AT THE SITE, ONE CAN GENERATE HIGH LEVEL OF THESE 13 BASE PARODY LESION. ONE QUESTION THAT EMERGES IS ALTHOUGH THIS CAN BE ACHIEVED AT HIGH LEVELS IN BULK, CD34 CELLS, THERE MAY BE A SELECTIVE DISADVANTAGE OF THIS SORT OF REPAIR IN LONG TERM EN GHASTING STEM CELLS. -- ENGRAFTING. I ALSO WANTED TO MENTION AS I ALREADY HAD DISCUSSED, THE BCL11 ENHANCER EDITING OR THE DISRUPTION TYPE ALLELES IS ONE OF THE POSSIBLE THERAPEUTIC OPTIONS IN TERMS OF GENE EDITING. OTHERS ARE BETA GLOBIN CORRECTION ITSELF. AND THIS IS THE WORK OF MULTIPLE LABS INCLUDING MARK WALTERS WHO IS HERE, WHOSE DATA I'M SHOWING WITH JACOB CORN, DAVID MARTIN AND THEN BEING ACTIVELY PURSUED BY OTHER GROUPS. AND THIS IS CERTAINLY MOVING IN THE RIGHT DIRECTION AND THE RESULTS I'M SHOWING HERE IN 2018 ARE BETTER THAN THE RESULTS I PREVIOUSLY WOULD SHOW FROM 2016 OR 2015. SO BUT I THINK A CHALLENGE FOR THESE APPROACHES IS THAT ALTHOUGH ONE CAN GET INCREASINGLY HIGH RATES OF CORRECTION IN CD34 CELLS AND IN THIS CASE, IN THE ORDER OF 30-40%, THERE APPEARS TO BE SOME DECKRAMENT IN THE LONG TERM ENGRAFTING CD34 CELLS IN THE MARROW OF RECIPIENT MICE AND ALL THOSE THIS DECKRAMENT IS NOT AS GREAT AS IT USED TO BE, THERE IS STILL SOME DISADVANTAGE OF THESE CORRECTED -- IN THE STEM CELLS AS COMPARED TO THE PROGENITORS. AND WHEN ONE LOOKS AT THE CELLS THAT COMPOSE THESE GRAFTS, ALTHOUGH THERE IS A SUBSTANTIAL FRACTION OF CORRECTED CELLS, THERE IS ALSO THE HOST UNCORRECTED CELLS BUT THEN THE LARGEST FRACTION IS ACTUALLY DISRUPTED AREAL ESTATEULAR NEWFOUND BETA THALASSEMIA PHENOTYPE. SO ONE NEEDS TO CONSIDER THE COEXISTENCE OF THREE HEMATOLOGIC CONDITIONS IN THESE CASES, SICKLE CELL DISEASE, CORRECTED HEMAPOIESIS AND THALASSEMIA. AND WHAT FRACTION OF THOSE WILL PLAY OUT TO GIVE DIFFERENT OUTCOMES, I THINK NEEDS CAREFUL OBSERVATION. IN SUMMARY, BCL11A ENHANCER CAN BE HIGHLY EFFICIENT IN HEMATOPOIETIC STEM CELLS. IT CAN BE PENETRANT AND DISRUPT THE GATTA MOTIF LEADING TO POTENT HEMOGLOBIN IN HEALTHY DONOR AND BETA THALASSEMIA CELLS WHICH I DIDN'T HAVE TIME TO SHOW, LACKING DETECTABLE GENOTOCKISSITY AND APPEARS TO BE SOME ENGRAFTMENT OF CELLS EDITED BY THESE SORTS OF DISRUPTION APPROACHES. SO THIS IS JUST A KIND OF VISUAL DESCRIPTION OF THE LANDSCAPE. THIS IS THE CHANNEL BEFORE US IS REALLY IMMENSE. WE HAVE MANY OPTIONS NOW FOR CURATIVE THERAPIES FOR SICKLE CELL DISEASE. WE NEED TO EXPLORE THEM ALL AND HOPE TO ACHIEVE OUR GOAL. SO, WITH THAT, THANK YOU FOR YOUR ATTENTION. [ APPLAUSE ] >> THANK YOU FOR TAKING ONE QUICK QUESTION AND WE'LL MOVE TO THE NEXT SPEAKER. >> HOW DO YOU ENVISION THIS IN A PERSON? DO YOU EXPECT OR WANT THEM TO HAVE A MINIMUM OF LIKE 20% LIKE JOHN HAD SUGGESTED? OR DO YOU THINK OF THIS AS TAKING OVER THE WHOLE MARROW SPACE? >> YES, I MEAN, I THINK WITH THIS SORT OF EFFICIENCY THAT WE ARE ACHIEVING, WE COULD HOPE TO ACHIEVE MUCH HIGHER THAN 20% ALLELE MODIFICATION IN A PATIENT. I THINK THE INITIAL TRIALS WOULD BE SIMILAR TO THOSE DISCUSSED BEFORE WITH MYELO ABLATIVE CONDITIONING. I THINK WHERE THIS MAY BE COMING IMPORTANT IS EVEN IN THE FUTURE AS ONE HAS NEW WAYS TO DELIVER THESE SORTS OF GENE EDITING, WHAT IS THE MINIMAL LEVELS NEEDED? AND PROBABLY JOHN AND MARK ARE RIGHT, SOMEWHERE IN THE 20-25% RANGE IS ENOUGH BUT I THINK THE MORE THE BETTER AND WE NEED CAREFUL CLINICAL STUDIES TO DETERMINE THESE OUTCOMES BOTH AT THE LEVEL OF THE PERIPHERY AND IN THE BONE MARROW. BUT OUR GOAL SHOULD BE TO CURE SICKLE CELL DISEASE AS BEST WE CAN AND TO HAVE THE BEST LONG TERM OUTCOMES POSSIBLE AND I THINK THE BEST CORRECTION WE CAN ACHIEVE WILL HELP US DO THAT. >> THAT WAS REALLY WONDERFUL TALK. THANK YOU VERY MUCH. I JUST WANT TO ASK A COUPLE OF QUESTIONS. WHEN YOU SHOWED THE TRANSDUCTION OF YOUR BCL11A IN HEALTHY STEM CELLS AND SICKLE CELL, THERE WAS HIGHER INDUCTION -- DO YOU THINK IT IS RELATED TO THE SELECTIVE SURVIVAL OF THE CELL? AND THEN SECOND THING IS, HAVE YOU ACTUALLY LOOKED AT THE F CELLS TO SEE WHETHER IT'S KIND OF CELLULAR OR HETEROCELLULAR? >> I THINK I WANT TO BE CLEAR THAT ALL OF OUR METHODS TO EVALUATE RYTH POISIS AND FETAL HEMOGLOBIN HAVE CAVEATS AND LIMITATIONS AND WE ARE USING A MOUSE THAT HAS A MUTATION OF KIT, WHICH ALLOWS FOR SOME RYTH ROID ENGRAFTMENT BUT CERTAINLY NOT TO THE LEVEL OF COMPLETE ENGRAFTMENT OF THE RYTH ROID COMPARTMENT AND MOST OF THE CELLS ARE PRECURSORS AND WE DON'T REALLY GET A LARGE FRACTION OF TRULY MATURE RETT CELLS. I THINK THERE COULD STILL BE SOME CORRECTION AT THE LEVEL OF PRECURSORS AND RETIC LOW SIGHTS IN SICKLE CELL DISEASE. WE SEE HIGHER BASELINE FETAL HEMOGLOBIN IN THE SICKLE CELL DISEASE DONORS. SO IT MAY REFLECT THE HIGHER BASELINE WHY WE SEE HIGHER INDUCTION IN THE SICKLE MATERIAL. AND THEN ABOUT THE PAN CELLULARITY. AT LEAST EVERY MEASURE WE HAVE DONE IS A PAN CELLULAR AFFECT. IF WE GET POTENT DISRUPTION OF BCL11A IT IS SEEN BY ALL THE RED CELLS. >> SO JUST FOLLOWING ON JOHN'S PRESENTATION EARLIER, WHERE HE SHOWED THAT YOU NEED MINIMUM OF 30% OF THE CELLS TO ENSURE THE MIXED CHI MARISM. SO DO YOU THINK FOLLOWING THAT YOU MAY NEED 30% OF THE CELLS TRANSDUCED IN SICKLE CELL PATIENTS? >> I THINK JANE WAS KIND OF ASKING A RELATED QUESTION. I THINK THE ISSUE IS WHEN WE GET POTENT GENE MODIFICATION IN OUR CD34 CELLS, WE GET POTENT AFFECTS ON LONG TERM STABILITY OF THOSE MODIFIED CELLS. WHEN WE HAVE KIND OF MARGINAL AFFECTS, THAT IS WHEN WE START SEEING MORE DROP-OFF OF THE EDITED CELLS COMPARED TO THE NON-EDITED CELLS. I WOULD BE UNCOMFORTABLE WITH A CLINICAL PROTOCOL THAT WAS IN FUSING A PRODUCT AT 20% MODIFICATION. I THINK WE WANT TO BE WELL ABOVE THOSE THRESHOLDS. AND I THINK WE CAN BE WELL ABOVE THOSE THRESHOLDS. NOW AGAIN, I THINK WE NEED TO VERY CLOSE CLINICAL FOLLOW-UP OF THESE PATIENTS TO REALLY ANSWER THESE QUESTIONS, WHICH I THINK ALL THE MODELS CAN HINT AT BUT ONLY CLINICAL FOLLOW-UP CAN REALLY ANSWER WHAT IS THE MINIMAL MODIFICATION TO GIVE THE OUTCOMES WE WANT. >> THANK YOU DR. BAUER. [ APPLAUSE ] AND THE LAST TALK FOR OUR SESSION IS ALEXIS THOMPSON, PROFESSOR OF PEDIATRICS AND HEAD OF THE HEMEATOLOGYGIST SECTION AT NORTHWESTERN UNIVERSITY AND SHE WILL GIVE US UPDATE ON GENE ADDITION THERAPY FOR SICKLE CELL DISEASE. THANK YOU. >> ALEXIS THOMPSON: THANK YOU FOR THE INVITATION TO PRESENT THIS DATA TODAY. MY TALK IS GOING TO BE LARGELY CLINICAL AND IT WILL CERTAINLY COMPLIMENT THE OTHER LECTURES, I HOPE IN THIS SESSION. AND THESE ARE MY DISCLOSURES. I'M GOING TO COVER THE CURRENT CLINICAL GENE THERAPY STRATEGIES BY PROVIDING YOU SOME RECENT RESULTS WITH THE HEMOGLOBINOPATHIES AND ALSO LEAVING AS A FINAL THE ONGOING CHALLENGES AND THE FUTURE DIRECTIONS. SO MARK HAS SHOWN THIS AND OTHER FAIRLY COMPELLING DATA TO DEMONSTRATE THAT HEMATOPOIETIC STEM CELL TRANSPLANTS IN PARTICULAR WITH DONORS SHOULD BE WELL ESTABLISHED AND ACCEPTED AS AN OPTION FOR CHILDREN WITH SICKLE CELL DISEASE. CONSIDERATIONS ARE AS ALREADY MENTIONED, THAT MOST OF THESE INDIVIDUALS WILL LACK A SUITABLE MATCH RELATED AND IN MANY INSTANCES AN UNRELATED STEM CELLSES SOURCE. THERE ARE OPEN RESOURCE STUDIES EVALUATING REDUCED INTENSTY OR HAPLO IDENTICAL DONOR TRANSPLANTS. BUT WITH ATTENDED COMPLICATIONS. THAT HAD CERTAINLY LED US TO CONSIDER ALTERNATIVES FOR POTENTIAL CUTERRIVE THERAPIES. AND SO, AT LEAST IN THE CLINICAL REALM, THE APPROACHES REALLY HAVE FALLEN INTO TWO AND THEN SOME INSTANCES SOME OF THE CLINICAL TRIALS ACTUALLY ADDRESS BOTH OF THESE. BY-AND-LARGE I'M GOING TO BE ADDRESSING GENE ADDITION WHERE WE ARE ADDING THE FUNCTIONALITY OF A NORMAL BETA GLOBIN. IN SICKLE CELL DISEASE, THE GOAL IN THAT SETTING WOULD BE TO CONVERT A PATIENT FROM SICKLE CELL DISEASE ESSENTIAL TOW SICKLE CELL TRAIT. IN THE SETTING OF THALASSEMIA WHERE THE PROBLEM IS GLOBIN IN BALANCE, BY PROVIDING BETA GLOBIN THAT ONE CAN ACTUALLY OVERCOME PART OR ALL OF THAT GLOBIN IN BALANCE AND REDUCE TRANSFUSION DEPENDENCE. INCREASING FETAL HEMOGLOBIN AS HAS ALREADY BEEN DISCUSSED, HAS A NUMBER OF THERAPEUTIC ADVANTAGES. THIS CAN BE DONE BY ADDING A GAMMA GLOBIN GENE TO PRODUCE GLOBIN F BY ADDING A GAMMA-LIKE BETA GLOBIN OR BY ALTERING EXPRESSION OF GENES THAT REGULATE FETAL GLOBIN. AND THIS GOES BACK TO DATA THAT MANY OF US LEARNED IN MEDICAL SCHOOLS SORT OF THINKING ABOUT THE INTERACTIONS BETWEEN ALPHA AND ALTERNATIVE CHAINS AND UNDERSTANDING HOW THOSE CAN BE MANIPULATED IN THE SETTING OF GENE THERAPY. SO THAT WHILE WE UNDERSTAND THE CONTACT POINTS BETWEEN NORMAL BETA AND NORMAL ALPHA, THERE CERTAINLY IS POSSIBLE TO ACTUALLY ENHANCE THAT BENEFIT BY MAKING A GAMMA-LIKE BETA GLOBIN AND THAT IS THE CASE WITH TD7Q. THERE ARE ADDITIONAL MANIPULATIONS THAT HAVE BEEN MADE THAT ARE AS3 AND I'LL SHOW YOU AN EXAMPLE OF A VECTOR THAT INCORPORATES THOSE, BUT THEY WOULD NOT ONLY INHIBIT POLYMERIZATION BUT ALSO INCREASE THE AFFINITY TO ALPHA GLOBIN. SO SOME OF THIS BASIC SCIENCE WE HAD FOR DECADES IS NOW BEING RECONSIDERED IN THE CONTEXT OF NEW APPROACHES FOR THERAPY. TO THE POINT, THESE ARE ACTUALLY THE CURRENT ROSTER OF LENTIVIRAL VECTORS THAT ARE IN THE CLINICAL ARENA AT THIS POINT FOR EITHER SICKLE CELL DISEASE OR THALASSEMIA. SO QUITE REMARKABLE IN THE ADVANCES THAT ONE CAN CONSIDER IN LOOKING AT THESE. AND MANY OF THESE HAVE EITHER BETA FLOW IN OR GAMMA GLOBIN AS THE GENE OF INTEREST UNDER THE REGULATION OF SOME FORM OF THE LOCUST CONTROL REGION WITH ADDITIONAL ENHANCER ELEMENTS. SOME WITH INSULATORS BUT MOST WITHOUT. THESE ARE THE CURRENT ACTIVE GENE THERAPY TRIALS FOR SICKLE CELL DISEASE IN THALASSEMIA. THE ONE CERTAINLY WITH THE LARGEST AMOUNT OF CLINICAL DATA REPRESENT THIS SWEEP BUT THERE ARE A NUMBER OF OTHER ACTIVE CLINICAL PROGRAMS. THIS IS A LENTE GLOBIN BB305 WHICH IS A LENTIVIRAL VECTOR THAT IS SELF-INACTIVATING THAT INCLUDES THE HUMAN BETA GLOBIN GENE IN ADDITION TO WHAT I HAVE ALREADY DESCRIBED AS THE ANTI-SICKLING BENEFIT OF THE T87Q, ANOTHER NOTABLE BENEFIT TO T87Q IS THAT ON HDLC, IT CAN BE DISTINGUISHED FROM HEMOGLOBIN A FROM THE BLOOD BANK. SO IT ALLOWS US TO A CONSTANT READ ON THE ABILITY TO DIFFERENTIATE VECTOR-DERIVED HEMOGLOBIN A FROM HEMOGLOBIN A FROM OTHER SOURCES. THIS IS A SCHEMATIC OF THE BETA THALASSEMIA TRIAL AND I THINK THAT THERE HAVE OBVIOUSLY BEEN MANY LESSONS LEARNED FROM THAT TRIAL THAT I THINK HAVE HELPED TO INFORM OUR APPROACHES TO SICKLE CELL DISEASE. THESE ARE INDIVIDUALS WITH BETA THALASSEMIA MAJOR SO TRANSFUSION DEPENDENT PATIENTS, WHO UNDERWENT STEM CELL MOBILIZATION WITH A COMBINATION OF GCSF AND PLERIXAFORE. THEIR CELLS WERE SENT TO A MANUFACTURING FACILITY WHERE THE CD34 SELECTION WAS COMPLETED AS WELL AS THE TRANSVECTION WITH THE BB305 LENTIVIRAL VECTOR. ONCE THEY WERE CRYOPRESERVED, THEY RETURNED TO THE SITE. AT THE CLINICAL SITE, THE PATIENT UNDERWENT PRE INFUSION CONDITIONING WITH THE INTENT FOR MYELO ABLATION AND RECEIVED THEIR CELLS BACK. THEY REMAINED HOSPITALIZED THROUGH A RECOVERY OF AN ANC OF GREATER THAN 500 AND WERE SENT HOME FOR TWO YEARS OF FOLLOW-UP. TO DATE, FORTUNATELY ALL PATIENTS HAVE AGREED TO LONG-TERM FOLLOW-UP STUDY WHICH WILL FOLLOW THEM OUT FOR A TOTAL OF 15 YEARS. OUR EXPECTATIONS ON THIS INITIAL TRIAL BEING VERY CANDID, WERE MODEST IN IN ADDITION TO LOOKING FOR SAFETY, EFFICACY READ FOR THIS PARTICULAR TRIAL WAS GREATER THAN TWO GRAMS OF HEMOGLOBIN T87Q PRODUCTION, 6 MONTHS OUT FOR OVER 6 MONTHS BETWEEN 18-24 MONTHS. SO CERTAINLY WE WERE SETTING THE BAR WHAT WE THOUGHT AS IT TURNS OUT IS QUITE LOW. NONETHELESS, IT LED TO THE DEMONSTRATION OF THE OUTCOMES FOR THAT TRIAL COMBINED WITH THE 205 TRIAL, A COMBINATION OF SICKLE CELL AND THALASSEMIA PERFORMED IN PARIS. PERFORMED INDEPENDENTLY BUT USING THE SAME VECTOR. SO THEY WERE INCLUDED IN THE SAME PUBLICATION. AND THESE ARE SOME OF THE RESULTS OF THAT TRIAL. THIS IS LOOKING AT THE OUTCOMES FOR PATIENTS IN THEIR ABILITY TO BECOME TRANSFUSION INDEPENDENT. THESE ARE THE PATIENTS ABOVE THE LINE. IN BLUE THESE ARE THE PATIENTS WHO WERE ON THE HGB204 TRIAL AND THE 47 STUDY ARE THE ONES IN RED. -- FRENCH STUDY. -- THE MORE INTENSE COLOR REPRESENT THE LENGTH OF TIME THESE INDIVIDUALS HAVE BECOME TRANSFUSION INDEPENDENT AND THEIR HEMOGLOBIN AS OF LAST VISIT, AND SO OF THE 22 PATIENTS THAT WERE ON THIS TRIAL, 15 HAVE BECOME TRANSFUSION INDEPENDENT. FOR THOSE THAT DID NOT BECOME INDEPENDENT, THEY HAD A MEDIAN OF 60% REDUCTION IN TRANSFUSION VOLUMES AND NEARLY 60% IN THEIR NUMBER OF TRANSFUSIONS. AND THIS IS COMPARING IN LIGHT BLUE THEIR DEMANDS FOR RED CELLS PRE-TREATMENT COMPARED TO THOSE POST-GENE THERAPY. AND SO I THINK THAT THE CONCLUSION WOULD BE WHETHER IT WAS TRANSFUSION INDEPENDENT OR REDUCTION IN THEIR TRANSFUSION VOLUME OR NUMBER AS THE VAST MAERT JOY OF INDIVIDUALS IN 24 LARGE-SCALE STUDY HAD CLINICAL BENEFIT. -- MAJORITY. THERE WAS ROOM FOR IMPROVEMENT GIVEN THE NUMBER OF INDIVIDUALS THAT DID NOT ACHIEVE TRANSFUSION INDEPENDENCE AND ONE OF THE WAYS TO ADDRESS THAT HAS BEEN DESCRIBED BY JOHN IN TERMS OF SOME OF THE MANUFACTURING ENHANCEMENTS THAT HAVE TAKEN PLACE. SOME OTHER THINGS THAT WE RECOGNIZED IN THIS TRIAL WERE SOME CORRELATIONS THAT HAVE HELPED AGAIN TO INFORM WHICH KINDS OF THINGS WE PURSUED. SO WHEN WE LOOKED AT THE VECTOR COPY NUMBER IN THE DRUG PRODUCT, WHAT WAS RETURNED TO THE PATIENT AND COMPARED THAT TO THE VECTOR COPY NUMBER IN THE PERIPHERAL BLOOD AT SIX MONTHS, THOSE ARE RELATIVELY STRONG CORRELATIONS SUCH THAT INDIVIDUALS WHO HAD HIGHER VECTOR COPY NUMBERS IN THEIR DRUG PRODUCTS WERE MORE LIKELY TO HAVE HIGHER VECTOR COPY NUMBERS IN THE PERIPHERAL BLOOD, HOWEVER PATIENTS WHO HAD RELATIVELY LOW VECTOR COPY NUMBERS IN THEIR DRUG PRODUCTS HAD RELATIVELY LOW VECTOR COPY NUMBERS SIX MONTHS LATER IN THEIR PERIPHERAL BLOOD. THIS VECTOR COPY NUMBER IN THEIR PERIPHERAL BLOOD AT SIX MONTHS CORRELATED WITH T87Q OR THE AMOUNT OF HEMOGLOBIN BEING PRODUCED BY THE VECTOR SUCH THAT AGAIN, THOSE WHO HAD RELATIVELY HIGH VECTOR COPY NUMBERS AT SIXER MONTHS ALSO HAD HIGHER AMOUNTS OF T87Q BEING PRODUCED. SO, TO THE EXTENT THAT WE WERE ABLE TO MODIFY THE VECTOR COPY NUMBER IN THE PRODUCT THAT THE PATIENT RECEIVED, THAT THERE SHOULD BE SOME EXPECTATION THAT WE WILL SEE IMPROVEMENT IN THE OUTCOMES IN TERMS OF THE ABILITY TO MAKE HEMOGLOBIN. THIS FIRST PATIENT THAT WAS PUBLISHED SICKLE CELL DISEASE WAS FROM THE FRENCH EXPERIENCE IN THE 205 TRIAL AND AS A PROVE OF CONCEPT, CLEARLY ACHIEVED THE MARK IN TERMS OF HAVING A PATIENT WHO OTHERWISE WAS AN INDIVIDUAL -- THIS WAS A CHILD, 13-YEAR-OLD, WHO WAS ON TRANSFUSIONS FOR A STROKE AND SO AS A CONSEQUENCE, HAD A HIGH AMOUNT OF HEMOGLOBIN A. BUT AT 12 MONTHS FOLLOWING GENE THERAPY, ESSENTIALLY HAS THE PHENOTYPE OF SOMEONE WITH SICKLE CELL TRAIT. HAVING SAID THAT, THE EXPERIENCE IN THE BROADER 206 STUDY WAS NOT NEARLY AS STRAIGHTFORWARD AS THIS INITIAL PATIENT. SO AS JOHN ALREADY DESCRIBED, THE INITIAL APPROACH WAS USING BONE MARROW HARVEST AND WITH RESULTS THAT WERE AT BEST MODEST IN TERMS OF THE EXPRESSION OF T87Q. I THINK JOHN HAS EXPLAINED IN FAR MORE DETAIL MANY OF THE LESSONS LEARNED, FUNDAMENTAL ONE WITH THE APPRECIATION THAT THE SICKLE CELL MARROW IS A FAIRLY UNHEALTHY MARROW. THAT THE HYPOXIC INFLAMED ENVIRONMENT PRODUCES STEM CELLS THAT SUMMERY WERE NOT IDEAL FOR TRANSDUCTION WITH A LENTIVIRAL VECTOR. SO LOW YIELDS, LOW EFFICIENCY OF TRANSDUCTION. ALTHOUGH THE TARGETS WERE VERY SIMILAR BETWEEN THE THALASSEMIA AND SICKLE CELL TRIALS, THE SIMILAR DOSES WERE ASSOCIATED WITH INADEQUATE MYELO ABLATION AND SO AS A RESULT, THERE WAS SUBOPTIMAL ENGRAFTMENT OF TRANSDUCED CELLS. WHAT HAPPENED SINCE THEN IS THAT ALL PATIENTS NOW UNDERGO PRE-HARVEST TRANSFUSIONS. PLERIXAFORE ONLY FOR MOBILIZATION. THE CELL PURIFICATION AND THE TRANSDUCTION HAS BEEN MODIFIED BUT CERTAINLY ONCE THAT HAS OCCURRED, THESE CELLS ARE AGAIN CRYOPRESERVED. THE PATIENTS UNDERGO SINGLE-DRUG CONDITIONING CHEMOTHERAPY THAT IS STILL WITH MYELO ABLATIVE INTENT BUT INCREASING THE TARGET AUC. ONCE THE CELLS ARE INFUSED, THE HOPE IS THAT WE WILL SEE SUCCESSFUL ENGRAFTMENT OF A HIGHER PERCENTAGE OF TRANSDUCED CELLS. THIS IS THE SCHEMA AS OF MAY. THIS WAS PRESENTED AT EHA EARLIER THIS SUMMER, LOOKING AT THE INITIAL GROUP, WHICH WAS ALREADY DESCRIBED UNDERWENT BONE MARROW HARVEST VERSUS A VERY SMALL NUMBER OF INDIVIDUALS WHO HAD BONE MARROW HARVEST BUT TO HELPED US TO UNDERSTAND THIS REFINED MANUFACTURING PROCESS AND THEN NOW LARGER GROUP OF INDIVIDUALS WHO HAVE UNDERGONE SOLELY PLERIXAFORE MOBILIZATION AND REFINED MANUFACTURING. I'M GOING TO BE SHOWING YOU DATA AS OF EHA AND WE ARE LOOKING FORWARD TO JOHN'S PRESENTATION AT THE ASH MEETING IN SAN DIEGO WHICH WILL GIVE US EVEN FURTHER NUMBERS OF PATIENTS WHO ARE IN GROUP C. THIS IS AGAIN WHAT WE SAW WAS THAT WE LOOKED AT VECTOR COPY NUMBER. NUMBERS THAT ACTUALLY WERE COMPARABLE TO THOSE THAT WERE SEEN IN THALASSEMIA PATIENTS, ALTHOUGH IT WAS ALREADY DESCRIBED CLEARED QUICKLY FROM THEIR PERIPHERAL BLOOD VERSUS THOSE WITH THE ENHANCEMENT IN THE MANUFACTURING PROCESS, MUCH HIGHER VECTOR COPY NUMBERS, HIGHER PERCENTAGE OF TRANSDUCED CELLS AND ALSO HIGHER CD34 CELL DOSES ESPECIALLY IN THIS LAST GROUP. WHAT THAT LED TO IS AN IMPROVED EXPRESSION OF T87Q WHICH IS REALLY WHAT MATTERS TO THE PATIENT. WE HAVE COMBINED THAT FIRST PATIENT THAT WAS IN THE HGB205 TRIAL FROM FRANCE, COMPARING THOSE PATIENTS THAT WERE THE ORIGINAL COHORT IN HGB206 AND NOW THE MORE RECENT PATIENT THROUGH HGB206 THAT HAVE NOT ONLY UNDERGONE PERIPHERAL BLOOD STEM CELL COLLECTION BUT ALSO WITH THE ENHANCED MANUFACTURING. AND SO FROM VERY EARLY ON, WE ARE SEEING CERTAINLY FAR BETTER HEMOGLOBIN AT87Q CONCENTRATIONS. WE ARE LOOKING FORWARD TO SEEING THE UPDATED DATA THAT WE SHOULD BE AVAILABLE FOR THE MEETING IN DECEMBER. THIS IS ALSO THE BOTTOM LINE FOR THESE INDIVIDUALS WHEN WE COMPARE THE DIFFERENT KINDS OF HEMOGLOBIN FRACTIONS AND THE IMPROVEMENTS THAT WE HAVE SEEN OVER TIME IN SICKLE CELL DISEASE. THIS BEING THE ORIGINAL COHORT OF PATIENTS WHO UNDERWENT BONE MARROW HARVEST AND THE PINK BAR IS REFLECTING THE HEMOGLOBIN THAT CONTAINS T87Q. AND CERTAILY THESE INDIVIDUALS WHILE SOME OF THEM HAVE HAD FEW SYMPTOMS, THEY STILL CARRY PREDOMINANTLY HEMOGLOBIN S. SOME OF THEM HAVE HAD SOME EXPANSION IN THEIR FETAL GLOBIN BUT IT IS STILL FAR BELOW WHAT WE THINK IS THERAPEUTIC. INDIVIDUALS WHO HAVE THE -- STILL HAD BONE MARROW AS THEIR SOURCE BUT WITH THE REFINEMENTS AND THE MANUFACTURING PROCESS HAVE SEEN IMPROVEMENTS IN THE PRODUCTION OF T87Q. WE ARE LOOKING FORWARD TO SEEING MORE PATIENTS LIKE THIS GENTLEMAN WHO AT THIS POINT WOULD ESSENTIALLY HAVE SICKLE CELL TRAIT WITH A NORMAL HEMOGLOBIN. ONE THING THAT WE'LL -- A COUPLE OF OTHER THINGS THAT WILL BE PARTICULARLY EXCITING AT THE ASH MEETING IN DECEMBER IS THE FIRST CLINICAL READ ON SOME OF THE OTHER GENE THERAPIES PROGRAMS. THIS IS A VECTOR WHICH IS QUITE INTERESTING IN THAT SHE IS EMBEDDED GAMMA GLOBIN SEQUENCES WITHIN BETA GLOBIN. AND IN THE LABORATORY HAS CERTAINLY SEEN REALLY REMARKABLE INCREASES IN TOTAL HEMOGLOBIN USING THIS APPROACH. SO THE FIRST INDIVIDUALS WHO HAVE ACTUALLY COMPLETED -- WHO HAVE UNDERGONE INFUSIONS WITH THIS VECTOR WILL BE REPORTED OUT IN THE GENE THERAPY SESSION IN DECEMBER. WE ARE ALSO VERY EXCITED THAT THAT SESSION WILL ALSO INCLUDE THE FIRST READ OUT FROM BOSTON CHILDRENS WHO HAVE TAKEN A VERY DIFFERENT APPROACH USING A KNOCK DOWN OF BC11A USING A SHORTED HAIR PIN RNA INTERFERENCE APPROACH THAT IS DOWN REGULATED THE DEFECTIVE BETA GLOBIN AND ESSENTIALLY HOPEFULLY NORMALIZED THE ALPHA BETA IMBALANCE AND SO, CERTAINLY THE FIRST PATIENTS THAT HAVE UNDERGONE THIS APPROACH WILL BE DISCUSSED AS WELL. THERE IS ALSO AN ADDITIONAL APPROACH USING A BETA AS3 VECTOR THAT HAS COMBINED A NUMBER OF ADDITIONAL MUTATIONS THAT WILL HAVE A NUMBER OF BENEFITS MUCH OF WHAT I DESCRIBED AT THE BEGINNING IN TERMS OF TRYING TO ACTUALLY IMPROVE INTERACTIONS, INHIBITING POLYMERIZATION BUT ENHANCING INTERACTIONS WITHASMA. THIS PROGRAM IS OPEN -- WITH ALPHA -- THIS PROGRAM SHOULD BEGIN ENROLLMENT IN PATIENTS IN THE NEAR FUTURE. GENE THERAPY, THE RISKS EVER SOMEWHAT DIFFERENT THAN THEY ARE WITH ALLOGENEIC STEM CELL TRANSPLANT. MOST HAVE BEEN TOXICITIES RELATED TO CONDITIONING ITSELF. THEY HAVE BEEN SHORT-LIVED. EVEN THOSE WITH DISEASE HAVE RESPONDED TO CONVENTIONAL THERAPY. THERE REMAINS A CONCERN FOR GRAFT FAILURE SUCH THAT EVERY PATIENT HAS HAD A BACKUP MARROW THAT IS UNMODIFIED THAT HAS BEEN STORED AT THE CLINICAL SITE. NONE HAVE BEEN USED TO DATE. CLONAL DOMINANCE OR INSERTIONAL ONCOGENESIS IS CERTAINLY ONE OF THE READ OUTS ON THE LONG-TERM FOLLOW-UP ON THESE INDIVIDUALS AS WELL AS VIRAL INFECTIONS. STILL LOOKING AT DOSES CURRENTLY EMPLOYED, WE EXPECT THEM TO CAUSE INFERTILITY. ALL PATIENTS ON THESE TRIALS ARE BEING OFFERED FERTILITY CRYOPRESERVATION AS PART OF THEIR CONSENT PROCESS. THERE STILL REMAINS SOME QUESTIONS. WILL THIS SINGLE INFUSION BE DURABLE? THAT'S A VERY FAIR QUESTION. THUS FAR WE ARE VERY ENCOURAGED IN THE THALASSEMIA TRIALS. THE VERY FIRST PATIENT WAS DONE IN 2009 BUT CERTAINLY IN THIS NEW ERA, THE PATIENTS ARE OUT ALMOST FIVE YEARS AND CONTINUE TO HAVE STABLE EXPRESSION FROM THE VECTOR. ARE THERE ADDITIONAL MODIFICATIONS TO FURTHER REDUCE THE RISK? I THINK THE ONE THAT MOST OF US ARE LOOKING FORWARD TO AS A NON-GENOTOXIC CONDITIONING RENTAL MIN THAT WILL OVERCOME A GREATER U. GREAT CONCERN THAT MANY OF THE FAMILIES HAVE ABOUT PARTICIPATING. WILL RESULTS BE BETTER IN YOUNGER PATIENTS? THE NOTION THAT THESE ARE INDIVIDUALS THAT HAVE LESSENED ORGAN DAMAGE, WHETHER THAT IS IN THALASSEMIA OR SICKLE CELL DISEASE, THAT PRESUMABLY HAVE GREATER MARROW RESERVE AND A GREATER ABILITY TO OVERCOME ANY OF THE SIDE EFFECTS OF TRANSPLANTATION. ONE CAN ONLY HOPE. THE SICKLE CELL TRIAL, WAS RECENTLY MODIFIED SUCH THAT WE ARE NOW GOING DOWN TO THE AGE OF 12. UP UNTIL NOW ONLY BEEN AVAILABLE FOR PEOPLE 18 AND ABOVE. AND IN THE U.S., THE THALASSEMIA TRIALS ARE DOWN TO AGE 5, REFLECTING INCREASED COMFORT WITH THE SAFETY AND LENTIVIRAL APPROACHES. AND ONE THING IS PARTICULARLY EXCITING IS WANTING TO UNDERSTAND HOW THE RESULTS OF THESE GENE THERAPY APPROACHES FOR SICKLE CELL DISEASE AND THALASSEMIA, DIFFER OR ALIGN. SO IN SUMMARY, I THINK IT IS FAIRLY CLEAR THAT WE HAVE MADE PROGRESS IN SICKLE CELL MANAGEMENT TO EXTEND THE LIFESPAN FOR MANY. THEY CONTINUE TO SUFFER FROM DISEASE OR TREATMENT-RELATED COMPLICATIONS THAT RESULT IN SIGNIFICANT MORBIDITY. DECISIONS TO OFFER TRANSPLANTS SHOULD BE BALANCED AGAINST THE RISKS THAT ARE INVOLVED WITH THE APPROACH AND THE SEVERITY OF THEIR DISEASE SUCH AS IT IS IN TERMS OF OUR ABILITY TO PREDICT SEVERITY. THE EARLY GENE THERAPY RESULTS IN MY OPINION, ARE PROMISING. THEY MAY PROVIDE CURES BUT THEY WANT FURTHER INVESTIGATION IN A RESEARCH SETTING. AND SO, WHILE I THINK MANY OR ALL OF US IN THE ROOM WHO ARE WEDDED TO BETA GLOBIN AS OUR CAREER PATH, CAN CERTAINLY SEE OVER THE COURSE OF OUR CAREER, HOW OUR UNDERSTANDING OF DNA AND ITS PLACE IN THE MILL YOU OF THE CELL CAN NOW IMPACT THE PATIENT. I BELIEVE THAT THIS ONE SINGLE GENE HAS THE POSSIBILITY OF TRANSFORMING HEMATOLOGY ONE GENE AT A TIME. TING IS ALWAYS IMPORTANT FOR US TO ALWAYS REMEMBER THAT WE WILL ONLY DO SO ONE PATIENT AT A TIME. THANK YOU. [ APPLAUSE ] >> THANK YOU. WE'LL TAKE QUESTIONS. >> HI, GREAT TALK. DO YOU ENVISION YOUR FUTURE IN WHICH GENE THERAPY CAN BE APPLIED WITHOUT THE NEED FOR THE BU SULF IN CONDITION? >> SO THAT'S A GREAT QUESTION. I THINK THE SHORT ANSWER IS, NO. BUT I CERTAINLY THINK THAT IS THE HOPE. OF THE PROGRAMS THAT ARE BEING PRESENTED -- REDUCED INTENSITY. IN MY OPINION, IT IS STILL MYELO ABLATIVE BUT IT CERTAINLY, NOT EVERYONE ISSUES BU SULF IN ALONE. BUT THERE HAVE BEEN ATTEMPTS AND CERTAINLY THERE IS DATA FOR INSTANCE IN THE SKIDS SCENARIO WHERE THEY ARE USING CERTAINLY FAR LESS AND IN SOME CASES NO MYELO ABLATION BUT ONE CAN ARGUE THAT I THINK IT IS SAFE TO SAY THAT HEMOGLOBINOPATHY IS QUITE DIFFERENT. THE NOTION ABOUT THE NON-GENOTOXIC APPROACHES ARE VERY APPEALING BUT I THINK THAT EVEN AS ONE LOOKS AT ENHANCED -- INCREASING THE PERCENTAGE OF STEM CELLS THAT ARE TRANSDUCED, THERE IS STILL NO SELECTION ADVANTAGE AT THE STEM CELL LEVEL IN OUR CURRENT APPROACH. SO WE WILL STILL SEE COMPETITION BETWEEN THEIR NATIVE STEM CELLS AND THESE MODIFIED ONES. SO IN MY OPINION, WHILE WE CAN LOOK FORWARD TO A NON-GENOTOXIC APPROACH, I THINK IN THE CURRENT SETTING, DOING SOMETHING LESS THAN MYELO ABLATION I THINK RUNS ITS RISK OF US NOT SEEING THE CLINICAL BENEFIT. >> THANK YOU. DO YOU SEE ANY EVIDENCE FOR CHAIN IMBALANCE AND DO YOU THINK IT IS GOOD OR BAD IN SICKLE CELL PATIENTS? >> I THINK WE DEFINITELY SEE SOME EVIDENCE OF CHAIN IMBALANCE. SO THERE IS A PORTION OF SICKLE CELL DISEASE THAT DOESN'T AFFECT RYTH ROW PARESIS. TO THE EXTENT THAT ONE CAN ACTUALLY OVERCOME THAT CHAIN IMBALANCE, ONE SHOULD EXPECT TO SEE RYTH ROW PARESIS IMPROVE. WHEN WE THINK ABOUT ADDING FOR INSTANCE, EXTRA BETA GLOBE IN BUT WITH NOT HAVING -- I THINK WE ARE GOING TO HAVE TO SORT OF MAKE SURE THAT WHEN WE LOOK AT FOR INSTANCE, INCREASING GAMMA, IF WE INCREASE GAMMA BY SOME OF THE -- WHICH IS THE CASE IN SOME OF THE OTHER PROGRAMS, DO YOU SEE AN OUTCOME THAT IS FUNDAMENTALLY DIFFERENT THAN SOLELY ADDING MORE BETA? I THINK NOW THAT WE HAVE OTHER VECTORS MOVING INTO THE CLINICAL REALM, I THINK THAT THAT IS GOING TO BE AN IMPORTANT QUESTION TO ANSWER. >> TO FOLLOW-UP ON WHAT YOU WERE JUST TALKING ABOUT IN TERMS OF THE COMBINATION OF CELLS THAT ARE CORRECTED AND NOT CORRECTED AT STEM CELL LEVEL AND THEN THE OUTCOME THAT YOU HAVE RED CELLS THAT ARE CORRECTED AND NOT CORRECTED, COEXISTING. DO YOU HAVE ANY INSIGHT INTO THE PATIENTS THAT YOU DESCRIBED WHO HAVE THAT RESIDUAL FRACTION OF SICKLE HEMOGLOBIN? HOW MANY OF THOSE CELLS ARE JUST CONTAINING S AND HOW MANY ARE CO-EXPRESSING SICKLE AND TRANSGENIC REPAIRED BETA GLOBIN? AND THAT'S IN THE CONTEXT OF THE VERY EXCITING REPORT FROM THE FRENCH PATIENT WITH CORRECTION WHERE IT'S ABOUT A 50/50 BALANCE, BUT THEN THE REPORT SUBSEQUENTLY THAT THAT PATIENT HAD EVASIVE OCCLUSIVE EVENT AT THE TIME OF GASTROINTESTINAL ILLNESS AND SOME FRACTION OF CELLS THAT ARE ONLY IN THAT PATIENT AT LEAST. >> I THINK YOUR POINT IS VERY WELL TAKEN. AND IN FACT, WE DON'T -- THAT IS SOMETHING THAT NEEDS TO BELIEVE EVALUATED MUCH MORE CLOSELY. I DON'T BELIEVE THAT WE, AT THIS POINT, CAN SAY THAT WE HAVE ANYTHING THAT VAGUELY RESEMBLES PAN CELLULAR EXPRESSION, BUT CERTAINLY THAT WOULD BE THE GOAL. THAT INDIVIDUAL, THAT FIRST CHILD, THE PERCENTAGE OF THEIR STEM CELLS THAT WERE TRANSDUCED WERE IN THE RANGE OF WHAT WE SAW WITH THALASSEMIA AND THAT WAS WELL UNDER 50% OF HIS STEM CELLS THAT WERE RETURNED TO HIM AT THE TIME OF THE TRANSPLANT ACTUALLY HAD ANY VECTOR IN THEM. CERTAINLY THE PERCENTAGE OF STEM CELLS BEING RETURNED NOW IS FAR HIGHER, WELL ABOVE 80%, AND IN MOST OF THE PATIENTS WITH BOTH THALASSEMIA AND SICKLE CELL DISEASE. HAVING SAID THAT, I STILL THINK WE HAVE TO ASK THE QUESTION, IS IT -- OF THE CELLS THAT ARE TRANSDUCED, WILL WE SEE FOR INSTANCE PAN CELLULAR EXPRESSION? AND I THINK THAT EVEN IF WE ARE NOT, THIS AGAIN SORT OF SPEAKS TO THE NOTION ABOUT REDUCING OR ELIMINATING CONDITIONING GIVEN THAT WE HAVE NOT ACHIEVED THAT, THIS IS PROBABLY NOT THE TIME TO THINK ABOUT PULLING BACK ON CONDITIONING. >> SO CAN YOU DEVELOP A KIND OF ANTIBODY AGAINST MODIFIED HEMOGLOBIN AND THEN YOU CAN DO A KIND OF DISTRIBUTION WITHIN THE CELLS? >> SO THAT BEING LOOKED AT NOW AND SOME OF THAT IS GOING TO BE PRESENTED AT ASH. AND BECAUSE AGAIN, I THINK THAT THAT IS SOMETHING THAT IS VERY IMPORTANT FOR US TO UNDERSTAND. IT'S ALSO, AND AGAIN WE WERE JUST GETTING SOME ABILITY TO LOOK AT -- SO WHAT I PRESENTED WAS SIMPLY FRACTIONS OF HEMOGLOBIN, WHICH GIVES US SOME IMPRESSION, GIVEN ALL OF THE OTHER WAYS WHERE WE HAVE CREATED A THRESHOLD AND WE THINK BETWEEN 20-30% NON SICKLING HEMOGLOBIN BEING OF CLINICAL BENEFIT. THE REALITIES ARE THAT IT SHOULD BE OTHER WAYS TO EVALUATE IN THE PATIENT HOW THIS ADDITION OF MODIFIED STEM CELL CAN ACTUALLY MODIFY THEIR DISEASE. SO BEING ABLE TO USE SOME NEWER ANTI-SICKLING ASSAYS -- BECAUSE THERE ARE SOME PATIENTS FOR INSTANCE WHO ARE ABLE TO RAISE THEIR HEMOGLOBINS EVEN THOUGH THEY STILL HAVE PREDOMINANTLY HEMOGLOBIN S. SO IT SUGGESTS THAT AGAIN, WHETHER IT IS IN EFFECTIVE RYTH ROW PARESIS OR REDUCTION HOMOLYSIS THAT PRESENCE OF THIS VECTOR THAT HAS SOME ANTI-SICKLING CHARACTERISTICS MAY HAVE A BENEFIT THAT EXCEEDS WHAT ONE CAN SOLELY ACCOUNT FOR BASED ON THE PERCENTAGE OF THE HEMOGLOBIN THAT IS PRODUCED. PERHAPS IT'S THAT INHIBITION THAT IS SOMETHING THAT WE NEED TO BE ABLE TO QUANTIFY BETTER BECAUSE THERE MAY BE THERAPEUTIC BENEFITS THAT IN ADDITION TO THE PERCENTAGE OF THE CELLS THAT NO LONGER PRODUCE HEMOGLOBIN S. >> THANK YOU DR. THOMPSON AND THANK YOU TO OUR SPEAKERS. THIS ENDS THE SESSION. [ APPLAUSE ] A LOT OF GREAT CONVERSATIONS. SO OF COURSE WE ARE OVER TIME. MAYBE I CAN ASK EVERYONE TO TAKE 10 MINUTES AND BE BACK 11:00. THANK YOU. [ BREAK ] >> GOOD MORNING, EVERYONE. WELCOME TO SESSION 5, CEREBRAL VASCULAR DISEASE IN SICKLE CELL DISEASE. OUR FIRST SPEAKER IS DR. LORI JORDAN, DIRECTOR OF THE PEDIATRIC STROKE PROGRAM AT VANDERBILT UNIVERSITY MEDICAL CENTER TALKING TO US ABOUT CEREBRAL VASCULAR DISEASE IN SICKLE CELL. >> GOOD MORNING. THANK YOU FOR THE INVITATION TO PRESENT. IT'S AN HONOR TO BE AT THIS CONFERENCE AND FULL DISCLOSURE, I AM A NEUROLOGIST AND SO, SOMETIMES I MAY THINK ABOUT SICKLE CELL AND BRAIN INJURY DIFFERENTLY BUT THAT IS THE FUN OF THIS CONFERENCE IS TO HEAR ALL OF THE DIFFERENT PERSPECTIVES. SO I'LL TRY TO FINISH IN TIME FOR A LITTLE BIT OF DISCUSSION. I REALLY DON'T HAVE ANY SIGNIFICANT DISCLOSURES. I DO HAVE SOME FUNDING, BUT I DON'T THINK IT IMPACTS MY TALKS HERE AND IT'S ALL FROM FOUNDATIONS OR THE NIH. AND I'M GOING TO COVER EPIDEMIOLOGY AND TYPES OF CEREBRAL VASCULAR DISEASE IN CHILDREN WITH SICKLE CELL DISEASE AND TALK A LITTLE BIT ABOUT WHY THE BRAIN IS VULNERABLE IN SICKLE CELL AND HOW THAT BRAIN INJURY IS SUBTLE SOMETIMES BUT CAN BE ACCUMULATIVE AND THEN TALK A LITTLE BIT ABOUT NEWER FORMS OF NEUROIMAGING THAT MAY GUIDE US IN THE FUTURE. JUST TO TALK ABOUT THE SCOPE BRIEFLY. A LOT OF TIMES WE TALK ABOUT ISCHEMIC STROKE AND ISCHEMIC BRAIN INJURY, BUT IT IS MORE BROAD AND ALL OF THESE TYPES LISTED HERE DO APPLY TO INDIVIDUALS WITH SICKLE CELL DISEASE SO THERE ARE HEMORRHAGIC STROKES WHICH NEUROLOGISTS LIKE TO DIVIDE INTO CEREBRAL HEMORRHAGE, WHICH IS HEMORRHAGE INTO THE PRANK MA OF THE BRAIN, AND SUB RACKINOID HEMORRHAGE, HEMORRHAGE USUALLY FROM ANEURYSM THOUGH CAN BE FROM TRAUMA, INTO THE FLUID-FILLED SPACES AROUND THE BRAIN. INFARCS, ANEURYSMS, CEREBRAL VASCULOPATHY, WHICH I THINK IS MORE CORRECTLY DISCUSSED AS INTRACRANIAL STENOSIS WITH THE MOST SEVERE FORM BEING MOIA MOIA AND CERVICAL VESSEL STENOSIS. SO WHY IS CEREBRAL VASCULAR DISEASE SO IMPORTANT IN SICKLE CELL DISEASE? I THINK IT'S PROBABLY OBVIOUS TO THE PEOPLE ATTENDING THIS CONFERENCE, BUT WE HAVE TALKED A LOT ABOUT OVER THE LAST 20 YEARS AND HOW THERE HAS BEEN A SHIFT FROM SICKLE CELL DISEASE BEING EARLY LIFE-THREATENING CONDITION TO MORE OF A CHRONIC DISEASE WHERE WE ARE THINKING ABOUT THE LONG TERM FOR THESE PATIENTS NOW THAT IN FOR EXAMPLE THE PARIS COHORT SURVIVAL WAS 99% TO THEINEth BIRTHDAY. AND SO -- 18th BIRTHDAY. IN CHILDREN, STROKE IS THE MOST COMMON DEBILITATING COMPLICATION IN SICKLE CELL DISEASE IN THAT 2-5% HAVE STROKES AND 39% WILL HAVE SILENT INFARCS BY AGE 18. CERTAINLY DEPENDING ON YOUR SUBSPECIALTY, YOU MAY HAVE DIFFERENT OPINIONS ABOUT WHAT IS DEBILITATING BUT I THINK THE CONSEQUENCES OF BRAIN INJURY ARE PERMANENT AND SO WE NEED TO REALLY THINK ABOUT IT. AND JUST BEFORE WE GET GOING, THESE ARE PRETTY WELL-ESTABLISHED TERMS BUT OVERT STROKE, OR JUST STROKE IS REALLY A NEUROLOGIC DEFICIT THAT IS CONSISTENT VASCULAR PATTERN. WE THINK OF IT AS WEAKNESS OF FACE AND ARM, FACE, ARM AND LEG, OR A CONSISTENT PATTERN WITHIN THE BRAIN THAT CORRELATES WITH A NEW LESION ON YOUR MRI THAT IS ISCHEMIC OR HEMORRHAGIC AND THAT EXPLAINS THE DEFICIT. SILENT CEREBRAL INFARCS, SILENT STROKE, THESE ARE ALL TERMS THAT ARE USED TO TALK ABOUT LESIONS SEEN ON MRI THAT DON'T HAVE ANY OVERT CLINICAL SYMPTOMS. SO AND THERE IS MEASUREMENTS IN AT LEAST IN CHILDREN IN THE SICKLE CELL DISEASE LITERATURE, THE SIZE IS 3 MILLIMETERS VISIBLE IN ONE PLANE AND THEN YOU CAN SEE IT IN A SECOND PLANE. EVERY SLICE ON AN MRI IS USUALLY BETWEEN 3-5 MILLIMETERS APART SO IT HAS TO BE AT LEAST 3 MILLIMETERS SO YOU CAN CONSISTENTLY SEE IT, AND THEN USUALLY THERE IS NOTHING FOCAL ON YOUR NEUROLOGIC EXAM, THOUGH WE ALL I THINK RECOGNIZE THAT SILENT INFARCS AREN'T REALLY SILENT IN THEIR COGNITIVE CONSEQUENCES. AND SO, WITHOUT PRIMARY STROKE PREVENTION, THE INCIDENCE OF STROKE IN CHILDREN WITH SICKLE CELL DISEASE IS 240 PER 100,000. THIS IS IN DIRECT CONTRAST TO OTHER CHILDREN WITHOUT SICKLE CELL DISEASE WHERE THE OVERALL RISK, IF YOU JUST SAY ALL COMMERCE REALLY STROKE IN CHILDREN IS 2-3 PER 100,000. WHICH IS ABOUT THE INCIDENCE OF CNS TUMORS, BUT IT'S ABOUT 100 FOLD LESS THAN THE RISK OF TO ECK IN CHILDREN WITH SICKLE CELL DISEASE. SO AND SICKLE CELL DISEASE ACCOUNTS FOR A LOT OF THE STROKE IN AFRICAN-AMERICAN CHILDREN, THOUGH NOT ALL OF IT. SO, ONE OF THE BIG SUCCESS STORIES HAS BEEN PRIMARY PREVENTION THAT HAS REDUCED THIS STROKE INCIDENCE DRAMATICALLY, AT LEAST 10 FOLD. AND THIS KIND OF HARKENS BACK TO THE OLD COOPERATIVE STUD WHICH SHOWS THAT THE BIG RISK FOR ISCHEMIC STROKE HAS BEEN IN CHILDREN BEFORE THEIR FIFTH BIRTHDAY AND THEN A BIGGER RISK FOR HEMORRHAGIC STROKE IN THE 20s AND 30s. BUT I THINK THIS EPIDEMIOLOGY IS LIKELY CHANGING AGAIN WITH BETTER CARE. WHAT'S NOT CHANGING RIGHT NOW AT LEAST IS THAT THERE IS SILENT INJURY THAT ACCUMULATES AND I CIRCLED THE 39% HERE BECAUSE THIS IS WHERE AT YOUR 18th BIRTHDAY BUT LOOK HERE, UPGREATER THAN 50% BY AGE 30. SILENT BRAIN INJURY IS REALLY LIFE-LONG AND IT HAS -- IF WE ARE THINKING ABOUT THIS AS A CHRONIC DECEASED, WE WANT TO PROTECT OUR PATIENTS LONG TERM. SO THEY CAN HAVE A SUCCESSFUL ADULT LIFE, NOT JUST A SUCCESSFUL CHILDHOOD. THE CEREBRAL VASCULOPATHY, THIS JUST IS AN MRA PICTURE OF A CHILD WITH WORSENING VASCULOPATHY FROM FOUR YEARS TO EIGHT YEARS OF AGE. YOU CAN SEE THE BLOOD VESSELS SLOWLY DISAPPEARING IN GROWTH OF NEW VESSELS THAT REALLY AREN'T SUPPOSED TO BE THERE. THESE HIS PEE VESSELS. SO THIS IS THE PICTURE -- HIS PEE -- THIS IS A PICTURE OF MOIIA MOIIA, BILATERAL OCCLUSIONS OR STENOSIS AND SOMETIMES OCCLUSION OF THE INTERNAL CAROTID AND MIDDLE CEREBRAL ARTERIES. IT'S NOT COMMON. 5-10% OF CHILDREN WITH SICKLE CELL DISEASE, 10-15% OF ADULTS HAVE THESE INTERCRANIAN STENOSIS. IT'S USUALLY PROGRESSIVE DESPITE OUR THERAPIES. AND THIS IS WORK BY ONE OF THE LATER SPEAKERS IN THIS PANEL LOOKING AT CHILDREN WHO WERE BEING TRANSFUSED WITH A HISTORY OF STROKE AND FINDING THAT VASCULOPATHY MAKES A BIG DIFFERENCE. SO IF YOU HAVE WORSENING VASCULOPATHY, HERE THIS DOTTED LINE, YOU'RE HAVING MORE STROKE SILENT AND OVERT STROKES DESPITE ADEQUATE TRANSFUSION THERAPY. SO VASCULOPATHY WHEN IT HAPPENS, IS A BIG DEAL IN THAT STUDIES, 45% HAD PROGRESSIVE SILENCED INFARC ON CHRONIC TRANSFUSION THERAPY AND VASCULOPATHY WAS A BIG RISK FACTOR WITH A RELATIVE RISK OF 12. SO IT REALLY IN THAT SETTING, I THINK BLOOD TRANSFUSION IS FAIRLY PALLIATIVE. IT'S HELPING BUT IT'S NOT FIXING THE PROBLEM, AND THAT'S WHY OTHERS HAVE TALKED SO MUCH ABOUT MORE CURATIVE THERAPIES LIKE TRANSPLANT. AND WHAT ABOUT CERVICAL VASCULOPATHY? THIS COMES UP A LOT AND I THINK IT'S THE MOST COMMON THING I'M ASKED WHEN I'M WRITING YOU A MANUSCRIPT ABOUT STROKE. DID YOU SCREEN THE CERVICAL VESSELS? AND I THINK WHAT'S IMPORTANT TO KNOW IS THAT MRI MAY OVERCALL STENOSIS. IT'S A FLOW STUDY AND MRA CLASSICALLY OVERESTIMATES STENOSIS. SO REALLY A GOLD STANDARD WOULD BE SOMETHING LIKE A CEREBRAL ANGIOGRAM BUT REGARDLESS, SOME OF THE BEST DATA WE HAVE IS OUT OF FRANCE WHERE THEY TOOK 104 CHILDREN AND LOOKED AT BOTH CAROTIDS, SO TWO CAROTIDS PER CHILD IN THE NECK, AND FOUND THAT IF YOU LOOK AT WHAT NEUROLOGISTS WOULD CALL A HEMODYNAMICALLY STENOSIS, STENOSIS THAT SHOULD PUT YOU AT RISK FOR STROKE OR OTHER COMPLICATIONS, THAT WOULD BE A STENOSIS THAT IS GREATER THAN 70%. AND THEY FOUND THAT IN SEVEN OF 208 VESSELS OR 3%. WHAT IS OFTEN QUOTED IS MORE LIKE 12% IF YOU ADD THESE UP, AND THAT IS BECAUSE THEY LOOKED AT STENOSIS THAT WERE GREATER THAN 50%. 50-69% STENOSIS IS NOT REALLY THOUGHT TO BE HEMODYNAMICICALLY SIGNIFICANT BUT IT'S NOT NORMAL SO IT IS SOMETHING YOU MIGHT WANT TO WATCH AND CERVICAL STENOSIS WAS ASSOCIATED WITH SILENT INFARC IN THIS FRENCH COHORT. IT DOES GIVE US REASSURANCE IN EVERY CHILD WITH SICKLE CELL DISEASE, YOU DON'T NEED TO BE IMAGING THEIR NECK VESSELS. HEMORRHAGIC STROKE, WHAT ARE THE RISK FACTORS? PREVIOUS ISCHEMIC ECK STROKE, HAVING ABNORMAL BLOSSVESSELS, SOME SAY HYPERTRANSFUSION, HIGH WHITE COUNT, LOW HEMOGLOBIN, ACUTE CHEST, HAVING ANEURYSM. HEMORRHAGIC STROKE IS A FEARED COMPLICATION BUT IT'S FAIRLY RARE IN CHILDREN BUT IMAGING LIKE THESE WITH A BIG HEMORRHAGE OR A BIG SUB ARACHNOID HEMORRHAGE -- AND THIS WAS FROM A VERY LARGE ANEURYSM WHERE THERE IS SUB ARACHNOID BLOOD WHERE THERE WAS A LARGE AREA OF HEMORRHAGE AS WELL AS SUB ARACHNOID BLOOD. THAT IS FAIRLY UNUSUAL BUT SOME CHILDREN HAVE MORE GIANT ANEURYSM. AND SO, OBVIOUSLY IT'S DEBILITATING WHEN IT HAPPENS THOUGH IT IS RARE. AND THERE ISN'T REALLY GREAT INCIDENTS DATA IN YOUNG CHILDREN. THERE IS SOME DATA ABOUT ANEURYSMS. THE GROUP AT PENN PUBLISHED A LARGE GROUP OVER 700 CHILDREN IN ADULTS AND THEY FOUND ANEURYSMS IN 1% OF CHILDREN AND A LITTLE OVER 10% IN ADULTS. AND SO, THE ANEURYSM RATE IN CHILDREN IS .001% PROBABLY. SO THIS IS A LARGE, RELATIVE INCREASE THOUGH STILL SMALL NUMBERS IN ADULTS AND RATES MORE LIKE 2%. SO AGAIN, IT'S PROBABLY A 5-FOLD INCREASE. SO, AND THEN IF YOU FIND ONE YOU SHOULD WORRY ABOUT MULTIPLE ANEURYSMS AND ANEURYSMS IN PLACES LIKE THE POSTER CIRCULATION IN THE BLOOD VESSELS IN THE BACK OF THE HEAD. SO, I THINK MRA SCREENING, AT LEAST IN THE ADULT OR YOUNG ADULT AGE GROUP IS PROBABLY REASONABLE. AND WHAT ARE THE COMPLICATIONS OF SICKLE CELL DISEASE? YOU GUYS ALL KNOW THESE BUT I JUST SHOW THIS SLIDE TO BASICALLY SAY, THE MOST COMMON THINGS HERE ARE ISCHEMIC STROKE AND SILENT INFARC AND DR. KING IS GOING TO TALK ABOUT COGNITIVE ISSUES. I REALLY FOCUS ON ISCHEMIC STROKE AND SILENT INFARC BECAUSE THEY ARE THE MOST COMMON THINGS IN CEREBRAL VASCULAR DISEASE. THIS JUST COMPARES RISK FACTORS FOR OVERT STROKE IN CHILDREN VERSUS ADULTS AND JUST SHOWS YOU THAT REALLY IT'S THE SAME RISK FACTORS. WHEN YOU GET TO THE 16 AND UP AGE GROUP, WE DON'T KNOW THAT TCD WORKS FOR THAT POPULATION AND DON'T REALLY HAVE A WAY TO SCREEN AND MONITOR THESE PATIENTS AS THEY GO FORWARD INTO ADULTHOOD, AFTER WE HAVE WORKED SO HARD ON THEM AS CHILDREN. AND WE ALL KNOW IN A LANDMARK STOP STUDY, BUT I BRING IT UP BECAUSE PRIMARY STROKE PREVENTION IS IN TCD AND TO SCREEN AND THEN CHRONIC BLOOD TRANSFUSIONS FOR THOSE WITH ELEVATED TCD, HAS DRAMATICALLY DECREASED THE RATE OF OVERT STROKE IN CHILDREN AND 92% RELATIVE RISK REDUCTION AND IN STUDIES FOLLOWING THAT UP, I MEAN THAT HAS HELD FAIRLY WELL IN CLINICAL PRACTICES AS WELL. THAT THE -- IT REDUCES RISK. AND WE FRANKINGLY SEE VERY FEW OVERT STROKES IN SICKLE CELL DISEASE ANYMORE. IT DOES INCREASE THE NUMBER OF CHILDREN ON CHRONIC BLOOD TRANSFUSION. TWITCH WAS LANDMARK AS WELL BECAUSE IT GAVE SOME REASSURANCE THAT CHILDREN WHO HAD RECEIVED AT LEAST A YEAR OF TRANSFUSION AND HAD NO AM ROID DEFENSE SEVERE VASCULOPATHY GREATER THAN 70% STENOSIS, COULD BE TRANSITIONED TO HYDROXYUREA AND THAT IS NOT INFERIOR TO REMAIN TCD VELOCITIES. AND THIS IS WHEN WE GET INTO SURROGATES AND BIOMARKERS. WE BELIEVE THE TRANSFUSIONS DON'T NEED TO BE LIFELONG FOR PRIMARY STROKE PREVENTION BUT LONG TOMORROW FOLLOW-UP IS NEEDED FOR KIDS TO BE TRANSITIONED TO BE SURE. WHERE ARE THE GAPS? SO PRIMARY STROKE PREVENTION IS GOING WELL. AND WE THINK PROBABLY NOW YOU DON'T NEED LIFELONG TRANSFUSION BUT WHAT ABOUT FOR PRIMARY STROKE PREVENTION, BUT WHAT ABOUT SECONDARY STROKE PREVENTION? WHAT ABOUT KIDS WHO HAD AN OVERT STROKE? THEY NEED LIFELONG TRANSFUSION OR OTHER DISEASE MODIFYING THERAPIES? IF YOU HAVE A SILENT INFARCTED, THE SIT TRIAL FOUND 58% RISK REDUCTION BUT THE NUMBER NEEDED TO TREAT IS HIGH, 13 WITH REGULAR BLOOD TRANSFUSIONS. SO, I THINK IT'S FAIR TO SAY VANDERBILT SHOWS THAT THE SIT PROTOCOL HAS NOT BEEN WIDELY ADOPTED BECAUSE TRANSFUSIONS ARE BURDENSOME, EXPENSIVE AND THERE ARE A LOT OF COMPLICATIONS. SO MORE WORK IS NEEDED FOR SECONDARY STROKE PREVENTION BECAUSE WE HAVE THESE THERAPIES. I WON'T GO OVER THEM AND SPEND TIME BECAUSE WE ALL KNOW ABOUT HIGH ACCIDENT DOE ARIA AND TRANSFUSION AND -- HYDROXYUREA -- AND STEM CELL TRANSPLANT. ASPIRIN, I THINK THERE HAS BEEN SOME STUDIES OF ASPIRIN IN SICKLE CELL DISEASE. I WOULD ARGUE NONE PROBABLY UPON WELL NOVEMBER POWERED WITH LARGE ENOUGH -- WELL -- I WOULD ARGUE PROBABLY NONE IN LARGE ENOUGH STUDIES. IT TREATS PART OF THE PROBLEM. THERE IS GREAT LITERATURE FROM THE ADULT STROKE WORLD IF YOU HAVE AN ADULT WITH A SIGNIFICANT INTERCRANIAL STENOSIS THAT ASPIRINMENTS AND WARFARIN DOESN'T ADD ADDITIONAL BENEFIT -- ASPIRIN HYMNS HELPS. SO IT MAKES SOME SENSE IF YOU ADD ASPIRIN TO INTERCRANIAL STENOSIS YOU WILL HELP THEM TO SOME DEGREE BUT DOESN'T NEGATE THE NEED FOR ALL THE OTHER SICKLE CELL RELATED THERAPIES. AND THEN WE HEARD MORE UP-TO-DATE LITERATURE THAN I HAVE ON STEM CELL TRANSPLANT BUT TRAIN A SHORT-TERM RISK OR MORBIDITY RISK OF 5-10% FOR LONG TERM CURE. SO THE QUESTION IS, AS THE TRIALS WERE ONGOING NOW, SHOULD WE BE IDENTIFYING PATIENTS WITH HIGH RISK OF TRANSPLANT? IT WAS NEWS TO ME THE EUROPEANS THOUGHT THAT WE SHOULD BE TRANSPLANTING FOR SYMPTOMATIC SICKLE CELL DISEASE REALLY YOUNG IN LIFE. SO WE'LL SEE WHERE THE FIELD GOES. AS A NEUROLOGIST, IT COMES TO CEREBRAL HEMODYNAMICS AND THE STROKE MECHANISMS IN SICKLE CELL DISEASE. SO WE TALKED ABOUT CEREBRAL VASCULOPATHY AND INJURY TO BLOOD VESSELS PRESENT IN 5-10% OF CHILDREN AND 10-15% OF ADULTS. VAST MAJORITY OF BRAIN INJURIES ARE HEMODYNAMIC. YOU HAVE IMPAIRED OXYGEN FROM ANEMIA, HEMOGLOBIN S AND VASCULOPATHY AND THEN YOU END UP WITH THESE STROKES, BORDER ZONE INFARC. SO THIS IS THE WATERSHED OR BORDER ZONE WHERE YOU HAVE THESE THREE ARTERIAL TERRITORY EARS, ANTORIAL TERRITORIES, POST CEREBRAL AND THE MIDDLE CEREBRAL TERRITORIES AND BETWEEN THEM IS A WATERSHED ZONE. THIS IS WHERE IF YOU'RE BLOOD PRESSURE DROPS IF YOU BECOME VERY ANEMIC, OR IF YOU HAVE VASCULAR STENOSIS, THIS IS THE LEAST SUPPLIED AREA AND THIS IS WHERE STROKES OCCUR, WHERE SILENT INFARC OCCUR ET CETERA. AND SO THIS IS NICE WORK FROM THE GROUP AT WASH U I KNOW THAT DR. HOL HULBERT WILL TALK ABOUT MORE BUT HIGHLIGHTING THAT SILENT INFARC 90% OF THEM OCCUR IN THIS BORDER ZONE REGION. AND AGAIN WHEN WE LOOK AT THE MRIs THERE THEY ARE. AND SO, WHY? WE ARE ALL TRYING TO MAINTAIN OUR MET LOLLIC RATE OF OXYGEN IN OUR BRAIN AT A STEADY STATE LEVEL. YOU DON'T WANT THAT TO GO UP AND DOWN AS YOU BECOME MORE ANEMIC AND BLUEPRINT CHANGES AND AS YOU STAND AND SIT DOWN. -- BLOOD PRESSURE -- AS YOUR BODY POSITION CHANGES YOU WANT ALL OF THAT TO AUTO REGULATE AND BE THE SAME. SO WE CAN INCREASE CEREBRAL BLOOD FLOW IN PATIENTS WITH SICKLE CELL DISEASE DO. THEY COMPENSATE BY INCREASING CEREBRAL BLOOD FLOW AND THEY CAN INCREASE OXYGEN EXTRACTION FRACTION AS WELL. AND SO, THINGS START TO FALL APART AS YOU GET INTO MORE ADVANCED DISEASE BUT THIS IS JUST A VISUAL OF CEREBRAL BLOOD FLOW AND IN HEALTHY CONTROLS AND IN PATIENTS WITH SICKLE CELL ANEMIA AND THIS IS SPIN LABELING, MANY WAYS TO MEASURE CEREBRAL BLOOD FLOW BUT RED IS HIGHER BLOOD FLOW. SO YOU JUST VISUALLY YOU CAN SEE THAT THE PATIENTS WITH SICKLE CELL HAVE A LOT MORE RED HERE. THEIR BLOOD FLOW IS HIGHER AND THIS HAS BEEN KNOWN AND SHOWN IN PET AND OTHER STUDIES. AND THIS RATIO OF OXYGEN CONSUMED OVER OXYGEN DELIVERED. SO IF YOU THINK ABOUT IT, IF YOU'RE DELIVERY IS LESS, YOU NEED TO CONSUME MORE OF WHAT IS DELIVERED TO MAINTAIN YOUR METABOLIC RATE OF CONSUMPTION. THAT IS WHAT PATIENTS WITH SICKLE CELL DO. THESE THINGS -- AS THE OXYGEN SATURATION IS HANGING IN THERE, YOU INCREASE YOUR CEREBRAL BLOOD FLOW. BUT THEN WHEN YOU CAN'T DO THAT, YOU ALSO INCREASE HOW MUCH YOU CONSUME. IN A HEALTHY PERSON, WE ALL CONSUME ABOUT 30% OF THE OXYGEN THAT OUR BRAIN RECEIVES. IN SICKLE CELL 35-60Y% IS PROBABLY WHAT IS CONSUMES. THERE ARE COMPENSATORY MECHANISMS BUT WHEN THEY FAIL OR SOMEONE GOES INTO ANEMIC CRISIS, WHILE THEY ARE REALLY COMPENSATING, THAT IS WHEN INFARC OCCUR. SO WE NEED TO BE THINKING ABOUT THAT AS WE ARE TRYING TO KEEP THE BRAIN HEALTHY. AND THIS IS JUST A NICE ARTICLE I WANTED TO SORT OF COME TO THE END OF MY TALK WITH ABOUT CHRONIC MICROVASCULAR INJURIES. SO THIS IS OUT OF THE LONDON GROUP. THEY USED DIFFUSION TENSER IMAGING MRI, A TECHNIQUE THAT LOOKS AT WHITE MATTER TRACKS AND THEY SHOWED THAT EVEN WHEN YOUR BRAIN MRI LOOKS NORMAL, YOU ARE HAVING A PROCESSING SPEED ISSUES, AND SO YOU CAN LOOK AT THE SILENT INFARC, LOOK AT THE WHITE MATTER TRACKS BUT EVEN IF THESE ARE NOT ABNORMAL, AND THE BRAIN IS NOT ABNORMAL-LOOKING, STILL IN THE SILENT INFARCT NEGATIVE GROUP, THEIR PROCESSING SPEED DROPS FROM THE HEALTHY CONTROLS UP HERE. SO, I THINK AS WE MOVE FORWARD INTO THINKING ABOUT SICKLE CELL AND CEREBRAL VASCULAR DISEASE CHRONICALLY, ALL OF THE IMAGING WE DO AND THE BETTER THE IMAGING GETS, WE SHOW THAT THE INJURY TO THE BRAIN IS PRESENT WHETHER WE CAN SEE IT OR NOT. AND SO, I THINK WE NEED MORE TOLERABLE SECONDARY PREVENTION STRATEGIES. WE NEED METHODDED TO STOP THE CHRONIC AND ACUTE BRAIN INJURY AND IN THESE PREC PATIENTS, SLOW COGNITIVE DECLINE ISN'T ACCEPTABLE FRANKLY. AND I THINK WHETHER WE CAN SEE IT OR NOT, THE SAME INJURY WE HAVE BEEN TALKING ABOUT IN THE KIDNEY AND THE LIVER AND OTHER PLACES IS OCCURRING IN THE BRAIN. AND SO THAT IS WHERE WE NEED TO FOCUS. AND I'LL CLOSE BY SAYING THERE ARE NO LOW-RISK CHILDREN WITH SICKLE CELL DISEASE. THESE ARE DIFFERENT GROUPS OF PATIENTS BASED ON THEIR RISK. THOSE ARE ABNORMAL TCD AND NODE TRANSFUSION. AND THESE ARE THE GENERAL POPULATION OF CHILDREN. THESE ARE KIDS WITH NORMAL TCD, NO SILENT INFARCT, NO TRANSFUSION. THEORETICALLY THE LOW-RISK GROUP, BUT STILL IN THIS, IF YOU KIND OF USE NUMBERS FROM ALL OF THESE STUDIES, STILL ARE RISK OF BRAIN INJURY THAT IS DRAMATICALLY HIGHER THAN OTHER CHILDREN. THANKS FOR GREAT COLLABORATORS AND THANKS FOR LISTENING. [ APPLAUSE ] >> TIME FOR ONE QUESTION. >> THIS IS SAVVY FROM CHILDREN'S NATIONAL. THANK YOU FOR A GREAT PRESENTATION. JUST A SPECIFIC COMMENT REGARDING ASPIRIN. SO, THE WAY I LOOK AT IT IS WITH INTRACRANIAL STENOSIS WE WILL HAVE PLATELET ACTIVATION AND A LOT OF THE POST-MOTOR EM STUDIES HAVE SHOWN THROMBUS BEING THE MAIN FINDING. SO WITH THAT IN MIND, I THINK ASPIRIN CERTAINLY NEUROLOGISTS PATIENTS ARE ON ASPIRIN BUT SICKLE CELL MAYBE A BIT OF HIGH ON ASPIRIN SENSITIVITY, SO-CALLED RESISTANCE, BUT IT COULD CARRY RESEARCH. I THINK IT WOULD BE INTERESTING TO ALSO LOOK AT OTHER ANTI-PLATELET AGENTS AS A POSSIBILITY. >> YOU'RE RIGHT. I DIDN'T REALLY GO OVER THAT. AND I SAY ASPIRIN BUT REALLY, JUST ANTI-THROMBOTTICS MAKES SENSE. ANTI-PLATELETS, TO ME, AT LEAST. BUT I AGREE, ASPIRIN RESISTANCE HAS COME TO THE FLOOR IN THE LAST COUPLE OF YEARS IN SICKLE CELL ALSO. WE LOOK FOR IT NOW IN MOST ADULT STROKE PATIENTS AS WELL. IT'S PART OF A STANDARD PANEL AT OUR HOSPITAL TO CHECK FOR IT. THANK YOU VERY MUCH. >> THANK YOU DR. JORDAN. [ APPLAUSE ] OUR NEXT SPEAKER IS DR. ALLISON KING. DR. KING IS A PEDIATRIC HEMATOLOGIST ONCOLOGIST AT WASHINGTON UNIVERSITY IN ST. LOUIS. SHE WILL BE SPEAKING TO US ABOUT NEUROCOGNITIVE OUTCOMES IN SICKLE CELL. >> ALLISON KING: THANK YOU TO THE ORGANIZERS AND TO NHLBI FOR INVITING ME AND HOSTING ME AT THIS MEETING. MY DISCLOSURES FOR MY RESEARCH FUNDING AND MY HUSBAND'S CULTSY. I'D LIKE TO START OFF THE TALK BY ADDRESSING INTELLIGENCE QUOTENCE OR THE GENERAL CONCEPT OF COGNITION. LATER WE'LL GET INTO WHAT IS MORE INTERESTING, THE SPECIFIC DOMAINS THAT ARE IMPACTED. BUT AS DR. JORDAN SAID ABOUT THE CEREBRAL VASCULAR INJURY THAT MANY OF OUR PATIENTS EXPERIENCE, WE KNOW AN OVERT STROKE CONTRIBUTES THE MOST TO DECLINE IN COGNITION. THEY SUFFER A SILENT STROKE, A DROP OF ABOUT 5 POINTS. FOR EACH YEAR THAT YOU'RE OLDER, YOU'LL SEE IN MOST MODELS THAT YOU ANTICIPATE THE IQ GRADUALLY DECREASES OVER TIME. SOME BY A POINT PER YEAR. AND THEN FOR OXYGEN SATURATION LEVELS BELOW 100%, MODELS PREDICT THAT THE IQ IS .75 POINTS LESS THAN WHAT YOU WOULD EXPECT. HOWEVER, SOME OF THESE DECLINES CAN BE MELIORATED BY HAVING PARENTS OR PRIMARY CAREGIVER WHO HAS A SLIGHTLY HIGHER EDUCATION LEVEL OF SOME COLLEGE OR MORE IN OUR MODELS WE HAVE DEMONSTRATED THAT THAT IS ASSOCIATED WITH A BUFFER OF INCREASE IN THE IQ BISIX POINTS LIKELY AS A RESULT OF PROVIDING A MORE RICH ENVIRONMENT AND MORE INTERACTION -- BY 6 POINTS. -- NOW DR. JORDAN MENTIONED THE SILENT INFARC AND REALLY THEY ARE NOT SILENT BECAUSE THEY IMPACT YOUR COGNITION. THERE HAS BEEN A LITTLE BIT OF DISCUSSION WITHIN THE FIELD OF HEMATOLOGISTS OF HOW SIGNIFICANT A SILENT INFARCT INJURY REALLY IS. I LIKE TO SHOW THIS FIGURE BY AN ENVIRONMENTAL SCIENTIST WHO CREATED A MODEL OF 100 MILLION CHILDREN TO SHOW ORIGINALLY WHAT THE DIFFERENCE OR THE IMPACT WOULD BE FOR LEAD POISONING BECAUSE THAT IS ASSOCIATED WITH AN IQ DROP. BUT LET'S USE HIS MODEL TO DEMONSTRATE THE IMPACT OF THE PRESENCE OF A SILENT INFARCT AND DROPPING YOUR IQ BY 100. SO WHAT YOU SEE IN THIS FIGURE ON THE TOP IS THE NORMAL DISTRIBUTION FOR IQ. SO YOU ANTICIPATE THAT THE AVERAGE IS 100. THE STANDARD DEVIATION IS 15. SO OUTSIDE OF THE PLUS OR MINUS TWO STANDARD DEVIATIONS, YOU SEE THE TAILS. SO ON THE FAR LEFT YOU'LL SEE YOU WOULD ANTICIPATE 6 MILLION CHILDREN ARE CONSIDERED INTELLECTUALLY DISABLED AND 6 MILLION WOULD BE CONSIDERED GIFTED. NOW IF YOU PICKED UP THAT CURVE AND SHIFT TODAY TO THE LEFT 5 POINTS -- SHIFTED IT -- YOU INCREASE BY 57% THE NUMBER OF CHILDREN NOW CONSIDERED INTELLECTUALLY DISABLED AND DECREASE THOSE THAT ARE GIFTED BY 60%. IF YOU'RE FAMILIAR WITH THE PEDIATRIC LITERATURE IN ASSESSMENTS OF COGNITION, YOU KNOW MOST OF OUR POPULATION IS ALREADY SITTING TO THE LEFT OF THE BELL-SHAPED CURVE. THIS IS A SIGNIFICANT DROP WHEN YOU THINK ABOUT OUR POPULATION BEING IMPACTED. DR. JORDAN SHOWED THIS WORK BY THE VANDERBILT GROUP THAT DEMONSTRATED THAT SILENT INFARC ARE COMMON AND THEY LIKELY CONTINUE TO INCREASE IN INCIDENTS OR PREVALENCE AS YOU AGE UP TO 50% BY THE TIME YOU'RE 30. AMONG THOSE WITH SICKLE CELL ANEMIA. AND THIS METANALYSIS WAS COMPLETED IN 2012 JUST GIVES YOU A PICTURE OF HOW INCREASED INJURY TO THE BRAIN IMPACTS THE FULL-SCALE IQ. SO ON THE Y AXIS YOU HAVE FULL-SCALE IQ. ON THE X AXIS, THIS IS A SUMMARY OF ALL THE STUDIES THAT HAVE BEEN PUBLISHED WITH SOCIOECONOMICALLY STATUS MATCHED AND ETHNICALLY MATCHED CONTROLS AND THEN A LITTLE BIT OF A DROP FOR CHILDREN WHO WERE CONSIDERED NORMAL OR NORMAL IMAGING WITH SICKLE CELL DISEASE. YOU SEE ABOUT A 5 POINT DROP AMONG THOSE WITH SICKLE CELL DISEASE AND SILENT INFARC AND A DROP FURTHER WITH THOSE WITH STROKE. THIS FIGURE DRIVES HOME THE POINT OF WHAT IS CONTRIBUTING TO THESE DECLINES. SO THIS FIGURE WAS CREATED BY DATA FROM THE SILENT INFARCT TRANSFUSION TRIAL AND AN ANCILLARY STUDY THAT JJ STROUS AND I CONTRIBUTED TO WHERE WE GOT IQ TESTING ON CHILDREN WHO SCREENED POSITIVE FOR SILENT INFARC BUT THEN TOOK CHILDREN WHO SCREENED NEGATIVE FOR SILENT INFARC AND ALSO DID COGNITIVE ASSESSMENTS ON THEM. AGAIN, IN THE Y AXIS, YOU SEE THE PREDICTED IQ AND ON THE X AXIS IS THE AGE OF CHILDREN FROM 5-15 YEARS. WHAT YOU SEE IN GENERAL IS THERE IS A NEGATIVE TRACK FOR THE OLDER CHILDREN. THEIR IQs WERE LOWER. WHAT YOU'LL ALSO APPRECIATE IS THAT IN THE TOP TWO GROUPS SO THOSE WITH THE HIGHEST IQs, WERE THOSE CHILDREN WHO HAD PARENTS WITH HIGHER LEVELS OF EDUCATION. SO SOME AMOUNT OF COLLEGE OR MORE. SO, A CHILD WHO HAD A CEREBRAL INFARCT BUT HAD A PARENT WITH MORE EDUCATION, WAS STILL USUALLY SCORING HIGHER THAN A CHILD WHO HAD A CLEAN MRI BUT THE PARENT OF THAT CHILD HAD A HIGH SCHOOL EDUCATION OR LESS. NOW WE TALK ABOUT MEASUREMENTS, LAB TESTS AND COGNITIVE Q, BUT REALLY WHERE THE RUBBER HITS THE ROAD, WHAT IS SIGNIFICANT FOR THESE CHILDREN AND THEIR FAMILY IS THE CHILD'S PRIME MARRY OCCUPATION WHICH IS GOING TO SCHOOL AND HIS OR HER EDUCATION IS REALLY GOING TO ASSIST IN OPENING UP OPPORTUNITIES FOR THEIR LIFE. SO WE ALSO DID A IN TAKE ON THE DEMOGRAPHICS OF WHAT THE EDUCATIONAL HISTORY WAS OF WHETHER OR NOT -- AND THIS IS FOR THE U.S. CHILDREN ONLY BECAUSE THOSE IN EUROPE WEREN'T TRACKING GREATER ATTENTION. BUT FOR THOSE IN THE U.S., WE ASKED WHETHER OR NOT THE CHILD HAD FAILED A GRADE. WHEN WE CREATED OUR MATHEMATICAL MODEL TO PREDICT GRADE RETENTION, BOYS WERE TWICE AS LIKELY TO RETAIN A GRADE OR REPEAT A GRADE THAN GIRLS AND THIS IS CONSISTENT WITH THE GENERAL POPULATION. BUT WHAT WE ALSO SAW WAS THE DOSE EFFECTIVE POVERTY. SO IF WE LOOK AT ONLY THE BOYS AND THEN WE DIVIDED THE FAMILY INCOME TO INCOME PER CAPITA AND THEN DIVIDED IT INTO QUARTILES, A BOY WHO IS FROM THE POOREST QUARTILE HAD A 65% CHANCE OF FAILING A GRADE BY THE TIME THEY WERE 15. AND THIS IS PARTICULARLY SIGNIFICANT FOR BOYS WHO HAD EXPERIENCED GRADE RETENTION WITHIN JUNIOR HIGH OR HIGH SCHOOL BECAUSE THAT IS SIGNIFICANTLY ASSOCIATED WITH DROPPING OUT OF SCHOOL AND HAVING LOWER LEVELS OF EMPLOYMENT, EARNINGS AND A HIGHER LIKELIHOOD OF ENDING UP IN PRISON AND I'LL SHARE SOME OF THOSE DATA FROM A POPULATION BASE LATER. SO, TO SUMMARIZE AND PAUSE IN THINKING ABOUT CHILDREN, THESE ARE THINGS THAT WERE DONE IN OUR PEDIATRIC PRACTICES TO TRY TO HELP PREVENT SOME OF THESE INJURIES TO THE BRAIN AND MELIORATE SOME OF THE DEFICITS THAT ALREADY EXIST. SO THE THING THAT WE CAN DO FROM THE VERY EARLY YEARS IS FOLLOW THE AMERICAN ACADEMY OF PEDIATRICS GUIDELINES, WHICH ARE TO COMPLETE DEVELOPMENTAL SCREENINGS AT VERY YOUNG AGES. OUR GROUP AND OTHERS DEMONSTRATED THAT 50% OF TODDLERS ARE ALREADY SIGNIFICANTLY BELOW AVERAGE FOR THEIR COGNITIVE DEVELOPMENT. AS DR. JORDAN MENTIONED, THE EVIDENCE FROM THE STOP TRIAL SUPPORTS SCREENING THOSE AT HIGH RISK FOR STROKE WITH ANNUAL TCDs AND PREVENTING THAT RISK OF OVERT STROKE. THEN NHLBI GUIDELINES PUBLISHED IN 2014 ENCOURAGE US TO OFFER HYDROXY RADIOYIA BY 9 MONTHS OF AGE -- HYDROXYUREA -- FOR SICKLE CELL ANEMIA AND DECREASE THE SIDE EFFECTS OF THIS DISEASE. WE NEED TO ASK ABOUT WHAT IS HAPPENING IN THE SCHOOL SYSTEM AND IF PARENTS GIVE US A HISTORY THAT SOMEBODY IS HAVING A CHANGE IN THEIR PERFORMS WITHIN SCHOOL OR A CHANGE IN BEHAVIOR, WE SHOULD REFER THOSE CHILDREN FOR COGNITIVE ASSESSMENTS. BUT NOT JUST GET THE ASSESSMENTS BU WE NEED TO SHARE WITH THE SCHOOL SYSTEM. BY FEDERAL LAW, IF CHILDREN HAVE SIGNIFICANT DEFICITS THOSE CHILDREN WHO ARE IN PUBLIC SCHOOLS HAVE THE RIGHT TO GET EDUCATIONAL SUPPORT VIA 504 PLAN OR SPECIAL EDUCATION VIA INDIVIDUALIZED EDUCATION PLAN. AND LASTLY, WITH BETTER PREPARATION FOR BOTH CHILDREN, THEIR FAMILIES AND THE SCHOOL SYSTEMS, HOPEFULLY WILL ESTABLISH A BETTER PLAN FOR TRANSITION OF CARE AS OPPOSED TO SIMPLY A HANDOFF OF CARE. SO NOW I'D LIKE TO TRANSITION TO THE ADULTS BECAUSE VERY FEW STUDIES HAVE BEEN PUBLISHED THAT ADDRESS ADULTS WITH SICKLE CELL DISEASE. AS DR. HOOTS MENTIONED YESTERDAY, THERE ARE EIGHT SITES THAT ARE FUNDED TO BE IMPLEMENTATION SCIENCE SITES AND OUR UNIVERSITY IS ONE OF THEM. THESE DATA JUST SUMMARIZE OUR ENROLLMENT IN THE REGISTRY TO DATE AND I WANTED TO SHARE THEM SO YOU GET A SNAPSHOT OF WHAT OUR ADULTS IN OUR CLINIC LOOK LIKE, AND THEN WE CAN COMPARE THAT TO A PILOT STUDY THAT I'LL SHARE DATA FROM. SO OF THE 263 PEOPLE WHO WERE IN OUR REGISTRY AT THIS TIME, THE AVERAGE AGE WAS ABOUT 28. WE WERE ASKED TO RECRUIT 15-45. BELL 59% OF THOSE WHO HAVE SIGNED UP SO FAR ARE FEMALE. SLIGHTLY MORE THAN 60% HAVE HEMOGLOBIN SS AND 25% HAVE SC. AND THIS IS VERY REPRESENTATIVE OF WHAT WE SEE IN OUR CLINICS. 54% REPORT THAT THEIR TAKING PAIN MEDICATION MEANING OPIOIDS ON A DAILY BASIS. OVER A THIRD HAVE HAD A STROKE. 40% VALUES A CO-MORBIDITY OF ASTHMA. 10% HAVE FOOT ULCERS AND 30% REPORTED THAT THEY ARE EITHER FEELING DEPRESSED NOW OR HAVE HAD DEPRESSION IN THE PAST. NOW, WHEN I HIGHLIGHTED HERE AS FAR AS THE REPORT OF EDUCATION LEVEL, WE HAVE 15% WHO HADN'T GRADUATED FROM HIGH SCHOOL YET AND 30% WHO HAD A HIGH SCHOOL DIPLOMA OR HEAD EARNED THEIR GED. I WANT TO DRAW YOUR ATTENTION TO THAT BECAUSE AS I SHOW YOU THE NEXT STUDY, YOU'LL SEE THIS IS DIFFERENT FROM THE STUDY POPULATION. THE OTHER REASON TO HIGHLIGHT THIS, WHEN YOU HAVE THAT LEVEL OF EDUCATION, WHAT YOU SEE BASED ON THE 2016 DATA FROM THE U.S. BUREAU OF LABOR STATISTICS YOU IS ANTICIPATE A MUCH LOWER SALARY FOR SOMEONE WHO HAS LESS THAN A HIGH SCHOOL DIPLOMA, OF ABOUT 26,000 DOLLARS PER YEAR COMPARED TO SOMEBODY MAKING 90,000 DOLLARS A YEAR FOR PROFESSIONAL DEGREE AND YOUR RATE OF UNEMPLOYMENT IS 7.4% VERSUS 1.6% IF YOU HAVE A GRADUATE DEGREE. SO AGAINST TRYING TO EMPHASIZE HOW CAN WE HELP THESE CHILDREN ATTAIN AS MUCH EDUCATION AS THEY CAN SO THAT THEY HAVE OTHER OPPORTUNITIES IN LIFE. WITHIN OUR OWN CLINIC, WE HAVE OVER 60% REPORTING THAT THEY HAVE LESS THAN 25,000 DOLLARS PER YEAR OF ANNUAL INCOME. ON AVERAGE, THE PEOPLE IN OUR REGISTRY WHO WERE ADULTS REPORTED THAT THEY HAD ABOUT THREE PEOPLE IN THE HOME. TWO ADULTS AND ONE CHILD. SO AGAIN, LESS THAN 25,000 DOLLARS. IN 2016 THE FEDERAL POVERTY LEVEL WAS 20,000 DOLLARS FOR A FAMILY OF THREE. SO OUR FAMILIES ARE LIVING AT OR NEAR POVERTY. SO, AS I MENTIONED EARLIER, THERE ARE MANY STUDIES THAT STUDY CHILDREN WITH SICKLE CELL DISEASE AND OFFER RESULTS FROM COGNITIVE ASSESSMENTS. YOU'LL FIND WELL OVER 150 STUDIES. A MEDICAL STUDENT AND OUR TEAM ARE TRYING TO DO THIS IN ADULTS, AND WE HAVE FEWER THAN 10 STUDIES TO ASSESS. WHAT WE'LL SEE THOUGH IN BOTH CHILDREN AND ADULTS IS THAT THE MOST COMMON COGNITIVE DOMAINS THAT ARE IMPACTED IN A NEGATIVE WAY WITH THOSE WITH SICKLE CELL DISEASE ARE SLOWED PROCESSING SPEED AND IMPAIRMENTS IN ATTENTION, THEIR MEMORY, AND EXECUTIVE FUNCTION. EXECUTIVE FUNCTION MEANING MORE COMPLEX THOUGHT BEING ABLE TO JUGGLE A FEW THINGS AT ONCE, BEING ABLE TO SEQUENCE, PLAN AND INITIATE COMPLEX TASKS. AND IMP IMPLICATIONS OF THESE DEFICITS ARE VERY SIGNIFICANT. SO THEY ARE SLOWER TO COMPLETE THEIR TASKS, VERY DISTRACTED, THEY ARE FORGETFUL, HAVE A VERY HARD TIME MULTITASKING. SO IF SOMEBODY IS LEAVING OUR CLINIC, WE ALWAYS WRITE OUT THE INSTRUCTIONS SOMETIMES WALK THEM OUT UNTIL THEY CAN MEET SOMEBODY WHO IS IN THE CLINIC TO HELP THEM, BECAUSE IF YOU GIVE SOMEONE A THREE-STEP COMMAND, THEY WILL USUALLY GET THE FIRST COMMAND AND THEN THEY FORGET THE SECOND TWO. THE OTHER SIGNIFICANT RESULTS OF THESE COGNITIVE IMPAIRMENTS IS THEY ARE ASSOCIATED WITH LOWER LEVELS OF EDUCATIONAL ATTAINMENT. AND THEN IN EUROPE, IN A POPULATION-BASED STUDY. NON SICKLE CELL DISEASE PATIENTS, THEY DEMONSTRATED THAT A SLOWER PROCESSING SPEED WAS ASSOCIATED WITH EARLIER MORTALITY. AND I WOULDN'T BE SURPRISED IF WE FOUND THE SAME THING AMONG OUR POPULATION. I'D LIKE TO TRANSPORTATION PRELIMINARY RESULTS OF A STUDY WE HAVE ONGOING IN OUR LOCAL INSTITUTION TRYING TO DEVELOP A FINER ASSESSMENT OF COGNITION OF OUR ADULTS, A PROSPECTIVE COHORT STUDY AND THIS IS THE FIRST CROSS SECTION IN AN EARLY ANALYSIS OF THAT. BUT ESSENTIALLY, WHAT WE HYPOTHESIZED IS THE ADULTS WITH SICKLE CELL DISEASE WILL HAVE IMPAIRED COGNITION IN TYPICAL MEASURES AS WELL AS IN FUNCTIONAL TASK PERFORMS COMPARED TO NORMATIVE CONTROLS AND WHEN WE REASSESS THESE PEOPLE IN THE STUDY OVER TIME, WE ARE GOING TO SEE A DECREASE OVER TIME. AND I WANT TO ACKNOWLEDGE OUR RESEARCH COORDINATOR WHO HAS DONE AN AMAZING JOB ORGANIZING THIS. SO, SO FAR, WE HAVE 18 PEOPLE IN THIS STUDY, SLIGHTLY MORE THAN HALF ARE FEMALE. THE AVERAGE SAGE SLIGHTLY LOWER THAN IN THE REGISTRY, ABOUT 24 YEARS. OVERWHELMING MAJORITY HAVE SICKLE CELL ANEMIA BY SS OR S BETA NULL. AND 55% EITHER HAVE A SILENT, OVERT TYPE OF STROKE. THE OVERWHELMING MAJORITY ARE ALSO USING SOME FORM OF A DISEASE MODIFICATION EITHER WITH HYDROXYUREA OR CHRONIC BLOOD TRANSFUSION. THIS IS A RELATIVELY HIGHLY-EDUCATED COHORT COMPARED TO OUR CLINIC. YOU CAN SEE WE HAVE 55% OF THOSE WHO ARE IN THE STUDY WHO HAVE SOME AMOUNT OF COLLEGE AND SOME HAVE ALREADY COMPLETED THIS. AND THE MAJORITY OF THOSE WHO PARTICIPATED ALREADY HAVE THEIR -- EITHER FULL-TIME EMPLOYED OR A FULL-TIME STUDENT. AND YOU CAN SEE THE DISTRIBUTION OF INCOME AGAIN IS SLIGHTLY HIGHER THAN WHAT WE SAW IN THE REGISTRY. SO YOU CAN KEEP THIS IN MIND AS WE SEE THE NEXT FEW SLIDES WITH RESULTS. SO AS PART OF BOTH THE REGISTRY AND THE STUDY, WHAT WE HAVE DONE IS USED THE PROMISE MEASURES OF SELF SCREENING FOR COGNITIVE PERFORMS TO ASK PEOPLE HOW THEY FEEL THINGS ARE GOING. SO THE QUESTIONS OR THE STATEMENTS THAT THEY RATE ON ARE WHETHER OR NOT THEY HAVE TO READ SOMETHING SEVERAL TIMES TO UNDERSTAND IT. THE IF THEY ARE UNCLING IS SLOW, IF THEY HAVE TO WORK HARDED TO PAY ATTENTION OR HAVE TROUBLE CONCENTRATING. OVERWHELMINGLY PEOPLE THOUGHT THIS REALLY WASN'T A PROBLEM. THEY SAID IT WAS EITHER A PROBLEM RARELY OR JUST SOMETIMES LIKE MAYBE TWICE A WEEK. KEEP THIS IN MIND AS YOU SEE THE RESULTS. SO, FOR A GENERAL ESTIMATE OF IQ, WE USED ABBREVIATED WASI2 WITH AGAIN FOR THE FULL-SCALE IQ, IT IS AN AVERAGE OF 100 WITH A STANDARD DEVIATION OF 15 AND FOR VOCABULARY SCORES, WHICH IS MORE VERBAL, AND MATRIX REASONING, WE USED T SCORES WITH AVERAGE 50 STANDARD DEVIATION IS 10 AND WE FOUND NO SIGNIFICANT DIFFERENCES ON THE GLOBAL MEASURES WEAN OUR STUDY POPULATION AND THOSE IN THE NORMATIVE DATASET. WHEN WE LOOKED AT SPECIFIC COGNITIVE DOMAINS, HOWEVER, USING THE NIH TOOLBOX, THAT WAS A DIFFERENT PROFILE. AND AGAIN, THAT IS WHYIGE THAT THESE SPECIFIC COGNITIVE DOMAINS ARE SO MUCH MORE -- I THINK -- INFORMATIVE TO UNDERSTAND HOW SOMEONE IS FUNCTIONING AND MORE HELPFUL IN PLANNING INTERVENTIONS. SO, THE WAY THAT THE TOOLBOX MEASURES ARE SCORED IS WITH A T SCORE. AGAIN THE BLUE LINE ACROSS THE MIDDLE IS 50 AND THAT IS AVERAGE. ONE STANDARD DEVIATION ABOVE WOULD TAKE YOU TO 60. BELOW IS 40. AND WHAT CAN YOU SEE IS THAT THE PEOPLE WHO PARTICIPATED HAVE SIGNIFICANTLY LOWER LEVELS OF FUNCTION. EXECUTIVE FUNCTION, WORKING MEMORY AND PROCESSING SPEED WHEN COMPARED TO NORMATIVE DATA. THE TOOLBOX SCORES ARE THEN LUMPED INTO TWO COMPOSITE SCORES, FLUID COMPOSITES, SO THAT IS THE COMBINATION OF ATTENTION EXECUTIVE FUNCTION, WORKING MEMORY, ET CETERA. AND THE CRYSTALIZED COMPOSEIT IS MORE OF YOUR VERBAL SKILLS OR VOCABULARY. THE MORE YOU'RE EXPOSED TO IN SCHOOL, YOU EXPECT THE CRYSTALIZED COMPOSITE TO BE HIGHER AND THAT IS WHAT WE SEE IN OUR GROUP. AND YOU SEE THAT IN THE STUDY SO FAR, THE PARTICIPANTS HAVE SIGNIFICANTLY LOWER FLUID COMPOSITES AND TOTAL COMPOSITE SCORES. SO, AGAIN, THAT IS INTERESTING BUT ONE OF THE THINGS THAT WE DID DIFFERENTLY IN THIS STUDY IS WE ALSO ARE ASKING THE PARTICIPANTS TO COMPLETE THE PERFORMS-BASED ASSESSMENTS BECAUSE THE SCORES OF THIS ARE INFORMATIVE NOT ONLY FOR DESCRIBING HOW PEOPLE ARE FUNCTIONING, BUT HELP US FIGURE OUT AT WHAT POINT IN COMPLETING A TASK DID THEY NEED HELP? SO, THE FIRST MEASURE THAT WE ADMINISTER IS THE EFPEM, AN EXECUTIVE FUNCTION PERFORMS TEST FOR MEDICATION SUBTESTS. THE PARTICIPANT RECEIVES INSTRUCTIONS FOR THIS AND THEN A BROWN PAPER BAG LIKE A LUNCH BAG. INNED THAT BAG ARE 3 LABELED CONTAINERS. ONE HAS THE PARTICIPANT'S NAME, MEDICATION AND SPECIFIC INSTRUCTIONS. ANOTHER HAS ANOTHER PERSON'S NAME ON IT AND THE THIRD IS AN OVERCOUNTER MEDICATION. IF THE PERSON READS THE INSTRUCTIONS CORRECTLY, THEY WILL BE TOLD THEY TAKE THAT MEDICATION WITH FOOD AND WATER. THERE IS ALSO A BOLTS OF WATER AND A FEW PACKS OF SAL TEEN CRACKERS IN THERE. THE PERSON ADMINISTERING THE TEST AFTER GIVENNING THE OVERVIEW SITS BACK AND TELLS THE PERSON TO GO AND COMPLETE THE TASK. IF THEY GET STUCK, THEN THEY GET CUES BY THE ADMINISTRATOR. SO THE WAY THAT THE QUEUING IS GRADED, IF YOU SAIL THROUGH THIS, YOU'RE GREAT AT READING INSTRUCTIONS AND YOU COMPLETE IT. ALL IS WELL. SOME PEOPLE NEED INDIRECT VERBAL GUIDANCE SO MAYBE LIKE AN EP-ENDED QUESTION TO PROMPT YOU TO MOVE ON -- OPEN-ENDED -- SOME MAY NEED A JUST GESTURE BUT NOBODY IS TOUCHING THEM TO HELP. SOME NEED MORE DIRECT COMMUNICATION LIKE READ THE DIRECTIONS, OPEN UP THE BOTTLE OF WATER AND TAKE A DRINK. SOME PEOPLE WHO HAVE A PHYSICAL IMPAIRMENT ACTUALLY NEED PHYSICAL ASSISTANCE WITH THIS AND THE MOST SEVERE CHALLENGES, SOMEBODY IS DOING THIS. SO THIS TEST WAS ORIGINALLY CREATED BY CAROLYN BOMB AND HER TEAM OF OCCUPATIONAL THERAPISTS. IT WAS VALIDATED IN 6 OR 700 PATIENTS WITH STROKE, NOT NECESSARILY SICKLE CELL DISEASE FOCUSED BUT SOME PEOPLE WITH SICKLE CELL DISEASE WERE IN THAT NORMATIVE DATASET. SO, IN OUR STUDY, OF THE 18 PEOPLE WHO PARTICIPATED, ALL OF THEM REPORTED THAT AT HOME THEY TOOK A MEDICATION. ON THE PROTEST EVERYONE THOUGHT THAT THEY ARE INDEPENDENT AND DOING WELL. DURING THE ACTUAL TASK, THE 17 OF 18 NEEDED HELP TO GET THIS DONE. 13 OF THE 18 NEEDED QUEUES TO SEQUENCE TO COMPLETE THIS CORRECTLY AND 10 NEEDED QUEUES TO MAKE SURE THAT THEY WERE USING THE CORRECT JUDGMENT FOR SAFETY AND LIKE PERHAPS THEY WERE TAKING THE MEDICATION THAT WAS REALLY INTENDED FOR SOMEONE ELSE. AND OVERWHELMINGLY MOST COMPLETED THE TASK WITH INDIRECTOR VERBAL OR GESTURAL CUES. ONLY ONE OF THE 18 WAS COMPLETELY INDEPENDENT AND ABLE TO COMPLETE THIS ON THEIR OWN. SO IN TOTAL, THE AVERAGE SCORE WAS 2.11 ON A SCALE OF 0-5. YOU MAY ASK YOURSELF, WHAT IS THE RELEVANCE OF THAT? SO IN DR. BALM'S NORMATIVE DATA, PEOPLE WHO ARE UNAFFECTED WITH ANY FORM OF STROKE TYPICALLY HAD A SCORE OF 0.42. USING THE NIH SCALE AND CATEGORIZING PEOPLE WITH MILD STROKE, THOSE PEOPLE HAD A SCORE OF 0.92 AND PEOPLE WITH A MODERATE STROKE HAD A SCORE OF 5.5. SO OUR PARTICIPANTS ARE FALLING SOMEWHERE IN BETWEEN THOSE WITH MILD AND MODERATE STROKE. AND ALL OF THESE DIFFERENCES WERE STATISTICALLY SIGNIFICANT. THERE IS A SECOND TASK THAT WE ASKED PEOPLE TO DO WHICH IS A WEEKLY CALENDAR PLANNING ACTIVITY SHORT FORM. AND I'M GOING TO SHOW YOU TWO EXAMPLES. SO WHEN PEOPLE PARTICIPATE IN THIS, THEY RECEIVE A XEROX COPIED SIMILAR TO WHAT WE HAVE UP HERE. YOU'RE TOLD YOU HAVE 10 APPOINTMENTS TO ENTER ON A CALENDAR. YOU'RE TOLD TO TELL THE ADMINISTRATOR WHEN SEVEN MINUTES HAVE PASSED, TO LOOK AT THIS LIST, RECORD THEM ALL ON YOUR PLANNER SO YOU CAN KEEP TRACK OF IT FOR THE WEEK. REMEMBER ON WEDNESDAY YOU'RE NOT GOING TO HAVE ANYTHING SCHEDULED. THAT WILL BE A TIME OFF. AND THEN LET THE PERSON WHOSE ADMINISTERING THE TASK, LET THEM KNOW YOU'RE COMPLETE. YOU ALSO DO AN ASSESSMENT BEFOREHAND ABOUT HOW YOU THINK YOU DO WITH THESE THINGS AND THE ASSESSMENT AFTERWARDS OF HOW YOU THINK IT WENT. SO THIS IS KELLIE. SHE GOT THE LIST. AND THIS IS THE COPY OF HER SHEET AT THE END. AND WE'LL HAVE SOMEBODY WE'LL CALL ANTOINETTE. WHEN SHE COMPLETED IT, SHE HAD DONE MORE THINKING AND SCRATCHING THROUGH AS SHE ENTERED THINGS ON THE CALENDAR. YOU CAN KEEP THIS IN MIND THEN AS I SHOW YOU HOW PEOPLE ACTUALLY SCHEDULE THINGS. SO KELLIE WHO HAD THAT PRISTINE LIST OF THE 10 THINGS, ACTUALLY TOOK THAT CALENDAR AND JUST LISTED EACH OF THOSE APPOINTMENTS ON THE DAYS BUT THEY WERE PURELY A LIST. SO ON MONDAY SHE PUT THE 1:00 APPOINTMENT AT 7:00 A.M AND A 7:00 MEETING WITH THE FRIEND THAT SHOULD HAVE TAKEN PLACE IN THE EVENING AT 8 A.M. IT WAS SIMPLY A LIST. SHE DID LEAVE WEDNESDAY OPEN. BUT AGAIN, EVERYTHING IS JUST CLUSTERED AT THE TOP AS A LIST. AND IN COMPARISON, ANTOINETTE WHO HAD ALL THE MARK UPS AND USED A HIGHLIGHTER TO ORGANIZE HERSELF HAD BLOCKED WEDNESDAY. SHE CORRECTLY MAPPED THE DENTAL AND DOCTORS APPOINTMENT AND WHEN SHE WAS GOING TO CARPOOL. SO SHE USED SEVERAL MORE STRATEGIES TO CORRECTLY MAP MOST OF THESE APPOINTMENTS. SO, THE THING THAT I WANT TO HIGHLIGHT TO YOU IN THE SCORING OF THIS IS THAT ON AVERAGE THE PEOPLE WHO COMPLETED THIS TASK HAD ALMOST THREE ERRORS BUT ONLY RECOGNIZED 0-1. AND THE TOTAL NUMBER OF APPOINTMENTS THEY WERE ABLE TO PLOT OUT WAS 6.8 BUT THEY THOUGHT THAT THEY HAD DONE THIS CORRECTLY, THE MAJORITY OF TIME AT 8.6. SO, AT THE END OF THE ASSESSMENT, PEOPLE REPORTED WHETHER OR NOT THEY THOUGHT THE TASK WAS EASY, DID THEY USE SUFFICIENT METHODS AND COMPLETE THE TASK? DID THEY DO IT ACCURATELY AND KEEP TRACK OF EVERYTHING THEY NEEDED TO DO? AND OVERWHELMINGLY, PEOPLE AGREED WITH THAT ASSESSMENT. SO YOU CAN SEE EVERYONE THOUGHT THEY WERE DOING GREAT BUT IN REALITY, THEY AREN'T ABLE TO COMPLETE THIS TYPE OF TASK THAT AT THE FIRST WAY OF APPLYING THIS IS SIMPLY TO THINK ABOUT SHOWING UP FOR YOUR MEDICAL APPOINTMENTS OR BEING ABLE TO TAKE YOUR MEDICATIONS. SO, AGAIN, WHEN WE COME BACK TO WHETHER OR NOT WE SHOULD BE DOING COGNITIVE ASSESSMENTS OR SCREENING FOR SILENT INFARC IN ADULTS, WE OFTEN HEAR WELL, WHY ARE YOU DOING THAT? THERE IS NOTHING YOU CAN DO FOR THE PEOPLE ONCE YOU FIND OUT THEY HAVE IT. AND THAT'S JUST NOT TRUE. SO, THIS FIGURE IS TAKEN FROM THE AMERICAN CONGRESS OF REHABILITATION MEDICINE WHICH IS THEIR EVIDENCE-BASED RECOMMENDATION FOR HOW DO YOU HELP SOMEONE WHO HAS A COGNITIVE DEFICIT? THE FIRST THING YOU HAVE TO DO IS MAKE THE PATIENT AWARE OF IT. SO I DON'T KNOW ANOTHER WAY OF DOING IT OTHER THAN ASSESSING SOMEONE. BUT ONCE YOU ASSESS THEM, WHAT CAN YOU DO IS THEN USE TECHNIQUES TO INCREASE THIS AWARENESS. AND SOME OF THESE WAYS ARE VERY SIMPLE. JUST BY PROVIDING EDUCATION AND FEEDBACK. IF ANYONE HAS COACHING FOR PUBLIC SPEAKING, IT'S A BIT HORRIFYING TO SEE A VIDEOTAPE OF YOURSELF AND SEE WHETHER OR NOT YOU ROCKED OR GRABBED THE PODIUM OR SAID UM, A LOT. THESE THINGS ARE VERY EFFECTIVE IN PROVIDING FEEDBACK TO GET THESE ASSESSMENTS. FOR YOU'RE ABLE TO DEMONSTRATE TO SOMEONE THAT THEY HAVE THE COGNITIVE IMPAIRMENT AND IT'S ONLY MILD OR MODERATE, THEN YOU CAN TEACH PEOPLE TO USE INTERNALIZED STRATEGIES LIKE THINKING THROUGH TO ALWAYS ORGANIZE THEIR APPROACH TO SOMETHING, AND RECHECK. IF THEY NEED MORE ASSISTNESS, YOU CAN TEACH THEM SPECIFIC STRATEGIES FOR A TASK IN THEIR LIFE SO YOU WORK WITH SOMEBODY TO SAY TO THEM, WELL, WHAT TASKS ARE MOST IMPORTANT FOR YOU? AND LET'S THINK ABOUT HOW WE CAN TEACH YOU SOME STRATEGIES THAT THEN CAN BE GENERALIZE. AND SO ONE MODEL FROM THE FIELD IN OCCUPATIONAL THERAPY IS THE CO-OP MODEL, YOU SET A GOAL, PLAN IT, DO IT AND THEN CHECK YOUR WORK. SO IN SUMMARY, BASED ON WHAT HAS BEEN PUBLISHED AS WELL AS THE PRELIMINARY FINDINGS OF OUR STUDIES, WE PLAN TO CONTINUE TO RECRUIT MORE OF THE PARTICIPANTS AND REPEAT THE MEASURES AND ONCE OUR SAMPLE SIZE IS LARGER, WE'LL BE ABLE TO DO MULTIVARIATE ANALYSIS TO SEE HOW MUCH CNS INJURY IMPACTS THE COGNITIVE FUNCTION TO DETERMINE THE IMPACT OF THE DISEASE MODIFICATION. I CAN'T UNDERESTIMATE THE IMPACT OF OPIOID USE SO OBVIOUSLY THAT IS ASSOCIATED WITH SLOW PROCESSING SPEED. SO WE'LL CONTROL FOR THE AVERAGE DAILY DOSE OF OPIOIDS. AND THEN THEIR EDUCATION LEVEL. WE KNOW FROM EVEN THE SNAPSHOT THAT MOST OF THE ADULTS LACK AWARENESS OF THEIR DEFICITS AND WHAT WE ARE HOPEFUL FOR IS THE RESULTS OF THIS WILL GUIDE MORE INTERVENTIONS AND WILL CONTINUE TO TRY TO IMPROVE THE PROCESS OF TRANSITION BY TAKING BETTER CARE OF THE KIDS TO REDUCE SOME OF THES DEFICITS IN ADULTHOOD. I'D LIKE TO ACKNOWLEDGE MEMBERS OF OUR LAB AND PARTICULARLY THE PATIENTS AND THEIR FAMILIES WHO TRUST US TO PARTICIPATE IN THESE PROJECTS. WITH THAT, I'M HAPPY TO TAKE QUESTIONS. [ APPLAUSE ] >> I HAVE A LOT OF QUESTIONS TODAY. A LOT OF OUR PATIENTS ARE YOUNG PARENTS AND I MEAN THAT IS A PROCESSING SPEED, INTENSIVE SKILL. IS THERE ANYTHING IN GENERAL WE SHOULD DO TO TRY TO HELP THEM BE BETTER PARENTS WITH THE LIMITATIONS THAT YOU HAVE DESCRIBED? >> SO, AT LEAST IN OUR STATE, WE HAVE A PROGRAM THAT IS CALLED PARENTS AS TEACHERS. SO WE DID THIS FOR PARENTS OF INFANTS AND TODDLERS WHO HAVE SICKLE CELL DISEASE BUT THE SAME WOULD BE APPLICABLE, I THINK, FOR MINORITIES HAVE SICKLE CELL DISEASE IN ADDITION TO HAVING SMALL CHILDREN AND THAT WOULD BE -- FOR PARENTS -- SOMEBODY TO GIVE YOU COACHING ABOUT THAT FROM THE OUTSIDE. IF YOU KNOW THAT THEY HAVE A DEFICIT AND THEY WANT AN ADDITIONAL SET OF COACHING, YOU CAN TURN TO YOUR LOCAL OCCUPATIONAL THERAPIST TO COME UP WITH PLANS TO SUPPORT THE PERSON WHO IS IMPACTED. BUT IT'S A VERY HIVE-RISK SITUATION BECAUSE IT'S NOT JUST THEIR OWN HEALTH, IT'S THE LITTLE GUYS. THANKS. >> HI. ATLANTA. THAT WAS A GREAT TALK. QUICK QUESTION. LIKE A BIT RELATED TO THAT, SHOULD ALL CHILDREN BE ON FEDERAL PROGRAMS LIKE KIDS CAN'T WAIT OR HEAD START, IF THEY HAVE IDENTIFIED SICKLE CELL DISEASE? AND SECOND QUESTION RELATED TO THE LAST STUDY THAT YOU SHOWED, WHAT ABOUT THE IMPACT OF DEPRESSION OR ANXIETY AND DID YOU LOOK AT EDUCATION TO THAT AFFECT THOSE SNOW SHOWERS. >> SO FOR THE FIRST QUESTION -- SCORES -- SHOULD THE CHILDREN BE IN PROGRAMS LIKE HEAD START? I THINK THE CHILDREN SHOULD BE IN ANY FORM OF ENRICHMENT PROGRAM THEY CAN GET ACCESS TO. AS I MENTIONED, WHEN JANE ASKED, WE PROVIDED A PROGRAM WHERE WE WENT TO THE HOUSE ONE TIME A MONTH TO HELP THE PARENT BECOME A STRONGER PARENT AND BE MORE INVOLVED WITH THE CHILD'S LIFE AND PROVIDE MORE BOOKS AND READ TO THEM. AND WITHIN A YEAR WE BUMPED THEIR COGNITIVE FUNCTION IN A SIGNIFICANT WAY. I THINK THE LAST PART OF THE QUESTION WAS AROUND THE IMPACT OF DEPRESSION OR ANXIETY. AND WHILE WE HAVEN'T GOT TONE THAT LEVEL OF ANALYSIS WITHIN OUR OWN STUDY, IT IS CLEAR THAT THOSE THINGS DO IMPACT YOUR ABILITY TO FUNCTION, HOPEFULLY AS WE GET MORE PEOPLE IN, WE'LL BE ABLE TOL GIVE YOU A MAGNET. >> HI. SO I HAD TO ADJUST THE MICROPHONE. SO MY QUESTION WOULD BE FOR MORE OF THE ADULTS. DID YOU NOTICE THAT AS THEY AGE, THE DEFICITS WERE GREATER? I WAS TRYING TO LOOK FOR THAT IN THE PRESENTATION BUT I GUESS TO MAKE THE QUESTION MORE VALID, AS A PATIENT WHO HAS SUFFERED A STROKE, IT SEEMS LIKE MY COGNITIVE ABILITIES HAVE BEEN MORE NOTICEABLE, THE DEFICITS, AS I AGE. AND WHEN I DO CONSULT WITH PATIENTS AND WORK WITH PATIENTS THAT ARE ADULTS, WE DO KIND OF COME WITH THE SAME CONSENSUS AS WE GET OLDER, WE NOTICE MORE DEFICITS THAN WE PROBABLY DIDN'T NOTICE AS CHILDREN. DO YOU THINK THAT IS BECAUSE WE ARE JUST MORE AWARE OF THEM OR DO YOU THINK THAT AGE IS A BIG FACTOR TO THAT? IS THERE SOMETHING THAT WE COULD DO AT HOME TO MAYBE -- YOU KNOW, HELP THAT OR WHAT IS YOUR ADVICE? >> SO I DO THINK THAT AGE IS A SIGNIFICANT FACTOR. AND SO FROM CROSS SECTIONAL DATA THAT PROJECTS LIKE THE FIGURE I SHOWED FROM EVEN 5-15, IT APPEARS THAT THE 15-YEAR-OLDS WERE WORSE OFF THAN THE 5-YEAR-OLDS. AND THEN WE'RE COMBINING OUR TOOLBOX DATA WITH ANOTHER INVESTIGATOR AT WASH U, MELANIE FIELDS, DOING THIS AMONG CHILDREN TO LOOK TOGETHER TO SEE AMONG ACTUAL DATA CAN WE DO THE SAME THING WITHIN OUR CENTER? WE ARE STILL AT EARLY STAGES SO I'M NOT SURE WE HAVE ENOUGH DATA BUT BASED ON A METANALYSIS THAT LOOKS LIKE THAT IS LIKELY THE IMPACT. AND IT'S PROBABLY THE CHRONIC DANGER TO THE BRAIN OF BEING ANEMIC. I THINK THAT SOME ADULTS DO HAVE THE ABILITY TO REALIZE THAT THEY HAVE MORE CHALLENGES NOW BECAUSE THE DEMANDS IN THEIR LIFE ARE MORE COMPLEX. AND AGAIN, I THINK THAT IF YOU NOTICE THESE THINGS YOU CAN TURN TO PEOPLE WHO ARE IN REHAB MEDICINE OR OCCUPATIONAL THERAPY TO GET COACHING TO FIGURE OUT HOW CAN YOU RESTRUCTURE YOUR DAY OR USE EXTERNAL DEVISES. I'M VERY WELL-KNOWN IN MY YOUNG ADULT CLINIC TO TAKE A SMARTPHONE FROM A PATIENT AND START PROGRAMMING THINGS INTO THEIR CALENDAR. THEY USE TO TEXT AND INSTAGRAM BUT NEVER USE THE CALENDAR APP. >> I'M VERY SORRY BUT DUE TO TIME CONSTRAINTS, WE'LL HAVE TO STOP THE QUESTIONS. PLEASE APPROACH DR. KING AFTER WITH YOUR QUESTIONS. THANK YOU. [ APPLAUSE ] OUR NEXT SPEAKER IS DR. MONICA HULBERT. SHE IS THE DIRECTOR OF THE SICKLE CELL PROGRAM AT ST. LOUIS CHILDREN'S HELP. SHE WILL BE TALKING TO US ABOUT CEREBRAL HEMODYNAMICS IN SICKLE CELL DISEASE AND SICKLE CELL CARRIERS. >> MONICA HULBERT: THANK YOU FOR THE OPPORTUNITY TO PRESENT INFORMATION ABOUT CEREBRAL HEMODYNAMICS. I DID MODIFY THE TOPIC TO BE SICKLE CELL DISEASE BECAUSE AS I'LL MENTION AT THE END, THERE IS ALMOST NOTHING BEEN PUBLISHED ABOUT PEOPLE WITH SICKLE CELL TRAIT. THESE ARE MY DISCLOSURES. I'M ALSO DISCLOSING I'M A CLINICIAN, NOT A MRI PERSON. SO THIS TALK WILL BE HOPEFULLY MORE CLINICALLY GEARED. FOR OBJECTIVES, WE WILL DEFINE CEREBRAL HEMODYNAMICS. I'M GOING EXPAND. I'M GOING TO DISCUSS THE LITERATURE THAT HAS BEEN PUBLISHED TO DATE IN SICKLE CELL DISEASE AND I'M GOING TO PROPOSE A ROLE FOR CEREBRAL HEMODYNAMICS AS MEASURES WE CAN FOLLOW FOR DISEASE MANAGEMENT AND CLINICAL INVESTIGATIONS. SO WHAT DO WE MEAN WHEN WE ARE TALKING ABOUT CEREBRAL HEMODYNAMICS? SO THESE ARE THE COMPONENTS THAT GO INTO CEREBRAL AUTO REGULATION AND CEREBRAL AUTO REGULATION IS A DYNAMIC PROCESS THAT MAINTAINS CEREBRAL OXYGEN AND METABOLISM. AND OUR BRAIN ACCOMPLISH THIS THROUGH DILATION AND CONSTRICTION OF BLOOD VESSELS IN RESPONSE TO DIFFERENT STIMULI TO CHANGE THE OXYGEN DELIVERY AND BLOOD DELIVERY THAT DEPENDS ON WHAT THE BRAIN NEEDS. SO IT'S A CONSTANTLY CHANGING PROCESS AFFECTED BY A LOT OF DIFFERENT FACTORS, INCLUDING ARTERIAL OXYGEN CONTENT, HYPOXEMIA OF THE BRAIN, HYPEY CAPNYIA, HYPOCAPNIA, CARDIAC OUTPUT AND MANY OTHER FACTORS. SO CEREBRAL OXYGEN METABOLISM IS WHAT EVERYONE WANTS TO MAINTAIN CONSTANTLY TO KEEP THE TISSUE ALIVE AND PREVENT A STROKE. SO, CMR02 IS THE PREVATIONS FOR CEREBRAL METABOLIC RATE OF OXYGEN CONSUMPTION AND IT'S THE PRODUCT OF THESE THREE FACTORS, THAT ARTERIAL OXYGEN CONTENT, PRIMARILY DETERMINED BY HEMOGLOBIN AND OXYGEN SATURATION, WHICH WE MEASURE BY PULSE OX IMTREE, CEREBRAL BLOOD FLOW AND THE OXYGEN EXTRACTION FRACTION. AND THE ROLES OF THESE DIFFERENT COMPONENTS IN MAINTAINING CEREBRAL OXYGEN METABOLISM HAVE PREVIOUSLY BEEN STUDIED MOSTLY WITH POSITRON TOMOGRAPHY WITH ADULTS WITH ADULT-TYPE STROKES AND THAT IS HOW A LOT OF THESE MODELS HAVE BEEN DERIVED. SO, TO GIVE YOU A LITTLE BIT OF A DYNAMIC VIEW OF WHAT CEREBRAL AUTO REGULATION IS PROPOSED TO DO IN ADULTS WHO HAVE ISCHEMIC STROKE DUE TO CAROTID OCCLUSION, WHERE ARTERIAL STENOSIS OF THE CAROTID IS THE SORT IT OF PROGRESSIVE DRIVER OF THIS PROCESS, CEREBRAL BLOOD FLOW DECLINES AS ARTERIAL STENOSIS ENDS. AND I SHOULD POINT OUT HERE THAT WE NEED TO BE CAREFUL WHEN WE ARE TALKING ABOUT THESE THINGS. CEREBRAL BLOOD FLOW IS DIFFERENT FROM CEREBRAL BLOOD FLOW VELOCITY, WHICH IS WHAT WE MEASURE WITH A TCD. OFTENTIMES WHEN YOU HAVE A STEN ON THETIC VESSEL, YOUR CEREBRAL BLOOD FLOW VELOCITY WILL GO UP BECAUSE YOU'RE TRYING TO PUSH THIS VOLUME THROUGH A SMALLER TUBE. BUT THE TOTAL AMOUNT OF VOLUME OF BLOOD THAT IS DELIVERED TO THE BRAIN WHEN YOU HAVE A STENOSIS, DECLINES. SO, BACK TO THE ADULTS. SO THIS CEREBRAL BLOOD FLOW VELOCITY DECLINES AS STENOSIS WORSENS AND THE BRAIN HAS A COMPENSATORY INCREASE IN OXYGEN EXTRACTION FRACTION, WHICH IT ACCOMPLISHES BY DILATING THE CEREBRAL AUTO REGULATION. AND THIS IS WITH THE GOAL OF KEEPING CMRO2 CONSTANT IN THE BRAIN. IT'S ASSUMED THE ARTERIAL OXYGEN IS STABLE OVER TIME. IF THE CEREBRAL BLOOD FLOW CONTINUES TO FALL YOU ABOUT THE OXYGEN EXTRACTION FRACTION HIT ITS PLATO AND CANNOT BE INCREASED ANY FURTHER, THEN CMR02 WILL DROP AND THAT IS WHAT RESULTS IN A CEREBRAL INFARCTION AT THAT TISSUE LEVEL. SO, AS DR. JORDAN DISCUSSED, SICKLE CELL STROKES ARE DIFFERENT FROM REGULAR STROKES BOTH IN TERMS OF AGE, THEIR LOCATION, BEING MORE LIKELY TO BE PERIVENTRICULAR AND LESS CORTICAL. ARTERIAL STENOSIS IS COMMON IN CHILDREN WITH SICKLE CELL DISEASE THAN IN ADULTS WITH CAROTID DISEASE. AND SO BECAUSE OF THIS, WE NEED A DIFFERENT MODEL FOR SICKLE CELL STROKE PATHOPHYSIOLOGY TO ACCOUNT FOR THE DIFFERENCES. SO AS I MENTIONED, HISTORICALLY, WE USED CEREBRAL BLOOD FLOW AND OXYGEN -- WE USED PET TO MEASURE THESE PARAMETERS IN ADULTS BUT PET REQUIRES THE USE OF RADIO TRACERS AND WE DON'T WANT TO EXPOSE CHILDREN AND MOST PEOPLE IF POSSIBLE, TO RADIATION SO WE -- OUR SITE AND OTHER SITES HAVE DEVELOPED THESE MRI-BASED MEASURES TO STUDY CEREBRAL BLOOD FLOW AND OXYGEN EXTRACTION FRACTION. SO, IMPORTANT THINGS TO NOTE ABOUT CEREBRAL BLOOD FLOW INCLUDE THAT IT PEAKS IN EARLY CHILDHOOD AND THAT GRAY MATTER SIEB REAL BLOOD FLOW IS HIGHER THAN WHITE MATTER CEREBRAL BLOOD FLOW. AND THE CEREBRAL BLOOD FLOW IS NORMALIZED TO THE VOLUME OF BRAIN TISSUE SO THAT IS WHAT THAT 100 GRAMS OF BRAIN, PART OF THAT EXPRESSION IS. SO THERE ARE DIFFERENT WAYS YOU CAN MEASURE IT. OUR GROUP USES A MEASURE CALLED PSEUDOCONTINUOUS AR TIRELY SPIN LABELING IN WHICH WATER PROTONS ARE LABELED BY A MAGNETIC PULSE THROUGH THE INTERNAL CAROTID ARTERY AND SHOWN BU THIS RED LINE, THAT'S THE LABELING PLANE AND THEN THE AMOUNT OF TRANSIT OF THOSE LABELED PROTONS INTO THE BRAIN IS MEASURED IN THIS BOX AREA. AND THIS ALLOWS US TO DO A REGIONAL CEREBRAL BLOOD FLOW ANALYSIS. SO EACH SECTION OF THE BRAIN WE CAN MEASURE SEPARATELY. PHASE CONTRAST IMAGING PROVIDES A WHOLE-BRAIN VIEW OF THE BLOOD FLOW. SO SOME RESULTS OF THESE STUDIES. MY COLLEAGUE DR. MELANIE FIELDS PUBLISHED THIS PAST YEAR IN WHICH WE DEMONSTRATED THAT CEREBRAL BLOOD FLOW IS ELEVATED IN CHILDREN WITH SICKLE CELL ANEMIA WHO WERE EITHER NOT ON HYDROXYUREA OR ON HYDROXYUREA BUT NOT ON TRANSFUSION THERAPY COMPARED TO AGE AND RACE-MATCHED CONTROLS. THIS HAS BEEN PUBLISHED ALSO BY DR. JORDAN'S GROUP AND BY SEVERAL OTHER GROUPS AS WELL. AND WHAT WE ALSO FOUND IN OUR LOCAL STUDY, WHICH WAS A STUDY OF 41 CHILDREN WITH SICKLE CELL AND 20 CONTROLS, IS THAT CEREBRAL BLOOD FLOW CORRELATES SIGNIFICANTLY WITH ANEMIA AND ARTERIAL OXYGEN CONTENT. SO IN THIS PLOT, THE RED SQUARES ARE THE SICKLE CELL PATIENTS WHO HAVE LOWER ARTERIAL OXYGEN CONTENT AND HAVE PREDOMINANTLY A HIGHER WHOLE-BRIAN CEREBRAL BLOOD FLOW. AND CONTROLS HAVE LOWER OR HIGHER ARTERIAL OXYGEN CONTENT AND LOWER CEREBRAL BLOOD FLOW. THERE ARE DIFFERENT TECHNIQUES TO MEASURE OXYGEN EXTRACTION FRACTION VIA MRI AND THE ONE WE USED IN OUR GROUP IS ASYMMETRIC SPIN ECHO. THIS RELIES UPON A DIFFERENCE IN BEHAVIOR IN A MAGNETIC FIELD BETWEEN OXYAND DEOXYHEMOGLOBIN. SO THE SCHEMATIC ON THE RIGHT SIDE IS MEANT TO SHOW THAT OXYHEMOGLOBIN DOES NOT DISRUPT A MAGNETIC FIELD WHEREAS DEOXYHEMOGLOBIN HAS A PARAMAGNETIC PROPERTY SO IT WILL DISTORT THE MAGNETIC FIELD WHEN THERE IS A LARGE AMOUNT PRESENT. BY MEASURE THE FIELD DISTORTION, WE CAN DO REGIONAL OXYGEN EXTRACTION FRACTION MEASUREMENTS IN OUR RESEARCH SUBJECTS. THE SEQUENCE THAT DR. JORDAN'S GROUP AND A FEW OTHERS USE AS WELL IS CALLED TRUST. AND THIS IS A DIFFERENT SEQUENCE WHERE THE PROTONS ARE LABELED IN THE BRAIN AND THEN MEASURED AND THAT GIVES THE WHOLE-BRAIN OXYGEN EXTRACTION FRACTION MEASUREMENT. SO, OUR GROUP AND OTHERS HAVE ALSO SHOWN THAT WHOLE-BRAIN OXYGEN EXTRACTION FRACTION IS ELEVATED IN PEOPLE WITH SICKLE CELL DISEASE AND SPECIFICALLY IN CHILDREN WHO ARE NOT ON CHRONIC TRANSFUSION THERAPY. WE FOUND THAT IT CORRELATES WITH ANEMIA. AND IN CHILDREN WHO ARE ON CHRONIC TRANSFUSION THERAPY, AND ANOTHER ONE OF MY COLLEAGUES, DR. KRISTEN GILLIANS, IDENTIFIED THAT IT CORRELATES WITH THE PERCENTAGE OF HEMOGLOBIN S IN THOSE CHILDREN. AND DR. JORDAN'S GROUP FURTHER ANALYZED THIS AND FOUND THAT WHOLE-BRAIN OXYGEN EXTRACTION FRACTION IS HIGHER UP TO ABOUT 50% HIGHER IN ADULTS WHO HAVE A GREATER DEGREE OF CLINICAL IMPAIRMENT, WHICH THEY DEFINED AS HAVING HAD A STROKE OR HAVING HAD, BEING ON CHRONIC TRANSFUSION THERAPY FOR EITHER A STROKE OR FOR PAIN THAT WAS NOT CONTROLLED WITH HYDROXYUREA THERAPY. SO TO GIVE YOU SOME MORE PICTORIAL REPRESENTATIONS OF WHAT WE ARE LOOKING AT IN THE BRAIN, THIS IS SHOWING ON THE LEFT A 13-YEAR-OLD FEMALE SIBLING CONTROL WHO HAD A HEMOGLOBIN OF 12.9 ON A DAY OF HER IMAGING. AND ON THE RIGHT IS AN 11-YEAR-OLD GIRL WITH SICKLE CELL ANEMIA WHOSEEM HEMOGLOBIN WAS 7.5 ON DAY OF IMAGING. THIS PATIENT HAD NO SILENT INFARC AND NEVER HAD ABNORMAL TC TCD. JUST FROM LOOKING AT THEM, YOU CAN TELL WITH THIS SCALED BAR ON THE SIDE, THAT THE CEREBRAL BLOOD FLOW IS MUCH HIGHER IN THE CHILD WITH SICKLE CELL THAN IN THE CONTROLLED SUBJECT. AND THEN WHEN WE LOOK AT THEIR OXYGEN EXTRACTION FRACTIONS, AGAIN, THE PATIENT WITH SICKLE CELL HAS A WHOLE-BRAIN OXYGEN EXTRACTION FRACTION THAT IS ABOUT 50% HIGHER THAN THE CONTROL. AND FURTHERMORE, WITH OUR REGIONAL ANALYSIS, WE IDENTIFIED THAT THERE WAS A SMALL PERIVENTRICULAR WHITE MATTER AREA WITH EXTREMELY ELEVATED OXYGEN EXTRACTION FRACTION AND WE THEN WANTED TO EXPLORE THAT FURTHER. SO, DR. FIELDS WAS ABLE TO USE THE DATA THAT WE GENERATE FRIDAY THIS TO DO AN OVERLAY MAP OF THE CEREBRAL BLOOD FLOW FOR ALL OF OUR SUBJECTS. AND SO, THE TOP PART OF THAT FIGURE THERE IS THE CEREBRAL BLOOD FLOW MAPPING OF THESE SUBJECTS. AND THE GRAY MATTER CEREBRAL BLOOD FLOW IS VERY HIGH. AND PERIVENTRICULAR WHITE MATTER HAS LOWER CEREBRAL BLOOD FLOW. THIS HAPPENS TO BE WHERE WE CLASSICALLY THINK OF MOST SICKLE CELL SILENT INFARC OCCURRING IN THAT PERIVENTRICULAR WHITE MATTER. THE BLUE OUTLINES ARE AREAS WHERE THE OXYGEN EXTRACTION FRACTION WAS 1.6 TIMES AS HIGH AS THE CONTROL. SO 60% HIGHER THAN THE CONTROL GROUP. AND YOU CAN SEE THAT THE AREA OF OEF ELEVATION COINCIDES WITH THE AREA WHERE THE CEREBRAL BLOOD FLOW IS THE LOWEST BY-AND-LARGE. AND THEN THE BOT BOTTOM PANEL OF THE FIGURE IS A INFARC DENSITY MAP FROM A SEPARATELY-IMAGED COHORT WE HAD AT WASH TO UNIVERSITY. -- WASHINGTON UNIVERSITY SHOWING THE RED PIXELS, THE HIGHEST DENSITY OF SILENT CEREBRAL INFARC. AND SO AGAIN, THE AREA WHERE THE CEREBRAL BLOOD FLOW IS THE LOWEST IS WHERE THE OXYGEN EXTRACTION FRACTION IS THE HIGHEST AND THAT INFARC DENSITY IS INCREASED. SO THEN, ANOTHER ONE OF MY COLLEAGUES, DR. ANDREA FORD, WAS ABLE TO DO AN ANALYSIS COMBINING OUR DATASET FROM WASH U WITH THE SIT TRIAL IMAGING COHORT WITH DR. DEBAHN AND AS DR. JORDAN MENTIONED, 90% OF THE SILENT CEREBRAL INFARC ARE CLUSTERED IN THAT PERIVENTRICULAR WHITE MATTER REGION. AND ON THESE BRAIN MAPS HERE, THE AREA THAT IS RED IS THE CEREBRAL BLOOD FLOW NADIR WHICH THEY DEFINED AS LESS THAN 45 MILLS PER 100 GRAMS PER MINUTE, WHICH IS QUITE LOW. AND THE BLUE AREA IS THE INFARC DENSITIES FROM THE SIT TRIAL AND THE PURPLE IS WHERE THESE OVERLAP. SO THERE IS QUITE A BIT OF OVERLAP FROM THOSE PHENOMENON TOGETHER THERE. AND FURTHERMORE, THEY GROUPED THE INFARC BRAIN MAPS BY INFARC DENSITY OF EACH BOXIL. SO BASICALLY WHAT THIS PLOT IS SHOWING HERE IS THAT WHEN YOU COMPARE INFARC DENSITY TO WHITE MATTER CEREBRAL BLOOD FLOW, THE DENSITY OFIGE FARC IS HIGHEST IN REGIONS THAT HAD THE LOWEST WHITE MATTER OF CEREBRAL BLOOD FLOW. -- INFARC. SO, USING ALL THIS INFORMATION TOGETHER, WE ARE PROPOSING A REVISED CEREBRAL HEMODYNAMIC MODEL FOR PATIENTS WITH SICKLE CELL ANEMIA, PRIMARILY THOSE WHO DON'T HAVE VASCULOPATHY BECAUSE THE ONES WITH MOIA MOIA PROBABLY ARE IN OVERLAP TO THE TWO SORT OF MODELS. SO, UNLIKE ADULT ISCHEMIC STROKE IN SICKLE CELL, THE RATE LIMITING FACTOR IS ANEMIA OR HYPOXIA AND AS WE HAVE DISCUSSED MANY TIMES, THROUGH THE COURSE OF THE PAST TWO DAYS, PATIENTS HEMOGLOBIN DROPS OVER TIME AND THEN WE HAVE ACUTE ILLNESS THAT CAUSES A SUDDEN DROP IN HEMOGLOBIN AND DECLINE IN ARTERIAL OXYGEN CONTENT. AND WHEN THAT HAPPENS, THE PATIENTS WILL HAVE A COMPENSATORY INCREASE IN OXYGEN EXTRACTION FRACTION AND THEIR CEREBRAL BLOOD FLOW TO MAINTAIN A CONSTANT CEREBRAL METABOLIC RATE OF OXYGEN CONSUMPTION. HOWEVER, IF THE ARTERIAL OXYGEN CONTENT CONTINUES TO INDIGN AND CB. AND OEF CANNOT BE INCREASED ANY FURTHER, WE SUSPECT THAT IS WHEN THE CMR02 WILL DROP AND RESULT IN CEREBRAL INFARCTION. AND THIS MAY BE DIFFERENT SHALLY ACTIVE IN DIFFERENT PARTS OF THE BRAIN -- DIFFERENTIALLY -- AS WE DISCUSSED, THE WHITE MATTER SEEMS TO BE PARTICULARLY VULNERABLE BECAUSE IT JUST BY ITS NATURE AS PART OF THE BORDER ZONE, HAS A LOWER CEREBRAL BLOOD FLOW TO START WITH. SO, THAT'S WHY IT IS SO, WE BELIEVE THAT IS WHY IT IS SO VULNERABLE. SO, UNDERSTANDING THE PATHOPHYSIOLOGY IS GREAT. WE ALSO WANT TO KNOW YOU HO DO THESE -- HOW WHAT CHANGES IN THESE PARAMETERS IN RESPONSE TO SICKLE CELL DISEASE DEFINE THERAPIES? SO, MY COLLEAGUE, DR. GILLIAM PUBLISHED THIS IN BLOOD THIS YEAR. AND THIS WAS A COHORT OF 21 CHILDREN RECEIVING CHRONIC BLOOD TRANSFUSION THERAPY WHO HAD A BRAIN MRI WITH THESE OEF AND CBF SEQUENCES AND THEN REGULARLY-SCHEDULED EXCHANGE TRANSFUSIONS, SOME WERE MANUAL AND SOMEWHERE NOT. AND WITHIN 24 HOURS AFTER THEIR TRANSFUSION, THEY UNDERWENT A SECOND MRI WITH THE SAME MEASURE MEASURES. AND WE WERE ABLE TO DEMONSTRATE THAT BOTH CEREBRAL BLOOD FLOW AND OXYGEN EXTRACTION FRACTION IMPROVED FOLLOWING A TRANSFUSION AND OF COURSE THE PATIENTS HAD A HIGHER HEMOGLOBIN AS TRANSFUSION SO THAT'S WHAT THE PLOTS SHOW ON THE TOP AND BOTTOM. YOU MAY NOTICE THE OXYGEN EXTRACTION FRACTION HAS A MORE CONSISTENT DECLINE AND THE CEREBRAL BLOOD FLOW IS A LITTLE BIT MORE HETEROGENOUS. AND CEREBRAL BLOOD FLOW, THIS MAY HAVE TO DO WITH AGE OF THE PATIENTS BECAUSE CBF IS LOWER IN OLDER PATIENTS, AND DR. JORDAN'S GROUP JUST PUBLISHED THEIR RESULTS ON THIS SAME QUESTION. I THINK IT JUST CAME ON MY PUBMED FEED ON SATURDAY. AND AGAIN TO SHOW SOME BRAIN MAPS, TO DRIVE THE POINT HOME, THIS IS A PATIENT WHO HAD HIS INITIAL SCAN ALL THE WAY ON THE LEFT. ON THE SAME DAY THAT HE HAD HIS REGULARLY-SCHEDULED TRANSCRANIAL DOPPLER ULTRASOUND, HE WAS NOT ON ANY DISEASE-MODIFYING THERAPY AT THAT TIME AND HE JUST HAPPENED TO HAVE A TCB VELOCITY OF ABOUT 215 CENTIMETERS PER AND HE COULD BILATERAL MIDDLE CEREBRAL ARTERIES. AT THE TIME WE DEMONSTRATED THAT HE WAS AT HIGH RISK OF STROKE BECAUSE OF HIS TCB ABNORMALITIES. HIS WHOLE-BRAIN CBF AND OEF WERE VERY ELEVATE AND WITH THE BLUE ARROWS YOU CAN SEE THAT REGION OF PERIVENTRICULAR WHITE MATTER ELEVATION OF OEF THERE ELEVATED ABOVE THE REST OF THE BRAIN. THIS CHILD THEN WENT ON TO BEGIN CHRONIC BLOOD TRANSFUSION THERAPY AND SO HE WAS REIMAGED ABOUT A YEAR AND A HALF LATER. WHEN HE IN HIS PRETRAINS FUSION TIME POINT, HIS HEMOGLOBIN WAS 9.3, SO TWO GRAMS HIGHER THAN UNTRANSFUSED SCAN. HIS WHOLE BRAIN CDF DECLINED BY ABOUT 15% AND HIS WHOLE-BRAIN OEF HAD GONE DOWN BY A THIRD. SO BACK CLOSE TO THE CONTROL RANGE. AND THEN HE WAS REIMAGED ON THE SAME DAY FOLLOWING HIS TRANSFUSION. HIS HEMOGLOBIN HAD GONE UP ANOTHER GRAM WHICH RESULTED IN YET ANOTHER DECLINE IN HIS CBF BUT HIS WHOLE-BRAIN OEF WAS STABLE AT THAT POINT. SO WE WERE ABLE TO DISSEM STRAIGHT HERE THESE CHANGES CAN OCCUR VERY RAPIDLY AFTER INTERVENTION TO RAISE THE PATIENT'S HEMOGLOBIN. AND THEN MY MAJOR PART OF THIS PROJECT HAS BEEN TO LOOK AT CHILDREN WHO HAVE HAD A HEMATOPOIETIC STEM CELL TRANSPLANT FOR THEIR SICKLE CELL ANEMIA AND IMAGE THEIR BRAINS BEFORE AND AFTER THE TRANSPLANT. SO FAR WE ENROLLED FOUR PATIENTS IN THE THIS COHORT AND OUR RESULTS ARE VERY NICE. THIS IS WHOLE-BRAIN CEREBRAL BLOOD FLOW. THE BLUE IS CONTROLS AND THE GREEN ARE THE PATIENTS BEFORE AND THEN AFTER THE STEM CELL TRANSPLANT. SO, PRE-TRANSPLANT THE RECIPIENTS HAD A MUCH HIGHER CEREBRAL BLOOD FLOW THAN THE CONTROLS, WHICH WAS STATISTICALLY SIGNIFICANT, AND AFTER THE TRANSPLANT, THEY WERE NO LONGER DISTINGUISHABLE FROM THE CONTROLS. AND THE SAME STORY FOR WHOLE BRAIN OXYGEN EXTRACTION FRACTION, PRE-TRANSPLANT THE RECIPIENTS HAD ELEVATED OEF COMPARED TO CONTROLS AND POST TRANSPLANT THEY WERE NOT SIGNIFICANTLY DIFFERENT FROM THE CONTROLS. AND I SHOULD POINT OUT THAT ONLY PATIENTS THAT DID NOT HAVE CEREBRAL VASCULOPATHY. THERE WERE NO KIDS WITH VASCULOPATHY IN THIS GROUP. WE HAVE MORE KIDS WHO WILL BE IMAGED THIS FALL AND WE'LL HAVE MORE NUMBERS TO REPORT SOON. THIS IS ONE OF THE PARTICIPANTS FROM THE PREVIOUS SLIDE. AGAIN COMPARED TO THAT SAME 13-YEAR-OLD CONTROL. THIS IS THE 11-YEAR-OLD GIRL PRE-TRANSPLANT WITH A SIGNIFICANT CDN AND OEF ELEVATIONS AND THEN POST-TRANSPLANT HER CB. AND OEF WERE COMPARABLE TO THE CONTROL GROUP AND NOTABLY THE WHITE MATTER OXYGEN EXTRACTION FRACTION INCREASED ON THE PRE-TRANSPLANT SCAN WAS NOT PRESENT ON THE POST-TRANSPLANT SCAN. SO WITH ALL THAT IN MIND, WE ARE SEEING THESE INTERVENTIONS TO TREAT SICKLE CELL DISEASE CAN DO SEEM TO REDUCE THE AMOUNT OF STRAIN ON THE BRAIN AND PERHAPS ALLOW THE PATIENTS A LITTLE MORE CUSHION TO WITH STAND INEVITABLE CHANGES IN HAVING A FEVER, THEIR BRAINS NEEDING MORE OXYGEN FOR THAT REASON, OR CHANGES IN BLOOD PRESSURE AND SO ON. SO, I THINK THE NEXT STEP IS HOW CAN WE USE THIS INFORMATION TO INFORM THE CARE OF PEOPLE WITH SICKLE CELL DISEASE? SO, POTENTIAL APPLICATIONS OF THESE MEASURES IN CHILDREN WITH SICKLE CELL OR ADULTS, I THINK THESE COULD POTENTIALLY BE USED IN CONJUNCTION WITH TRANSFERRING DOPPLER ULTRASOUND TO REFINE OUR RISK PREDICTIONS FOR OVERT OR SILENT STROKES. WE TALKED A LOT ABOUT HOW THE FACT THAT THERE ARE NO RISK PREDICTION MODELS FOR ADULTS WITH SICKLE CELL ANEMIA TO HAVE AND SO THIS COULD POTENTIALLY BE -- THERE ARE A NUMBER OF REASONS WHY TCD ISN'T THAT FEASIBLE. SOMETIMES THEIR SKULL BONES ARE TOO HIGH PER TROPHIED AND YOU CAN'T GET A GOOD SIGNAL. NOT A NORMALIZED DATASET. SO THIS COULD POTENTIALLY BE USED TO DEVELOP A RISK PREDICTION TOOL FOR SICKLE CELL IN STROKES. WE THINK THAT PERHAPS WE MIGHT BE ABLE TO USE THESE TO ALSO PREDICT NON-STROKE NEUROLOGICAL ENDPOINTS, THINGS LIKE CEREBRAL ATROPHY, WHITE MATTER, DISINTEGRITY LIKE DR. JORDAN SPOKE ABOUT WITH DIFFUSION TENSER IMAGING AND ALSO COGNITIVE DYSFUNCTION AND THE DECLINE AND DIFFICULTIES IN EVERY DAY LIVING THAT DR. KING DESCRIBED TOO. SO AGAIN, IF THIS WAS PREDICTIVE OF FUTURE CHANGES OR DECLINES, WE COULD PERHAPS DESIGN INTERVENTIONS TO ADDRESS THOSE THINGS. AND THEN FMRI IS A PRETTY HOT TOPIC THESE DAYS T USES SIMILAR TECHNOLOGIES, NOT EXACTLY THE SAME SEQUENCES BUT IT DOES MEASURE CHANGES IN BLOOD FLOW AND OXYGEN EXTRACTION FRACTION TO DIFFERENT PARTS OF THE BRAIN. AND MAYBE USEFUL TO IDENTIFY BRAIN NETWORKS THAT HAVE EITHER INCREASED ACTIVITY OR DECREASED ACTIVITY IN PEOPLE WITH SICKLE CELL DEPENDING ON THE PARTICULAR FUNCTION OR ACTIVITY THAT WE ARE TRYING TO STUDY. I HESITATE TO USE THE WORD BIOMARKERS AFTER YESTERDAY'S DEBATE BUT HUMOR ME FOR ONE SLIDE. I DID PUT A QUESTION MARK. SO I THINK THAT WE THINK THAT THESE MEASURES COULD BE FEASIBLE TO BE CONSIDERED AS POTENTIAL BIOMARKERS AND THEY ARE PLAUSIBLE MEASURES BECAUSE THEY ALREADY CORRELATE WITH SOME DISEASE SEVERITY INDICATORS LIKE WE DISCUSSED SUCH AS ANEMIA AND DECREASED ARTERIAL OXYGEN CONTENT. AND WE KNOW THAT PLACES WHERE THE CEREBRAL BLOOD FLOW AND THE OXYGEN EXTRACTION FRACTION ARE ABNORMAL IS THE REASON THAT IS PRECISELY VULNERABLE TO INFARC IN THESE PATIENTS. SO, AGAIN, IF WE WERE ABLE TO IDENTIFY AN INTERVENTION, WE COULD USE THIS TO TEST WHETHER THAT WAS EFFECTIVE. ANOTHER GREAT THING ABOUT THESE AS POTENTIAL BIOMARKERS OR POTENTIAL OUTCOME MEASURES, IS THAT THEY ARE DYNAMIC. THEY IMPROVE RAPIDLY IN RESPONSE TO A TRANSFUSION. MY COLLEAGUE DR. FIELDS HAS THE MANUSCRIPT UNDER REVIEW THAT IS GOING TO DISCUSS THE DIFFERENCES IN CHILDREN ON HYDROXYUREA AND NOT ON HYDROXYUREA. SO I EXPECT THAT WILL BE PUBLISHED SOMETIME SOON. BUT BECAUSE OF THIS IMPROVEMENT IS RAPID, IT MIGHT BE MORE FEASIBLE TO USE THEM TO STUDY THE AFFECTS OF INTERVENTION IN THE SHORT-TERM. RIGHT NOW IF WE WANTED TO DESIGN A STUDY TO SEE WHETHER A CERTAIN INTERVENTION PREVENTED SILENT INFARC, IT WOULD TAKE 10 YEARS OF FOLLOW-UP TO DISCERN A DIFFERENCE FROM THE BASELINE TO WHEN THE FOLLOW-UP MEASURES. AND SO, THIS MIGHT ALLOW US TO SHORTEN THE TIMEFRAME TO SEEING AN OUTCOME MEASURE. AND AS I MENTIONED, VERY ENCOURAGED THAT AFTER SUCCESSFUL TRANSPLANT, WE HAVE NORMALIZATION OF THESE MEASURES. AGAIN, WE DON'T HAVE THAT PARTICULAR OUTCOME MEASURE THAT THESE MIGHT BE USED TO PREDICT YET BUT I THINK THAT THAT IS SOMETHING THAT OUR GROUP IS ACTIVELY LOOKING AT AND I'M SURE THE OTHER GROUPS THAT STUDY THIS ARE AS WELL. SO QUICKLY TO COMPARE WITH OTHER CONDITIONS, AS I MENTIONED, SICKLE CELL PATIENTS WITH THE MOIA MOIA ARE PROBABLY DIFFERENT. AND DR. JORDAN'S GROUP SHOWN THAT PEOPLE WITH OR MOIA MOIA WHO DON'T HAVE SICKLE CELL, DO HAVE ELEVATED WHOLE BRAIN OEF AND REGIONAL DEPRESSIONS IN CDF AND WITH THAT KNOWLEDGE THAT MAY HELP US EXPLAIN WHY CHILDREN WITH STENOSIS ARE AT SUCH HIGH RISK OF STROKES. IN ANEMIC PATIENTS WITHOUT SICKLE CELL -- NOT ENTIRELY KNOWN. HEMOGLOBIN S TRAIT, THERE IS REALLY NO DATA PUBLISHED ON THIS ASIDE FROM THESE 10 CONTROL SUBJECTS FROM ONE OF JOHN WOODS PAPERS IN WHICH THEY NOTED THAT THE CEREBRAL BLOOD FLOW IS ABOUT THE SAME IN PEOPLE WITH SICKLE CELL TRAIT AS WITHOUT. AND THEN I THINK A FREQUENTLY -- A PART OF THE DISEASE NOT STUDIES AS OFTEN IS SICKLE CELL SC DISEASE.& IT WILL BE IMPORTANT TO CONSIDER HOW IS THIS DIFFERENT FOR WEEP WITH SICKLE CELL AN WITH HEMOGLOBIN SC DISEASE WHEN YOU KNOW THEY DON'T RESPOND TO THERAPIES THE SAME. THEY DON'T HAVE THE SAME RISK OF STROKES. BUT THEY DO HAVE COGNITIVE ISSUES AND THEY DO HAVE STROKE RISK AS THEY AGE. SO, WHAT CAN WE LEARN ABOUT THAT FROM THIS? SO SOME OF THE CHALLENGES THAT WE HAVE WITH THESE STUDIES, I THINK THE CHIEF CHALLENGE FOR US AS A SCIENTIFIC COMMUNITY IS THAT WE CANNOT COMPARE THESE DIFFERENT STUDIES ACROSS DIFFERENT CENTERS. EVERYBODY IS USING SLIGHTLY DIFFERENT SEQUENCES, DIFFERENT MRI EQUIPMENT, EVERYBODY'S RESULTS ARE CONSISTENT IN TERMS OF TRENDS BUT THE NUMBERS ARE NOT EXACTLY THE SAME. SO, EVERY SITE THEREFORE NEEDS TO ENROLL ITS OWN CONTROL GROUP WHICH WE HAVE HAD AHEC OF A TIME TRYING TO GET ANEMIC CONTROLS WHO DON'T HAVE SICKLE CELL. ALL THE IMAGING TECHNIQUES I DISCUSSED REQUIRE ASSUMPTIONS TO BE MADE MATHEMATICALLY IN ORDER TO DO THE COMPUTATIONS THAT ALLOW US TO HAVE THESE RESULTS. AND DEPENDING ON WHAT ASSUMPTIONS YOUR U. YOU'RE MAKING, YOU MAY END UP WITH DIFFERENT RESULTS. SO NOT EVERY STUDY IS CONSISTENT WITH ALL THE PUBLISHED ONES OR THE OTHER PUBLICATIONS. SO TRYING TO EXPLAIN THESE DISCREPANCY AND REFINE OUR MODELS IS REALLY IMPORTANT. AND I THINK ULTIMATELY, THIS POINT IS A NEED FOR MULTI-CENTER COLLABORATIVE STUDIES WHICH WE HOPE TO PURSUE SOON, ESPECIALLY TRANSPLANT COHORT I'M WORKING WITH GRUELING AT ALBERTA CHILDREN'S HOSPITAL TO IMAGE CHILDREN BEFORE AND AFTER HEMATOPOIETIC TRANSPLANTATION AS WELL. SO CONCLUSIONS. HEMODYNAMIC STUDIES SHOW GLOBAL AND REGIONAL METABOLIC STRESS IN SICKLE CELL. CEREBRAL BLOOD FLOW IS LOWEST AND OX EN EXTRACTION FRACTION IS HIGHEST IN -- IT MAY NOT BE ABOUT BAYSO OCCLUSION SO MUCH ABOUT ANEMIA OR COULD BE BOTH AND WE DON'T KNOW YET. AND THESE HEMODYNAMIC MEASURES NEED TO BE USEFUL AS BIOMARKERS TO PREDICTY IS VARIATEY AND QUANTIFY EXISTING THERAPIES AND THERAPIES THAT MAY NEED TO BE DEVELOPED IN THE FUTURE. THANKS. [ APPLAUSE ] >> THAT WAS A GREAT TALK. THANK YOU. I THINK YOU POINTED OUT THAT ANEMIA AND YOU RECOGNIZED ANEMIA IS A IMPORTANT CONFOUNDER. SO I WAS WONDERING HAVE YOU HAD A CHANCE OR LOOKED IN PATIENTS WHERE YOU HAVE A PRE-TRANSFUSION HEMOGLOBIN THAT REMAINS THE SAME FOR POST-TRANSFUSION BUT -- DROPS TO WHAT THE CBF AND OEF IN THOSE PATIENTS? >> THAT'S A GREAT QUESTION. I THINK A FEW OF OUR TRANSFUSION PATIENTS THEIR HEMOGLOBIN DID NOT CHANGE MUCH FROM BEFORE AND AFTER LIKE MAYBE WITHIN A GRAM. BUT I DON'T THINK WE HAVE ANALYZED SPECIFICALLY LIKE THAT SUBSET OUT OF THE ENTIRE TRANSFUSION COHORT. BUT THAT IS A GOOD QUESTION. >> AND CEREBRAL BLOOD FLOW AND OXYGENECTION TRACTION CORRELATES WITH ANEMIA. WHAT IF IMPROVED ANEMIA BUT THEN UP TO THIRD IS BOUND AND YOU CAN OFF LOAD OXYGEN. COULD THAT BE MORE DILATORRUOUS? >> WHAT WAS THE LAST PART? >> COULD IT BE MORE HARMFUL? YOU IMPROVED ANEMIA QUITE IMPROVED -- [ INAUDIBLE ] BUT -- [ MULTIPLE SPEAKERS ] >> RIGHT. >> RIGHT. >> SO THE QUESTION IS WHETHER FETAL HEMOGLOBIN IS EFFECTIVE AS HEMOGLOBIN A. >> -- MODIFIED ONE FRACTION OF THE -- >> OKAY. I SEE. >> ONE -- >> YES. SO I DON'T THINK WE KNOW THE ANSWER TO THAT QUESTION YET AS TO WHETHER THE -- I SUSPECT IF THE HEMOGLOBIN CAN'T OFF LOAD OXYGEN YOU WILL HAVE CHANGES BUT I DON'T KNOW FOR SURE. PART OF IT TOO IS THAT WHAT WE ARE MEASURING IS DEOXYHEMOGLOBIN VERSUS OXYHEMOGLOBIN. SO IT MAY LOOK LIKE THE OXYHEMOGLOBIN OR THE DEOXYHEMOGLOBIN IS NOT AS MUCH BUT WHAT KIND OF STRESS THAT IS PUTTH ON THE BRAIN, I DON'T THINK WE KNOW YET. >> ARE ANY OF THE MEASURES YOU DESCRIBED PAID FOR BY INSURANCE OR PURELY RESEARCH? >> THAT'S -- >> SO MOVING IT TO -- >> THAT'S PROBABLY THE NUMBER 1 QUESTION I AM TALKING WITH PEOPLE AT OTHER SITES. THIS IS RESEARCH-FUNDED. MY COLLEAGUE HAS AN RO1 PAYING FOR THIS. AT OUR PEDIATRIC HOSPITAL WE ARE LUCKY THAT A STANDARD CLINICAL MRI TAKES 45 MINUTES BUT THEY BOOK IT FOR AN HOUR. SO WHATEVER YOU DO IN THAT LAST 15 MINUTES IS YOURS. BUT IF IT HAS TO BE DONE AT THE RESEARCH FACILITY, WE HAVE TO PAY FOR IT. WE END UP PAY ARE FOR MOST OF THESE. >> WASHINGTON. YOUR SLIDE MENTIONED THAT IN ANEMIAS WHICH ARE NOT DUE TO SICKLE CELL DISEASE, YOU HAVE INCREASED BLOOD FLOW. I'M WONDERING WHETHER OR NOT IF THERE ARE STUDIES SHOWING THAT INTERMEDIA ANEMIA OR IRON DEFICIENT ANEMIA, THE SAME LEVEL, BECAUSE THEY HAVE THE SAME DYNAMICS OR BETTER OR ARE THEY WORSE? I DO NOT BELIEVE THEY ARE A RISK FOR STROKES. >> I THINK, SO IF YOU LOOK AT SOME LITERATURE, SO MICHAEL DOWLING WROTE A PAPER SOME YEARS AGO LOOKING AT ACUTELY ANEMIC PATIENTS WHO EITHER HAD SICKLE CELL OR LIKE APLASTIC ANEMIA AND HE FOUND ACUTE SILENCE CEREBRAL ISCHEMIC EVENT. A LARGE PORTION OF THE NON-SICKLE ANEMIC PATIENTS TOO. WHAT THE LONG-TERM CONSEQUENCES OF THOSE ARE, I DON'T THINK WE KNOW, BUT THE CHLA GROUP HAS A SMALL COHORT OF ANEMIC CONTROLS WHO ARE PRIMARILY THALASSEMIA PATIENTS WHO ARE ON TRANSFUSIONS. WE ARE TRYING TO RECRUIT ANY CONTROLS AND WE HAVE A HANDFUL AND THEY ARE VERY HETEROGENOUS. SOME WITH IRON DEFICIENCY AND SOME WITH APLASTIC ANEMIA. WE DON'T HAVE ENOUGH DATA TO SAY FOR SURE YET. >> THANK YOU. >> THANK YOU. >> THANK YOU, EVERYONE. I THINK IT'S TIME FOR LUNCH. [ APPLAUSE ] >> INFLAMMATION AND VASCULAR INJURY IN SICKLE CELL DISEASE, OUR FIRST SPEAKER WILL BE TOM WILLIAMS WHO IS THE CHAIR OF HEMODPLOAB--HEMOGLOBEIN RESEARCH AND HE HAS CARRIED OUT EPIDEMIOLOGIC RESEARCH AS AN INVESTIGATOR IN THE KEMERY, RESEARCH PROGRAM IN KENYA. HE PUBLISHED EXTENSIVELY ON THE BURDEN AND CLINICAL CONSEQUENCES OF SICKLE CELL DISEASE IN AFRICA WITH A SPECIAL EMPHASIS ON THE SUSCEPTIBILITY OF CHILDREN WITH SICKLE CELL DISEASE WITH CHILDHOOD INFECTIONS SUCH AS BACTERIAEREMMIA, PNEUMONIA AND MALARIA. TODAY WE WILL LEARN MORE ABOUT INFLAMMATION AND VASCULAR INJURY IN SICKLE CELL DISEASE BY EXAM INING THE COMMON GROUND SHARED BETWEEN SICKLE CELL DISEASE AND MALARIA. >> THANK YOU. YEAH, THIS IS WORKING. THANK YOU VERY MUCH. I'M NOT SURE THAT YOU LEARN INFORMATION ABOUT VASCULAR INJURY BUT MAYBE AFTER THE NEXT TALK AFTER MINE BUT I WILL START WITH THE COMMON GROUND BETWEEN SICKLE CELL DISEASE AND MALARIA, IT'S SILV TO KNOW WHERE TO START OTHER THAN THE FACT THAT THE 1 IS THE CAUSE OF THE OTHER. AS WE ALL KNOW, THE ONLY REASON WE HAVE SICKLE CELL DISEASE IS BECAUSE OF MALARIA. IT IS THE ARCH TYPAL EXAMPLE OF A POLYMORPHISM AS DESCRIBED BY THIS MAN NEARLY 50/60 YEARS, SINCE 1954 THIS MAN TONY ALLISON CAME UP WITH THE FIRST TO BE ATTRIBUTED WITH THE HYPOTHESIS THAT SICKLE CELL TRAIT WAS PRO TECTIVE AGAINST MALARIA, AND FOR MANY YEARS, THERE WAS SOME DEBATE AND DISCUSSION ABOUT WHETHER THAT WAS TRUE, AND EVEN WHEN I STARTED WORK IN KEN KENYA IN THE 2000 THERE WAS WORK ABOUT IT BUT THE DEBATE IS OVER, THE DISCUSSION IS FINISHED, WE'VE DONE A WHOLE LOAD OF STUDIES ON SICKLE CELL TRAIT AND MALARIA IN THE LAST 20 YEARS AND I THINK THERE'S NO DOUBT AT ALL THAT IT'S THE MOST PROTECTIVE THING AGAINST MALARIA EVER DESCRIBED. SO SICKLE CELL TRAIT IS NEARLY 90% PROTECTIVE AGAINST DEATH FROM MALARIA AND IT'S A FANTAST ICALLY GOOD THING TO HAVE IF YOU LIVE IN A MALARIA ENDEMIC COUNTRY. IT'S NOT JUST GOOD AGAINST MALAR IA, SO IT'S INCREASINGLY GOOD AGAINST DIFFERENT FORMS OF CLINICAL MALARIA, A LITTLE BIT OF--IT'S GOOD AGAINST GETTING PARASITES, GOOD AGAINST HAVING CLINICAL MALARIA OF ANY FORM AND EVEN BETTER AGAINST SEVERE MALAR IA BUT IT ALSO PROTECTS YOU AGAINST OTHER THINGS AS WELL, IF IT TEXTS YOU AGAINST ADMISSION TO HOSPITAL WITH ALL SORTS OF DIFFERENT CONDITIONS. AND IT DOES THAT BECAUSE MALARIA IS A VERY BAD THING TO HAVE IF YOU HAVE MALARIA, YOU'RE MORE LIKELY TO BE MALNOURISHED AND MORE LIKELY TO HAVE SEQUESTRATION IN THE GUT AND CAUSE LEAKINESS AND BACTERIAEREM MIA, IT'S MORE LIKE LY TO BE IMMUNE O SUPPRESSED AND SO THEREFORE MALARIA IS BAD FOR YOU IF YOU GET MALARIA YOU GET LOTS OF OTHER THINGS INCLUDING BACTERIAL INFECTIONS, SO SICKLE CELL TRAIT PROTECTS YOU AGAINST LOTS OF OTHER THINGS IN THE PANDEMIC ENVIRONMENT, IT LEADS TO AN INCREASED RISK OF SURVIVAL AND EVEN TODAY, IN A COHORT STUDY WE'VE DONE IN KENYA , IT'S 40% PROTECTIVE AGAINST ALL CAUSE MORTALITY EVEN IN THE ERA WHERE THERE'S RELATIVELY LITTLE MALARIA ON THE COAST OF KENYA IN 2015. AND SO THERE'S THE METHOD OF MALARIA AND THAT'S THE MATH OF SICKLE AND THEY LAYER ON TOP OF 1 ANOTHER, THEY SUPER IMPOSE AND HISTORICOT PREVALENCE OF SICKLE CELL TRAIT IN POPULATIONS PARTICULARLY AFRICA. SO BECAUSE OF THAT, THAT'S THE FIRST COMMON GROUND BETWEEN SICK LE CELL DISEASE AND MALARIA, IS MALARIA HAS CAUSED SICKLE CELL DISEASE, THERE WOULD BE NO SICKLE DISEASE IF IT WASN'T FOR MALARIA HISTORICALLY BECAUSE THERE'S SUCH A HIGH SELECTION IN MANY PARTS OF AFFRIC ATHE PREVALENCE OF SICKLE CELL TRAIT IS 15-20%. AND BECAUSE THERE'S A LOT OF SICKLE CELL TRAIT THERE'S A LOT SICKLE CELL DISEASE SO THEY'RE HAND IN HAND AND THEY CAN'T BE SEPARATED. SO WHAT ARE THE CONDITIONS BEYOND THAT. WE ALL KNOW FROM WORK THAT'S DONE WAY BACK WHEN, THE FIRST ROOT CAUSE OF ALL THE CONSEQUENCES OF SICKLE CELL DISEASE IS POLYMERIZATION OF THE HEMOGLOBIN IN THE RED CELL WHICH CAUSES--I THINK A COUPLE OF YEAR S AGO FROM SARESH'S GROUP FROM NEW YORK WAS SHOWN, THIS VIDEO AND I LOVE TO SHOW THESE BECAUSE YOU SEE THE CONSEQUENCE OF SICKLE CELL DISEASE IN THE CAP ILLEGALSARYS. SO IN NORMAL CIRCUMSTANCES WHERE BLOOD IS OX GENERATEDDATED--OX GENERATEDDATED, THE SICKLE CELLS MOVE THROUGH THE SYSTEM BUT WHEN IT BECOMES DEOXYGEN GENERATED DATED THEY SICK AND HE WILL THEY LOG JAM AND OCCLUDE IN THE CAPILLARYS AND CAUSE VASC ULAR OCCLUSION WHICH YOU SEE THERE AND WHEN YOU REOX GENERATEDDATE THE CELLS MOVE AGAIN, SO DEOX GENERATEDDATION AND POLYMERIZATION OF HEMOGLOBIN AND RED BLOOD CELLS AS A MAJOR THING BUT THAT'S IMPORTANT. IT'S THE ROOT CAUSE BUT IT'S NOT SUFFICIENT TO CAUSE ALL THE DOWN STREAM CONSEQUENCES OF SICKLE CELL DISEASE SO MANY OF YOU WILL BE FAMILIAR WITH THIS LOVELY PAPER THAT WAS WRITTEN A COUPLE OF YEARS AGO IN BLOOD BY ZANG AND THE OTHER GROUP IN NEW YORK WHICH I THINK WILL BE ELABORATED ON A BIT MORE PROBABLY IN THE NEXT TALK, I HOPE WHICH GOES THROUGH SOME OF THE OTHER THINGS THAT CONTRIBUTE TO THE PATHO PHYSIOLOGY OF SICKLE CELL DISEASE AND THEN NUMEROUS AS YOU ALL KNOW AND THIS IS AN AUDKRENS WHICH IS WELL FAMILIAR WITH, SOME OF THESE THINGS, SO CONSEQUENCE OF SICKLING AND POLYMERIZATION INCLUDE HEME OLDER PEOPLE SIS,RY LEASE OF FREEDOM HEME AND SOME OF THE THINGS THAT ARE SET IN TRAIN INCLUDE THE ACTIVATION OF ENDO THELIUM, THE UPREGULATION OF EXPRESSION OF SOME OF THE RECEPT ORSOT ENDOTHELIUM THAT WE SEE HERE, ACTIVATION OF PLATELET S, NUTRIFILLS AND THE CONSEQUENCE OF ALL THAT IS THAT YOU HAVE A MULTICELLULAR EVENTS WHICH LEAD TO VASCULAR OCCLUSION WHICH IS NOT JUST FROM THE SICK LING OF THE RED CELL BUT THE TRIGGERS OF THOSE OTHER DOWN STREAM CONSEQUENCES. AND OTHER EVENTS INCLUDE THE RE LEASE OF NITROUSEROUSOXIDE AND FREE RADICAL DAMAGE TO THE ENDO THELIUM, SO YOU GET A PAN INFLAMMATORY RESPONSE AND VASC ULAR INJURY AS A RESULT OF THAT. SO SOME OF THOSE EVENTS THAT ARE WELL DESCRIBED AND WILL PROBABLY BE TOUCHED ON IN THE MULTITONE IN THE NEXT TALK LEAD TO THE NEW SORT OF DRUGS THAT ARE PROPOSED FOR SICKLE CELL DISEASE BEYOND JUST THE HISTORIC 1S AND INCLUDE PAN SELECTED INHIBITORS OF P- SELECTIN SUCH AS THESE 2. THEY INCLUDE ANTIPLATELETS, DRUG S, THEY INCLUDE DRUGS THAT REVERSE THE METABOLIC DEPLETION INCLUDING GLUTA MIN, ANTIINFLAMM ATORIES AND ANTICO AGUMENTS AND SOME--WE WILL COME TO SOME OF THESE IN A MOMENT. BUT FIRST BEFORE WE COME ON TO THOSE, THE COMMON GROUND BETWEEN THE 2 CONDITIONS, I LIKE ALSO TO SHOW THIS NICE LITTLE VIDEO WHICH JUST GIVES YOU THE LIFE CYCLE OF MALARIA FOR THOSE WHO ARE NOT FAMILIAR WITH IT, SO MALARIA IS TRANSMITTED BY MOSQUITOES WHO INJECT INFECTED BLOOD INTO THE HUMAN, YOU GET IT RELEASED INTO THE PERIPHERAL BLOOD WHICH INVADE RED CELLS AND OVER A PERIOD OF ABOUT 24 HOURS- -LIKE THIS. SO THE YOUNG RINGS ARE IN CIRC ULATION, THE MORE MATURE PARASIGHTS WHICH CONTAIN PARASITES MORE THAN 24 HOURS OLD OR 18-24 HOURS OLD STICK IN THE MICROVASCULAR SO IT'S REALLY NICE WITH MICROFLUIDIC TYPE DEVELOPMENT OF MICROFLUIDICS IN THE LAST YEAR, WE'VE BEEN ABLE TO SEE THIS IN MORE DETAIL, AND THIS VIDEO IN THE GROUP IN HIDE LE BERG BY SCWHARTS HAPPENS IN FLOW CONDITIONS WITH THOSE MATERIALS STICKING TO AN END O THELLIAL MODEL SYSTEM AND YOU CAN SEE THEREY A--THERE'S A SHIZ ANT ACROSS THE SCREEN ROLL ING STICKING TO THE ENDOTHEL IUM AND IT'S BEEN BY THE SHEER FORCES IT'S ROLLING AND STICKING, AND ROLLING AND STICK ING SO IT'S OCCLUDING BUT NOT COMPLETELY OCCLUDING SO HAVE YOU A ROLLING ADHESION OF [INDISCERNIBLE]OT FLOW. WE'VE ALSO GOT OTHER ADHESION ACTIVITIES THAT GO ON IN THE BLOOD WHEN YOU HAVE BLOOD INFECT ED WITH MALARIA SO THIS IS A ROSETTE. THE OTHER THING IN THE MIDDLE ON THE LEFT IS AN INFECTED SHIZANT, AND YOU GET THIS SITUATION WHERE THE UNINFECTED CELLS STICK TO THE SHIZANT TO STICK, IN THE MICROGRAMOT RIGHT. SO AGAIN WITH MICROFLUIDIC SORT OF EXPERIMENTS, YOU CAN SEE THIS IN EXPERIMENTAL CULTURES CAN YOU CAN SEE THIS GREAT SNOW STORM OF ROSETTES THAT ARE FLOWING THROUGH THE BLOOD. SO THE UNINFECTED CELLS ARE STICKING TO THE PARASITE INFECT ED SEAL CELLS. THERE'S A LOT OF WORK DONE ON MALARIA AND ROSETTING, BUT THERE'S SOME PARASITES ROSETTE MORE THAN OTHERS AND THERE'S A GENERAL CORRELATION BETWEEN ROSETTING AND SEVERE AND COMPLICATED MALARIA AND IF YOU SEE SOMETHING LIKE THAT IT'S HARD TO IMAGINE THAT IT'S NOT A- -NOT A PARTICULARLY GOOD THING IF YOU HAVE A ROSETTING PARASITE IN THE RED, IN THE BLOOD THAT'S CREATING THESE CLUMPS OF CELLS GOING ROUND IN CIRCULATION. SO THERE'S A NUMBER OF DIFFERENT ENDO--SORT OF PHENOMENA INCLUDING THOSE 2 AND INCLUDING THE CONCEPT OF CLUMPING OF PARA SITIZED THAT INVOLVES PLATE LET MEDIATED ACTIVITY, AND YOU HAVE CLUMPING AND ALL USING DIFFERENT CELLS AND INTERCELL ULAR INTERACTIONS. THE NET RESULT OF WHICH IN PARTICULARLY SEVERE FORMS OF MALARIA, CAN RESULT IN A PICTURE LIKE THIS. AND I THINK FOR A SICKLE AUD IENCE IT'S NOT DIFFICULT TO SEE THE PARALLELS IN THE COMMON GROUND BETWEEN MALARIA AND CIRC LE CELL DISEASE WHEN YOU SEE CAP ILLEGALSARYS AND SMALL VESSELS OCCLUDED LIKE THIS WITH MULTICELLULAR ADGLUTENATES AND THE CONQUENCE OF SEVERE MALARIA IS THAT WE HAVE A PROPORTION OF CHILDREN DEVELOPING VERY SEVERE CONSEQUENCES OF THESE SORTS OF EVENTS LEADING TO COMA, CEREBRAL MALAR KRA, SEVERE ANEMIA WHERE YOU HAVE A SEVERE AND ACUTE DE CREASE IN HEMOGLOBIN AND ACID OSEIS AS A RESULT OF SOME OF THOSE DIFFERENT CONSEQUENCES AS WELL. SO THE SORTS OF MECHANISTIC PICTURES THAT YOU SEE FOR SEVERE MALARIA LOOK REALLY VERY SIMILAR TO THE PICTURE I SHOWED YOU EARLIER ABOUT THE MECHANISTIC HYPOTHESIS FOR THE CONSEQUENCES OF SEVERE--OF SICKLE CELL DISEASE, YOU SEE, THE SAME SORT OF MULTICELLULAR CONCEPTS WHERE YOU GET SEQUESTRATION OF BOTH INFECTED PARASITES TO THE ENDO THELIUM AND ALSO UPREGULATED WHITE CELLS, UPREGULATED PLATE LETS THAT ARE INVOLVED AND YOU GET CYTOKINE RELEASE AND NITRIC RICK OXIDE IS MENTIONED AS WELL. SO IT'S A CHRONIC INFLAMMATORY CONDITION THAT EFFECTS A LOT OF CHILDREN GROWING UP MA LAIA AND ENDEMIC ENVIRONMENTS AND KILLS A LARGE PROPORTION. SO LET'S JUST--I THOUGHT FOR THE REST OF IT, I THOUGHT THE INTERESTING THING WOULD BE TO SEE HOW 1 CAN LEARN FROM THE OTHER, WHAT IS--WHAT ARE THE POTENTIAL SORT OF VALUE--YOU'VE SEEN THE PATHOPHYSIOLOGICAL PROCESSES, WE HAVE PROFOUND SIMILARITIES OF MANY RESULTS AND MANY CASES, AND WHAT IS THE MUT UAL LEARNING BETWEEN THOSE 2 DISEASE SYSTEMS. SO I THOUGHT I WOULD START JUST BY LOOKING AT THE DRUGS THAT ARE IN THE PIPELINE FOR SICKLE CELL DISEASE AND LEADING ON THIS NICE PAPER FROM MARYLAND TELIN, BUT IT'S PUBLISHED A COUPLELE YEARS AGO, LOOKED AT THE SUMMARIZED DRUGS IN THE PINE LINE AND I OVERLAID THOSE DRUGS WITH THE DRUGS IN THE EXPERIENCE OF SOME OF THOSE THINGS WHICH HAVE BEEN THOUGHT THROUGH AND USED IN CLINICAL TRIALS FOR SEVERE MALAR IA. SO PLATELETS, I THOUGHT START WITH ANTIPLATELET AGENTS. THIS IN THE FIELD OF MALARIA WAS THOUGHT THROUGH QUITE A FEW YEAR S AGO. THERE'S ONLY 1 CLINICAL TRIAL I CAN FIND IN THE LITERATURE THAT 'S USED AN ANTIPLATELET AGENT IN SEVERE AND COMPLICATED MALARIA IN SEVERE CEREBRAL MA LA IA, IT WAS A FACE 1 TRIAL. IT USED--ONLY INCLUDED 10 CHILDREN WITH SEVERE MALARIA. IT USED PENTOXIFILEN AS AN ADJUNCTIVE TREATMENT FOR CHILDREN WITH CEREBRAL MALARIA AND IT STOPPED UNSUCCESSFULLY WITH ONLY--WITH 10 CHILDREN RECRUITED THERE WAS A MUCH HIGH ER CASE FATALITY IN THE TREATED GROUP THAT IN THE NONPEN TOXAFFILE AND THE CONTROL GROUP SO 40 CHILDREN IN THE PENT OXIFYLLINE, WHICH SORT OF KILLED EXPERIMENTAL TRIALS ON THESE OF ANTIPLATELET AGENTS IN SEVERE MALARIA AND THERE HASN'T BEEN 1 SINCE. IT'S BEEN PUT UP AS A POTENTIAL, I THINK THAT WE STILL HEARD THIS MORNING IT'S STILL GOT SOME LEGS ON IT IN SOME AREAS OF TREATMENT BUT IN--IN THE MAIN--THE BIG TRIAL OF [INDISCERNIBLE] WHILE IT DIDN'T PERFORM AND IT'S BEEN A--SORT OF A--A BIT OF FALLEN A BIT OFF THE RAILS. NEXT 1 IS [INDISCERNIBLE] THIS IS AN INTERESTING AGENT BECAUSE IT HAS A BROAD RANGE OF DIFFERENT EFFECTS. IT'S AN ANTIOXIDANT, IT HAS ANTI CO AGULATE PROPERTIES AND HAS A BROADLY ENDOTHELIAL STABILIZER SO IT HAS DIFFERENT POTENTIAL IMPACTS IN DIFFERENT PARTS OF THAT SORT OF INFLAMM ATORY AND MICROVASCULAR PROCESS, SO IN MALARIA THERE'S BEEN 1 TRIAL OF N-ACETYLCYSTINE AND IN ADULTS WITH SEVERE SERIES POINTSEBERAL MALARIA. HAD NO BENEFIT WHATSOEVER. IT HAD NO EFFECT ON THE RESOLUTION OF COMA. IT HAD A SLIGHTLY ADVERSE EFFECT ON PARASITE CLEARANCE. ADULTS TREATED WITH N-ACETYLCYSTINE CLEARED IT SLOW LY, SO THAT WAS THE DEATH OF N-ACETYLCYSTINE IN CLINICAL TRIALS OF SEVERE MALARIA. I HAVEN'T SEEN ANYTHING IN THE CLINICALTRIALS.GOV, TO SUGGEST THAT WILL BE BROUGHT BACK. SICKLE CELL DISEASE, IT HAS BEEN --IT IS ON THE LIST OF THING S THAT HAVE BEEN CONSIDERED IN SICKLE IT'S BEEN USED AND SUGGESTED AS A PROPHYLACTIC AS OPPOSE FOR TREATMENT, SO THERE'S 1 STUDY THAT'S REPORTED ON USING N-ACETYLCYSTINE AS A PROTECTION AGAINST CLINICALS, SICKLE SEASON , HAD--IT HAD NO EFFECT THERE EITHER. IT WOULD BE BGH SO IT DIDN'T MAKE THE CUT AND YOU CAN SEE THE P-VALUES ACROSS THE BOARD THEY WERE INSIGNIFICANT. SO I DON'T THINK THAT'S PROBABLY GOING ANYWHERE, EITHER. STATINS IS ANOTHE THING THAT'S BEEN--BEEN SUGGESTED AS THE VARIOUS REASONS, AND IT REDUCES NUTRIFILL ADHESION, THAT BROADLY AND NONSPECIFIC ANTIINFLAMMATORY AGENTS AND ARE SUGGESTED AS A POTENTIAL BOTH FOR SICK AND HE WILL FOR MALARIA. SO MALARIA, THEY'VE GOT NO OTHER --THERE HAVE BEEN 3 OTHER NEGATIVE STUDIES OF MOUSE MODELS THAT HAVE SHOWN NO BENEFIT OF STATINS IN SICKLE CELL DISEASE. THERE ARE 5 TRIALS REGISTERED. ONE IS REPORTED THAT I CAN ONLY FIND 1 AND THAT WAS A TRIAL BY CAROLINE HOPY WHICH HAS SHOWN POTENTIAL FOR SURGTER RESEARCH. IT WAS--IT WAS A SMALL STUDY OF 19 PATIENTS AND THE OUTCOME WAS PAINFUL CRISIS AND IT WAS A BEFORE AND AFTER STUDY RATHER THAN RANDOMIZED CONTROL TRIAL BUT IT'S THE--THERE WAS SOME SUGGESTION OF A BENEFIT OF SIMPLE STATIN IN THAT TRIAL AND I THINK THERE ARE PLANS FOR FURTHER STUDIES THERE BUT IT'S NOT GALLOPING AHEAD. GLUTA MINE, I DON'T WANT TO MENTION TOO MUCH DPLIEWTA MINE, SICKLE CELL DISEASE, I THINK YOU ALL KNOW THE STORY AND IN MALAR IA THERE'S BEEN ONLY 1 STUDY WHICH IS RELATEDDED TO GLUTA MINE AND THAT'S DPLIEWTA-- GLUTAMINE ANALOGUE WHICH IS ABBREVIATED TO D. O. N. WHICH IS SUPPOSED TO BE ABSOLUTE LY FANTASTIC AND ALMOST CURATIVE IN MOUSE CEREBRAL MALAR IA SO CURATIVE IT MAKES THE PNAS A MONIKER, BUT THERE'S ANXIETY ABOUT THE UTILITY OF MOUSE MODELS AND HOW WELL THEY LINE UP AGAINST HUMAN CEREBRAL MALARIA. I HAVE NOT SEEN ANY REGISTERED TRIALS SUGGESTING THESE GLUTA GLUTAMINE OR IN HUMANS BUT MAYBE THAT'S IN THE PIPELINE FOR FUTURE STUDIES. ANTICO AG IEWNLTS, WE'VE HEARD ABOUT ANTICO AGULATES AT VARIOUS POINTS DURING THE LAST 2 DAYS. SO IN MALARIA IT'S BEEN APPRECIATED FOR MANY YEARS THAT THERE IS A HYPER--YOU KNOW GLUTENNABLE STATE. MORE PRONE TO GLUTENNATE, TO CLOTTING. LET--AND IT'S ALSO KNOWN THAT HEPATITIS E RIN REVERSES THE BINDING OF RED CELLS TO SHIZON, HEPARE--ADMINISTRATIVE--HEAPPROX IMATE, ARIN, CAUSES THE CELLS ON MA LAIA SHISWRONS AND HEP A RIN IS A BLOCKING AGENT FOR THAT. THERE'S BEEN A LOT OF INTEREST IN HEP A RIN, BUT IN MALARIA THERE'S BEEN A RETICENCE TO USE ANTICO AGULATES OF PATIENTS FOR RISK OF CEREBRAL BLOODING THERE'S A LOT OF REVIEWS AND RE PORTS OF USE OF THESE, ABOUT HEPATITIS E RIN, I'VE NOT SEEN A CLINICAL TRIAL THAT USED IT AND I THINK THERE'S RETICENCE THERE. IN SICKLE CELL DISEASE, IT'SOT LIST, MORE FOR--I HEARD ABOUT THIS USE, IT'S A SUGGESTION FOR PATIENTS WITH CLOTTING DEFECTS AND WITH LUNG PROBLEMS AND ADMIT TED TO HOSPITAL AND IM MOBILE SO AS PROPHYLAXIS AGAIN DVT, ET CETERA BUT IT'S ALSO BEEN SUGGESTED AS A PROPHYLAXIS AGAINST PAINFUL CRISIS OR THE TREATMENT, SORRY TREATMENT OF PAINFUL CRISIS, THERE'S 1 STUDY THAT IS IN CLINICALTRIALS.GOV, WHICH IS USED DELTA PILOT PROJECT--PYRIN AS TREATMENT FOR PAINFUL CRISIS AND THE OUTCOME BEING THE TIME TO RESOLUTION OF PAIN BUT THAT--THAT WAS ACTUALLY REGISTERED IN 2015 VERY MUCH HAPPENED BUT I DON'T THINK IT WOULD BE GRATEFUL TO KNOW IF ANYONE KNOWS THE RESULT OF THAT TRIAL. I CAN'T FIND ANYTHING SPECIFIC BEING PUBLISHED IN THE LITERAT URE. SO I THINK TBROABL AFTER ALL OF THIS, THE MOST INTERESTING AND POSSIBLY MOST TRANSLATABLE TREATMENT WHICH IS SOMETHING THAT'S SEVERAL OF US IN THE BOTH WORLDS OF MALARIA AND SICKLE COME UP WITH THE DRUG CALLED SEV APILOT PROJECT RIN, ONLY IT'S NOT GOT THE CURE PROPERTIES, SO AND IT WAS DEVELOPED BY MATS WAL GREN, THE MAN IN THE INSTITUTE WHO DEVELOPED IT FOR THE TREATMENT OF COMPLICATED MALARIA BECAUSE HE'S BEEN WORKING ON ROSETTING FOR MANY YEARS AND WORKED ON HEPARAN CELL FATE AND IDENTIFIED THE UTILITY OF HEPATITIS E RIN AGAINST ROSETTING AND CYTOADHESION COMPLICATIONS. AND THERE HAVE BEEN 2 STUDIES OF THE USE OF SEP A RIN IN MALARIA, 1 IN CLINICL TRIAL AND 1 EXVIVO STUDY AND IT SHOWS THAT--IT DOES SHOW THAT SEP A PYRIN, THE MORE YOU GIVE UP, THE USUAL DOSE IS 500 MILLI GRAMS OF, AND IT RE DUCES ROSETTING AND IN MODEL SYSTEMS IT ALSO OBLITERATES CYTO ADHESION. AND IN TREATMENT TRIALS, BUT THE RED LINE IS ACCEPTA PILOT PROJECT RIN TREATED PATIENTS AND THE OTHER IS CONTROL TREATED PATIENTS AND IT RELEASES A LOT OF [INDISCERNIBLE] AND THEY COME THIS IN EARLY OUT OF SEQUESTRATION AND INTO CIRC ULATION AND CLEAR PARASITES MORE QUICKLY. SO THERE'S SOME INTEREST IN SEP A RIN, AND IT'S BEEN--THE COMPANY THAT PRODUCED THIS HAVE REPURPOSESSED IT FOR THE TREATMENT OF SICKLE CELL DISEASE BECAUSE OF FOR COMMERCIAL REASON S, THEY THINK IT'S A BET TER FIRST TARGET AND THERE'S 1 CLINICAL TRIAL THAT'S CURRENT LY UNDERWAY ON THE USE OF SEP A RYN, THAT SHOULD BE REPORT ING SOON BECAUSE IT'S ON CLINICAL TRIALS.GOV, IT SAYS IT'S COMPLETED RECRUITING IN OCTOBER AND SHOULD BE DUE FOR RE PORTING SO, THIS IS A STUDY THAT'S--SOME OF THIS INVITRO WORK BY MARILYN SUGGESTS THAT SE P A RIN SELECTING THIS PAN- SELECTING BLOCKING SO NOT JUST P-SELECTINS AND E-SELECTINS , THEY ARE BLOCKED BY SEP A RIN AND ALLOWED THEREFORE TO DECREASE THE FETAL COMPARTMENT PHENOMENON AND IN THE MODEL AN ENDOTHELIAL MODEL SYSTEM OF BLOOD GENERALLY RED CELL PROTEINS AND WHILE CELL PRODUCTS WHO ARE REDUCE I'LL SAY THIS 1 CLINICAL TRIAL THAT'S GOING ON IN THE MOMENT WHICH HOPEFULLY SHOULD BE REPORTING SOON, SO WE'LL SEE THAT IT WOULD BE INTERESTING TO SEE THE ANSWER TO THAT. SO THAT IS THE COMMON GROUND AS FAR AS THERAPEUTICS ARE CONCERN ED. YOU CAN SEE THAT THERE'S--THERE ARE VERY CLOSE SIMILARITIES BETWEEN THE PATHOPHYSIOLOGY OF THE SICKLE CELL DISEASE AND PATHOPHYSIOLOGY OF MALARIA, THAT LEND THEMSELVES TO POTENTIAL JOINT LEARNING WHICH IS A VERY RARELY ACTUALLY APPRECIATED IT IN THE LITERATURE, SO ALL OF THOSE STUDIES I CAN SEE VERY LITTLE CROSS TALK BETWEEN THE COMMUNITIES AND CROSS REFERENC ING OF THOSE 2 DIFFERENT THERAPEUTIC DIRECTIONS. SO YOU CAN SEE, THE MOST COMMON GROUND IS THE 1 CAUSED BY THE OTHER. ONE THING I HAVEN'T MENTIONED IS THEY'RE BOTH EXTREMELY NEGLECTED , PARTICULARLY SICKLE BUT MALARIA HAS BEEN FOR MANY, MANY YEARS AS WELL, THERE'S COMMON PATHOLOGICAL PROCESS AS WELL AND OPPORTUNITIES, THANK YOU VERY MUCH TO MY FUNDERS AND TO INVITING ME HERE TO THE NIH AND ALSO TO MY COLLEAGUES IN THE PROGRAM IN KENYA. >> I'D LIKE TO INVITE QUESTIONS FOR DR. WILLIAMS AND I'LL MAKE THE FIRST 1 BEFORE SOMEONE BEATS ME TO IT. ONE OTHER INTERESTING COMMONALITY BETWEEN SICKLE CELL AND MALARIA IS THAT EACH OF THEM IS MADE LESS SEVERE IN PEOPLE WHO HAVE ALPHA THAT WILLSEMIA AND WHAT DO YOU THINK ABOUT THAT AND WHAT DOES THAT TELL US ABOUT THE DISEASES. >> YES, AS YOU KNOW IT'S A SUBJECT CLOSE TO MY HEART BUT I THINK THE REASON--THE MECHIMISM- -MECHANISM IS THE SAME WITH THE PROTECTIVE SICKLE TRAIT , SICKLE TRAIT WE'RE TALKING ABOUT, RATHER THAN SICK LE CELL DISEASE, THE PROTECT IVE TRAIT IS DOSE DEPENDENT FOR THE AMOUNT OF SICK LE IN THE SICKLE HEMODPLOAB IN IN THE RED CELL. AND SO, I THINK THAT IT'S AN INTERACTION BETWEEN--IT'S A COMPETITION BETWEEN THE ALPHA 1 BETA AND GLOBUE LYNN CHAIN THAT AMELIORATES THOSE THINGS AND HERE'S COMMON GROUND. WE DON'T HAVE ENOUGH TIME TO GO INTO IT IN GREAT DETAIL. >> WELL ARE THERE ANY OTHER QUESTIONS FOR DR. WILLIAMS? WELL I'LL GO AHEAD AND INTRODUCE OUR NEXT SPEAKER THEN. [ APPLAUSE ] OUR NEXT SPEAKER TO--CONTRIBUT ING ORIGINAL RESEARCH IN CAREFULY CONTROLLED MODEL SYSTEMS AS WELL AS IN REAL SICKLE CELLA THE THERAPY CENTER, HERE WORK IS ELUC DATING HOW INFLAMMATORY MOLECULES CELLS AND SIGNALING PATHWAYS ARE ACTIVATED IN SICKLE CELL DISEASE AND WHAT ROLE THEY PLAY IN THEIR SEVERE CLINICAL MANIFESTATIONS SO NICKOLAY LOOK FORWARD TO HEARING ABOUT WHAT THESE MEAN FOR SICKLE CELL PATHOPHYSIOLOGY. >> IS THIS ON? YEAH. >> THANKS FOR THE INVITE IS TAKING PART IN THE MEETING BECAUSE IT'S BEEN EXCELLENT AS ALWAYS. SO, I THINK IT'S REALLY IMPORTANT TO REMEMBER WHY INFLAMMATION IS SO IMPORTANT IN- -PARTICULARLY NOISE RECEPTOR AND THEY ALSO CONTRIBUTE TO ORG AN DAMAGE AND WAWE SEE IN SICKLE CELL PATIENTS IN THE PATHOPHYSIOLOGY IS BOTH ACUTE AND CHRONIC INFLAMMATORY RE SPONSES GOING ON, WE HAVE CONTINUED ACUTE INFLAMMA TOORY RESPONSES GOING ON THAT LEAD TO A VICIOUS CIRCLE OF INFLAMMATION THAT THEN LEADS TO THE CHRONIC INFLAMMATORY STATE THAT'S ASSOCIATE WIDE SICKLE CELL DISEASE. AND IT'S VERY IMPORTANT TO REMEMBER WHEN WE'RE TALKING ABOUT INFLAMMATION IN SICKLE CELL DISEASE, THAT IN FACT, WE'RE GENERALLY TALKING ABOUT THE STERILE INFLAMMATORY RE SPONSES THAT ARE ACCELERATED IN THESE PATIENTS IN AN ATTEMPT OF INNATE IMMUNITY SYSTEM TO RE SOLVE THE TISSUE INJURY THAT TRS IN THESE PATIENTS BUT OF COURSE WE DO HAVE SOME PATHOGEN ASSOCIATED INFLAMMATION GOING ON IN THESE PATIENTS AS WELL THAT WE WILL SEE LATER ON. SO WHICH ARE THE SOURCES OF INFLAMMATION IN SICKLE CELL DISEASE? WELL FIRST OF ALL, THE SICKLE RED BROOD CELL, ITSELF IS IMPORTANT FOR THIS INFLAMMATION. WE HAVEOXIDATIVE STRESS BEING PRODUCED BY THESE RED BLOOD CELL S DUE TO POLYMERIZATION AND ALSOOXIDATION OF THE HEMODPLOAB IN S AND THESE ARE MUCH MORE [INDISCERNIBLE] THEY'LL STICK TO THE ENDOTHELIAL CELLS AND END UP ACTIVATING THEM AND THESE CELLS ALSO CONTAIN HIGHER CONCENTRATIONS OF PLACENTA SEBTAL GROWTH FACTOR WHICH IS AN IMPORTANT ANGIOGENIC FACTOR AND SICKLE RED BLOOD CELL S PRODUCE MORE MICROPARTICLE S. SO OF COURSE WHEN THESE SICKLE CELL RUPTURES THEY WILL THEN GO ON TO PRODUCE FURTHER INFLAMM ATION, SO WHEN WE HAVE CELL FREE HEMOGLOBIN IN HEMO GLOBEIN WILL REACT WITH CIRC ULATING NITRIC OXIDE AND THIS HAS A VERY IMPORTANT INFLAMMATORY EFFECT BECAUSE AS WELL AS BEING EVASIVE, AND IMPORTANT VASAL DILATOR, NITRIC OXIDE IS AN INHIBITOR OF INFLAMMATION AND INHIBITS THE ENDOTHELIAL CELLS AND ALSO OF LEUCOCYTES AND IS A VERY POTENT INHIBITOR OF PLATELET ACTIVATION AND ADHESION. SO IF YOU LOOK AT THIS, YOU WILL INDUCE A STRONG INFLAMMATORY RE ACTION, SO THIS IS ALSO REACT IVE NIGHT NITRIC OXIDE WHICH WE NOW KNOW IS A POTENT INFLAMMATORY DAMP WHICH HAS IMPORTANT EFFECTS AND WE CAN TRIGGER ACUTE CHEST SYNDROME PROCESSES AND ALSO VASCULAR STASEIS. IN ADDITION TO THIS RED CELLS THEY CONTAIN AN AWFUL LOT OF INFLAMMATORY DAMP SO DANGER ASSOCIATED MOLECULAR PATTERNS AND THESE WHEN THEY ARE RELEASED INTO THE CIRCULATION THEY WILL INNATE IMMUNE RESPONSES INCLUDING THE FORMATION OF INFLAMMA STUDIES OF MULTIPLE ENDOCRINE AND PRODUCTION OF INTERLUKEIN 1. SO IN ADDITION TO HEME OLDER PEOPLE SIS, WE ARE INFACT THE BASAL OCCLUSIVE PROCESS IS IMPORTANT FOR INDUCING INFLAMM ATION ITSELF. THE VASCULAR OCCLUSION LEADS TO ASCHEMIA AND HYPOXIA AND THIS WILL LEAD TO CELL DEATH MECHANISMS IN TISSUE INJURY WITH RELEASE OF DAMPS AND THE RE GENERATION OF OXYGEN SPECIES AND THEREFORE OXIDATIVE STRESS. AND THEN WHEN THE BLOOD FLOW RE TURNS TO THESE OCCLUDED PLOOD VESSELS, WE THEN GET REPROFUSION INDUSTRY WITH FURTHER OXIDATIVE STRESS AND AWLTS CALCIUM UPLOAD SO THE OCCLUSIVE PROCESS IS A MULTICELLULAR, MULTICOMPONENT PROCESS, WHICH INVOLVES INIT IATION PHASE, PROPERIGATION PHASE, RESOLUTION PHASE AND FIRST OF ALL OF COURSE, THE ACT IVATED AND BEING IN PLACE OF COURSE A VERY IMPORTANT ROLE. WE HAVE ENDOTHELIAL DYSFUNCTION DUE TO HEME OLDER PEOPLE SIS WHICH ALSO INPAIRS NITRIC OXIDE PRODUCTION THESE DISP CELL RECRUITMENT TO THE PLOOD AND VASCULAR ROLE AND HYPOXIA AND HEME OLYMPIC SIS AND WHICH THEN LEADS TO EXPRESSION OF ADHESION HOLDING COMPANY KIEWLS ON THE ENDOTHELIAL CELLS AND ALSO TO THE RELEASE OF POTENT INFLAMM ATORY MOLECULES AND GROWTH FACTORS SUCH AS INTERLUKE IN 1 BETA AND GMCSF. WE KNOW THAT LEUCOCYTES FILED IN INCREASED NUMBERS IN SICKLE CELL DISEASE AND THESE ARE ALSO ACT IVATED AS THEY PRODUCE INCREASED NUMBERS OF ADHESION MOLECULES ON THE SURFACE AND THEY ALSO--THESE ADHESION MOLECULES ARE ACTIVATED FOR THE CONFIRMATION SO THIS MEANS THAT THESE INTERLUKEIN SITES CAN BE RAPIDLY IPT GREATER CREASE TO THE CELL SURFACE WITH WHEN IT'S ACTIVATED AND PLAY AN IMPORTANT ROLE IN THE BETA OCCLUSIVE PROCESS BECAUSE THEY CAN THEN PLACENTA I A ROLE IN THE SECONDARY RECRUITMENT OF RED BLOOD CELLS AND PLATELETS. IN ADDITION TO THIS, LEUCOCYTES VERY IMPORTANT FOR PRODUCING PRO INFLAMMATORY MOLECULES AND PRODUCE LARGE QUANTITIES OF INTERLUKEIN 1 B AND TNF AND THESE WOULD BE IMPORTANT FOR FURTHER ACTIVATING NEIGHBORING ENDOTHELIUM AND WE ALSO HAVE ACT IVATED NUTRIFILES AND THE G- GRANULATION OF CELLS IN THE SICKLE CELL DISEASE WILL LEAD TO INCREASED LEVELS OF EFTHIMIOSA MINE WHICH CAN BE--PLAY A ROLE IN LUKEEE SIGNIFYITOSE EXPIS ANG IO GENESIS AND ENDOTHELIAL ACTIVATION. AND I THINK IT'S BECOMING IN CREASINGLY CLEAR THAT THESE ARE IN THE PROCESS, AND THESE ARE ACTIVATED IN THE [INDISCERNIBLE] STATE AND THIS LEADS TO INCREASED EXPRESSION OF THE NUMBER OF ADHESION MOLECULES - THE SURFACE SO AS SOON AS THE ENDOTHELIUM ARE ACTIVATED THEY ARE RECRUITED TO THE END OF SERVICE AND THEY FORM A LAYER ALONG THE ENDOTHELIAL SURFACE WHEN IT'S ACTIVATED AND THIS IS IMPORTANT BECAUSE IT CAN PLAY A ROLE IN THEN THE THE FURTHER RECRUITMENT OF LEUCOCYTES AND ALSO THIS PLAYS A ROLE IN THE CELLULAR ADVOCATES WHICH ARE IMPORTANT FOR THE PROCESS AND [INDISCERNIBLE] PROCESSES. IN ADDITION TO THIS PLATELET STOCK OR HUGE NUMBER OF INFLAMM ATORY MOLECULES AND THE GRANULES INCLUDING TNF SUPER FAMILY MOLECULES AND WHEN THEY ARE ACTIVATED THEY WILL RELEASE THESE INFLAMMATORY MOLECULES INTO THE CIRCULATION OF THIS AND THIS PLAYS A VERY IMPORTANT ROLE IN THE PROPAGATIONIGATION OF THE CIRCLE CELL DISEASE. THESE ARE ALL STERILE IN INDUC ING INFLAMMATION IN THE SICKLE CELL DISEASE BUT WE DO HAVE A ROLE FOR PATHOGEN INDUCED INFLAMMATION IN THE CELL DISEASE , SO WE KNOW THAT PATIENT S IF THE CELL DISEASE AND MORE BACTERIAL INFLAMMATION AND INFECTION FEKS AND THIS WILL LEAD TO THE PROJECTION OF PATHO GEN ASSOCIATION WITH PATTERNS OR PUMPS SUCH AS LPS IN THE CIRCULATION OF THESE PATIENT S AND THESE PASMS MAY BE IMPORTANT FOR THESE INFLAMMATORY CELLS, SO WHEN THEY'RE PRIMED THEY CAN BE SUSCEPTIBLE FOR SECONDARY SIGNALING METHODS AND WITH REACTIVE OXYGEN SPECIES PRO DUCED BY STERILE [INDISCERNIBLE] AND HYPOXIA AND THIS WILL LEAD TO THE TRIGGERING OF INNATE INFLAMMATORY RESPONSES SUCH AS THE INFLATION OF THE INFLAMMA STUDIES OF MULTIPLE ENDOCRINE AND ALSO INTERLUKEIN 18 PROCESSING. WE ALSO HAVE A ROLE IN OF THE INFLAMMATION IN THE SICKLE CELL DISEASE ESPECIALLY INTESTINAL MICROBI OTA. SO IF WE DEPLETE THE INTESTINAL MICROBI OTA USING ANTIBIOTICS IN BOTH PATIENTS AND IN MY SICKLE CELL DISEASE, WE END UP REDUCING ACTIVATION AND ALSO IN MICE IN SICKLE CELL DISEASE, DEPLETION OF THE MICROBIOTA RELEEDS TO THE RELATED ORGAN DAMAGE. SO WE HAVE THE MAIN SOURCES OF INFLAMMATION OF THE DISEASE AND HEMOGLOBIN S, AND THE INFLAMM AT ORY OR VOWSHES OBVIOUSLY VASC ULAR PROCESSES BUT THESE ALSO PLAY A PROVOCATION ROLE IN THE INFLAMMATION IN SICKLE CELL DISEASE AND THIS CASCADE OF INFLAMMATTORY EVENTS AND MULTIPLE ACTIVATION OF THE MULTIPLE CELL TYPES MEANS THAT WE GET THE PRODUCTION OF A HUGE NUMBER OF INFLAMMATORY MOLECULES DURING STEADY STATE SICKLE CELL DISEASE AND THIS IS JUST A LIST OF MOLECULES, IT'S A HUGE NUMBER OF MOLECULES CIALTION THERE'RE IMPORTANT PROINFLAMMATORY CYTO KINES PRODUCED BY PLATELETS AND OTHER CELL TYPES, THESE HAVE MULTILE EEVENGHT--EFFECTS INCLUDING ACTIVATION OF CELLS AND THE INDUCTION OF ADHESION MOLECULES ON THE SURFACA WELL-- SURFACE AS WELL AS PRODUCTION AND DIFFERENTIATION OF SMOOTH MUSCLES. CHEMO KINES ARE ALSO UPWARD IN STEADY STATE SICKLE CELL DISEASE , AND THESE INCLUDE INTER LUKEIN 8, AND U-TAXIN AND THEY'RE IMPORTANT FOR INDUCING CELL MIGRATION. WE HAVE A LARGE NUMBER OF GROWTH FACTORS IN THE STEADY STATE SICK LE CELL DISEASE, VEG F AND THE THESE WILL INDUCE THE CELL PROLIFERATION AND DIFFERENT IATION OF CELLS AND ALSO ANGIOGENIC PROCESSES IN THE END THOUGH THELLIAL CELLS AND WE ALSO HAVE A NUMBER OF ACUTE PHASE PROTEINS THAT ARE THEY ARE INCLUDING SUBSTANCE AND C-REACT IVE PROTEIN FROM [INDISCERNIBLE]. AND THESE ARE IMPORTANT FOR THE AMPLIFICATION OF THESE INFLAMM ATORY PROCESSES. INCREASED IN STEADY STATE SICKLE CELL DISEASE, WE SEE HIGHER LEVELS OF THE PROOF THE GLANDIN AND LEUCOTRYIN BEFORE. THEY'RE INVOLVED IN PAIN INDUCTION AS WELL AS THE AMPLIFICATION AND ALSO IN THE MOTOR ACTION. AS WE'VE SEEN BEFORE, WE DID HAVE INCREASED LEVEL LEVELS OF CIRCULATING ADHESION MOLECULES SUCH AS COLUBLE GLECAM 1 AND GLO CAM 1 AND INCREASED EXPRESSION OF THESE ADHESION MOLECULES ON THE SURFACE, AND THEY'RE PROBABLY MARKERS OF ENDO THELIAL ACTIVATION AND I HAVE MENTIONED BEFORE ENORMOUS A MOUNT AND THEY ARE PRODUCED AND RELEASED BY DAMAGED CELLS AND HEME OLDER PEOPLE SIS AND THESE INCLUDE HEME, PROTEIN 70 AND HGB 1 AND THEY WILL ALL BE INNER VOSMED IN THE TRIGGERING OF INNATE IMMUNE INFLAMMATORY RE SPONSES SUCH AS ACTIVATION OF THE INFLAMMA STUDIES OF MULTIPLE ENDOCRINE AND THE AMPLIFICATION OF INFLAMMATION AND THERE ARE SOME ALARMINGS THAT HAVE BEEN FOUND IN ELEVATED LEVELS AND STEADY STATE SICKLE CELL DISEASE INCLUDING S188 WHICH IS PRODUCED BY ACTIVATED LEUCOCYTES AND WE HAVE DATA TO INDICATE THAT THIS PROTEIN MAY BE A MARKER OF HEMA LYTIC ACTIVATION IN SICKLE CELL DISEASE. SO I THINK IT'S WORTH CALLING ATTENTION TO SOME OF THESE INFLAMMATORY MOLECULES. PARTICULARLY TNF ALPHA WHICH IS A TYPE 1 CYTOKINE IS THOUGHT TO BE GENERATED AS AN EARLY CONSEQUENCE OF ASCHEMIA AND PRO FUSION AND THE EFFECTS ARE MEDIATED BY THE CNP RECEPTOR AND BY NF CAPPA B TRANSCRIPTION ACT IVATION AND IT'S MAIN EFFECT IS TO ACTIVATE THE ENDOTHELIAL CELL WHICH OF COURSE WOULD HAVE AN PARENT ROLE IN ACTIVATING THE PROCESSES, AND OF COURSE, TNF ALPHA AS YOU KNOW IS USED AS A TRIGGER AFTER NEW MOUSE SICKLE CELL MICE WITH SICKLE CELL MICE TO INDUCE BASAL [INDISCERNIBLE] SO IT'S A VERY IMPORTANT IND ICATOR OF HOW IMPORTANT TNF ALPHA IS IN SICKLE CELL DISEASE. WE ALSO HAVE INCREASED LEVELS OF TNF OF INTERLUKEIN 1 BETA AND INTERLUKEIN 1 BETA HAS BEEN CONSISTENTLY REPORTED AS IN SICK LE CELL DISEASE, IT'S PRO DUCED BY THE INFLAMMA STUDIES OF MULTIPLE ENDOCRINE PLATFORM AND FOR THIS INFLAMMA STUDIES OF MULTIPLE ENDOCRINE TO BE AND FIRST UNDERGO PRIMARY SIGNAL TO INCREASE GENE TRANSCRIPTION OF THE MACHINERY AND THEN THE CELL UNDER GOES A SECONDARY SIGNAL IN DUCINGED BY DAMP TO ASSEMBLE THE INFLAMMA STUDIES OF MULTIPLE ENDOCRINE AND THEREFORE PROCESS- -PROCESS, PROINTERLUKEIN 1 BETA INTO ACTIVE, INTERLUKEIN 1 BETA WHICH THEN ALSO HAS POTENT STIMULATING EFFECTS ON THE ENDOTHELIAL CELLS AND THE LEUCOCYTES AND THERE IS MORE RECENT DATA TO INDICATE THAT IN OTHER INFLAMMATORY DECEASES, INTERLUKEIN 1 BETA MAY BE AN IMPORTANT CAUSE OF MUSK LO SKELETAL PAIN WHICH IS I THINK IN SICKLE CELL DISEASE MAY HAVE IMPORTANT IMPLICATIONS. ANOTHER INFLAMMATORY MODULE WHICH HAS AN IMPORTANT ROLE IN SICKLE CELL DISEASE AND PRESENT ER GROWTH FACTOR. IT'S FOUND IN INCREASED CONCENTRATIONS IN RED BLOOD CELL S OF SICKLE CELL INDIVIDUALS AND THIS IS DUE TO INCREASED RED BLOOD CELLS 10 OVER IN THESE PATIENTS. CIRCULATING LEVELS OF PLACENTA GROWTH FACTOR ARE INCREASED, THERE'S A LOT OF HEME OLYMPIC SIS AND THIS MOLECULE IS A VERY IMPORTANT POTENT ANGIOGENIC MOLECULE INDUCES PROCESSES IN ENDOTHELIAL CELLS AND IT INDUCES PRODUCTION OF CYTOKINES AND CHEMO KINES IN LEUCOCYTES AND THIS WILL END UP PLAYING AN IMPORTANT ROLE IN THE PROPAGATION OF INFLAMMATION AND ALSO IN ORGAN DAMAGE, AND IF YOU NEUTRALIZE PLACENTA GROWTH FACTOR, IN MICE, THE SICKLE CELL DISEASE, YOU CAN INFACT INHIBIT THE INDUCTION OF THE BASAL OCCLUSION DUE TO HYPOXIA AND SO I THINK THAT'S QUITE A GOOD EXAMPLE OF HOW IMPORTANT PLACENTA GROWTH FACTOR IS IN THE BASAL OCLUBHOUSIVE PROCESS. --OCCLUSIVE PROCESS. IT'S A VERY IMPORTANT ROLE IN PULL MONITORARY HYPER TENSION BECAUSE IT APPEARS TO INDUCE ENDOTHELIAL 1 RELEASE WITH THE ENDOTHELIAL CELLS AND THIS TOGETHER WITH OTHER ANGIOGENIC MOLECULES AND DOES HE CREASING NIGHTRIX OXIDE WOULD LEAD TO THE VASCULAR REMODELING THAT'S ASSOCIATED WITH PULL MONITORARY HYPER TENSION. THAT'S ALSO AN INFLAMMATORY COMPONENT IN ASCHEMIC STROKE AND INCREASED LEVELS OF THROMO SPONDY LIGHTISIN 1 AND ALSO SELECTING INTERLUKEIN 6 AND INFLAMMATORY MOLECULES HAVE BEEN ASSOCIATED WITH AN INCREASED RISK OF OF STROKE--RISK OF STROKE. AS WAS MENTIONED YESTERDAY, INFLAMMATION PLAYS AN IMPORTANT ROLE IN THE ONSET OF ACUTE CHEST SYNDROME. THERE ARE A NUMBER OF INFLAMM ATORY MOLECULES THAT HAVE BEEN FOUND TO BE ASSOCIATED WITH THE ONSET OF ACTUALLY CHEST AND AN ACUTE PHASE RESPONSE IN ASSOCIATION WITH PLATELET ACT IVATION AND LEUCOCYTE ACT IVATION AND AS MENTIONED YESTERDAY, VERY, VERY HIGH LEVEL S OF SECRETEATORY HAVE BEEN FOUND UPON ONSET OF ACUTE CHEST SYNDROME AND THIS MAY BE IMPORTANT FOR THE RELEASE OF FREE FATTY ACIDS IN THE LUNG WITH A PRODUCTION OF [INDISCERNIBLE] AND POSSIBLY A CUTE LUNG INJURY. WE KNOW THAT IN FACT, ALMOST ALL OF THOSE INFLAMMATORY MOLECULES THAT WE HAVE BEEN FOUND TO BE INCREASED IN STEADY STATE SICKLE CELL DISEASE ARE IN FACT FURTHER ELEVATED DURING BASAL INCLUSIVE CRISIS SO WE KNOW THAT MILE O PEROX DACE ACTIVITY IS INCREASED IN PATIENTS DURING CRISIS IN ADDITION TO INCREASED LEVELS OF NUTRIFILL MICROPARTICLES WHICH IS INDICATIVE OF NUTRIFILL ACT IVATION. MANY PROINFLAMMATORY CYTOKINES ARE FURTHER ELEVATED AS AS CHEMO KINES, PLATELET PROTEINS HAVE FURTHER INCREASED AND INDEED, 3 LAYERS GROUP PUBLISHED A PAPER TO SHOW THERE'S INCREASED PLATE LET NLP R-3 INFLAMMA STUDIES OF MULTIPLE ENDOCRINE ACTIVITY IN THE PLATELET OF PATIENTS UNDERGOING CRISIS. THERE ALSO SEEMS TO BE AN EXAC ERBATION OF ACUTE PHASE RE SPONSE IN THESE PATIENTS AND AT THE MOLECULE SUCH AS ADHESION MOLECULES AND GROWTH FACTORS ARE THOUGHT TO BE FURTHER ELEVATED. I THINK 1 IN--1 EXAMPLE OF THE STUDIES THAT HAVE BEEN CARRIED OUT TO LOOK AT INFLAMMATORY MOLECULE DURING CRISIS IS THIS PAPER THAT WAS RECENTLY PUBLISH ED BY [INDISCERNIBLE] AND COLLEAGUES IN THE BRITISH GROWRN AL RECENTLY, THE PROFESSOR SHOWED THIS PAPER, TOO, YESTERDAY, I THINK IT'S A GOOD EXAMPLE BECAUSE THEY MEASURD A NUMBER OF THE INFLAMMATORY MOLECULES IN A LARGE GROUP OF STEADY STATE PATIENTS AND ALSO IN A FAIR NUMBER OF PATIENTS UPON HOSPITALIZATION FOR SICKLE SEAL CRISIS. I THINK WHAT'S IMPORTANT TO NOTICE IS THAT WE SEE A SUPPORT FOR THOSE INCREASED LEVELS OF THESE PROINFLAMMATORY MOLECULES SUCH AS TNF ALPHA AND INTERLUKE IN BETA AS WAS BROUGHT OUT BEFORE, WE DON'T SEE A HUGE DIFFERENCE IN THE LEVELS OF THESE CYTOKINES ONCE THESE PATIENTS ARE IN CRISIS SO IT'S VERY DIFFICULT TO DEFINE CUT OFF POINTS FOR THESE INFLAMMATORY MOLECULES SO WHAT WE SEE A AN EXACERBATION OF ALL THESE INFLAMMATORY PROCESSES GOING ON BUT WE CAN'T PINPOINT ANY PARTICULAR INFLAMMATORY MOLECULE OR RESPONSIBLE FOR BASAL CRISIS. INTERESTINGLY, SOME ANTIINFLAMM ATORY PROCESSES ARE PERCOLATED DURING CRISIS. WE KNOW THAT INTERLUKEIN 10 LEVELS WHICH THIS IS AN ANTI INFLAMMATORY CYTOKINE ARE ELEVATED DURING STEADY STATE SICKLE CELL DISEASE AND THEY'RE FURTHER ELEVATED DURING THE CRASE CRISIS AND THERE'S INTERESTINGLY THIS MULTIFUNCTION AL CYTOKINE TGF BET A WHICH HAS BEEN FOUND IN ELEVATED LEVELS DURING STEADY STATE, BUT THIS SAME STUDY BY CARL AND COLLEAGUES SHOWED THERE WAS A DRASTIC INCREASE IN THE ANTIINFLAMMATORY CYTOKINE IN PATIENTS ON THE ONSET, AND IT MAY BE IMPORTANT TO ELECTRIC AT INFLAMMATORY MARKERS FOR THE O CLUBHOUSE CLUESIVE--OCCLUSIVE CRISIS, MAYBE WE'RE CONCENTRAT ING SO MUCH ON FINDING PROINFLAMMATORY MOLECULES WHICH ARE VERY, VERY VARIABLE AND PATIENTS AND MAYBE WE SHOULD BE LOOKING AT FIRST MOLECULES THAT ARE ACTUALLY DECREASED UPON BASIC CRISIS AND ONSET. SO WE DO HAVE AN ANTIINFLAMM ATORY APPROACH AVAILABLE FOR SICKLE CELL TREATMENT AND THAT'S HYDROXURIA, IT HAS IMMEDIATE AND ACUTE ANTI INFLAMMATORY EFFECTS THAT ARE INDEPENDENT OF THE ELEVATION OF THE FETAL HEMOGLOBIN. IF YOU GIVE A SINGLE ADMINISTRATION OF THE HYDROXURIA TO MY SICKLE CELL DISEASE AT THE SAME TIME AS THE BASAL A CLUBHOUSIVE PROCESS, HE WILL INHIBIT THIS BASAL INCLUSION AND INHIBIT THE RECRUITMENT AND--TO RELEASE HYDROXIA. AND OF COURSE HYDROXURIA THERAPY& HAS LONG-TERM ANTIINFLAMMATORY EFFECTS THAT WE'VE SEEN BEFORE, HYDROXIA URIA, LEUCOCYTE NUMBERS AND THIS IS OFTEN SEEING BEFORE FETAL HEMOGLOBIN ELEVATION AND WE KNOW THAT THERAPY IS ASSOCIATED WITH REDUCTION IN THE ACTIVITY OF ADHESION MOLECULES OF RED BLOOD CELLS LEUCOCYTES AND ENDOTHELIAL CELLS AND PLATE LETS. WE DON'T KNOW WHETHER THIS IS AN INDIRECT EFFECT OF THE ELEVATION OR IF THIS IS DUE TO THESE ANTI INFLAMMATORY EFFECTS OF THESE ACUTE ANTIINFLAMMATORY EEIVELGTS OF HYDROXURIA HAS BEEN ASSOCIATE WIDE THE MODULATION OF INFLAMMATORY MOLECULES IN SICKLE CELL DISEASE, IT DECREASES A NUMBER OF PROINFLAMMATORY MOLECULES INCLUDING AND TNF ALPHA AS WELL AS SOLUBLE AD HESION MOLECULES AND GROWTH FACTORS AS WELL AS EPPED O THEL IA AND IT'S ALSO HAD AN UP REGULATING EFFECT INCLUDING A FURTHER INCREASE IN ISHT LUKEIN 10 AND CYTOKINE AND THE EXPRESSION OF HEME OX GENERATED ACE 1 WHICH IS IMPORTANT FOR THE DEGRADATION OF HEME. SO I THINK TOM TOUCHED ON SOME OF THESE DRUGS THAT ARE IN EARLY AND LATE RELEVANT FOR ANTI INFLAMMATORY APPROACHES THE SICKLE CELL DISEASE AND THERE ARE SOME DRUGS THAT ARE ACTUALLY REAPPROPRIATED FOR USE IN SICKLE CELL DISEASE, THERE ARE DRUGS SUCH AS STATINS AS WE MENTIONED THAT MAY BE IMPORTANT FOR INHIBITING ENDOTHELIAL AND NUTRI FILL ACTIVATION BY INHIBITION ON THE LNF CAPPA B ACTIVITY AND I THINK VERY IMPORTANTLY ARE ON THE CLASS OF IMMUNE O MODULATORS. THE BIOLOGICAL DRUGS THAT WILL BLOCK THE EFFECTS OF IMPORTANT PRO INFLAMMATORY CYTOKINES SUCH AS TNF ALPHA AND INTERLUKEIN WOB BETA. ONE APPROACH IS TO GIVE HEMO DPLOABIN AND HEME SCAF ANGER S TO PATIENTS AND ALSO AS WE'VE SEEN INHIBITION OF CELL AD HESION MECHANISMS MAY BE AN IMPORTANT ANTIINFLAMMATORY APPROACH IN SICKLE SEAL DISEASE. DELIVERY OF CARBON MONOXIDE WHICH HAS ANTIINFLAMMATORY EFFECTS MAY ALSO BE AN APPROACH FOR DECREASING INFLAMMATION AS WELL AS INHIBITION OF PLATELET ACTIVATION AS WE'VE SEEN. ONE CLASS OF DRUGS THAT I THINK ARE VERY IMPORTANT AT THE MOMENT ARE DRUGS WHICH AMPLIFY THE SIGNALING OF GMP WHICH IS THE SECOND NATURE OF NIGHT NITRIC OX IDE AS 1 PSYCHE LACE STIMULAT OR THAT'S IN CLINICAL TRIALS FOR SICKLE CELL DISEASE AT THE MOMENT ANDIN INHIBITORS SO THESE DRUGS ARE ALL IMPORTANT FOR AMPLIFICATION OF CYCLIC GMP SIGNALING AND PARTICULARLY INHIBITORY OF [INDISCERNIBLE] MIGHT BE IMPORTANT FOR DO THANKSGIVING IN A HEME AT O POET IC CELL--FOR DOING THIS IN A HEMATOPOIETIC CELL. AND FINALLY AS YOU ALL KNOW FOORM SUITICAL GRADE ALGLUTA MINE AS BEEN APPROVED FOR USE IN THE U.S. AND IT'S A VERY GOOD ANTIOXIDANT. SO I THINK WE'RE GOING BACK TO THE QUESTION OF THE TALK WHETHER INFLAMMATORY MARKERS MEAN ANYTHING IN SICKLE CELL DISEASE, WE'RE ALL LOOKING FOR IN SICKLE CELL DISEASE ARE RELIABLE MARKER S FOR PREDICTING COMPLICATEICATIONS SUCH AS BASAL OCCLUSIVE CRISIS ACUTE CHEST SYNDROME AND ORGAN DAMAGE AS WE TALKED ABOUT BEFORE, IT MAY BE IMPORTANT TO FIND INFLAMMATORY MODULES THAT COULD POSSIBLY BE USED FOR MOBITTORRING PAIN AND ALSO CLINICAL END POINTS TO USE ONCE PATIENTS ARE HOSPITALIZED FOR THE CRISIS AND ALSO FOR USE DURING CLINICAL TRIALS AND I THINK IT'S IMPORTANT TO BE TRY ING TO FIND SPECIFIC BIOMARK ERS FOR INFLAMMATORY MARK ERS FOR MONITORING THE EFFECTS OF EFFICACY, FOR THE LONG-TERM OF ANTIINFLAMMATTORY THERAPEUTIC APPROACHES SO AS WE'VE SEEN IT'S BEEN VERY DIFFICULT TO IDENTIFY THESE INFLAMMATORY MARKERS IN SICKLE CELL DISEASE AND THAT'S BECAUSE THESE INFLAMMATORY MOLECULES VERY HUGELY FROM PATIENT TO PATIENT AND THEY ALSO VARY IN THE SAME PATIENT FROM WEEK TO WEEK. AND THAT'S BECAUSE THERE ARE MANY CONFOUNDING FACTORS. A NUMBER OF THINGS INFRU-- INFLUENCE PROINFLAMMATORY MARKERS SUCH AS OBEEZITY AND-- OBESITY AND MAYBE DIET. WE WILL NEED IDENTIFIERS FOR THESE MARKERS AND AS I SAID BEFORE WE SHOULD LOOK AT ANTI INFLAMMATORY MARKERS AS WELL , SO WE HAVE MECHANISMS HAS BEEN REALLY IMPORTANT FOR WHAT HAS BEEN THE IDENTIFICATION OF DOWN STREAM TARGETS FROM THE HEMODPLOABIN POLYMERIZATION WHICH ENABLED THE DEVELOPMENT OF THE NEW OR REAPPROPRIATION OF THESE DRUGS TO THE PREVENTION OF BASAL OCLOSSIVE CRISE EXPIS ALSO FOR THE TREATMENT OF OCCLUSIVE EPISODES ONCE THEY'VE BEGUN SO THANKS VERY MUCH FOR YOUR ATTENTION. [ APPLAUSE ] >> THANK YOU. QUESTIONS FOR DR. CONRAN? I HAVE A QUESTION I WOULD LIKE TO ASK, IF THAT'S ALL RIGHT. HEMOGLOBIN RELEASED FROM THESE RED BLOOD CELLS DURING HEME OLYMPIC SIS, WE'VE LEARNED ABOUT THE ABILITY TO BIND NITRIC OXIDE AND CAUSE BASAL CONSTRICTION AND YOU'VE ALSO SHOWN THAT IT BINDS TO TLR 4 AND ACTIVATES INFLAMM ATORY PATHWAYS AND I WOND ER IF IT ALSO HAS BASAL DILL ATTORY EFFECTS? >> IN THE HEME? >> HEMOGLOBIN? >> I DON'T ACTUALLY. IT MAKES SENSE BECAUSE IT'S A HEME, ANOTHER NITRICOXIDE BIND ING GROUP BUT ONCE IT'S BEEN RELEASE FRIDAY THE HEMOGLOBIN IT'S THIS OCCURS TOO. ALL RIGHT, THANKS. [ APPLAUSE ] WE WILL CONTINUE WITH THE NEXT SESSION, SO, IT'S SYSTEM MEDICINE AND BIG DATA TRANSFORM ING CARE OF SICKLE CELL DISEASE TO THE 21st CENTURY. AND OUR FIRST SPEAKER IS SWEE LA Y THEIN WHO IS THE CHIEF OF THE SICKLE CELL BRANCH AT THE NIH AND SHE WILL BE MAKING THING S SIMPLE, I GUESS. AND TALKING ABOUT COMPLEX GENETICS FOR A SIMPLE MUTATION, GETTING TO THE HEART OF THE MATTER. >> THANK YOU VERY MUCH. BEFORE I START I WANT TO MAKE 1 ANNOUNCEMENT, I HAVE A VACANCY FOR STAFF CLINICIAN, SO FOR THE RIGHT PERSON, YOU BE THRIVING IN A VERY HEAVY ATMOSPHERE OF TRANSLATION SCIENCE HELPING TO LOOK AFTER SICKLE CELL PATIENTS. SO IF INTERESTED PLEASE REACH OUT TO ME. [LAUGHTER] OKAY. SO LET'S GO TO MY TALK. I'VE GOT MYSELF TO BLAME NEAR THIS TITLE BECAUSE I THOUGHT IT LOOKED VERY COOL, COMPLEX GENETICS FOR A SIMPLE IN YOU ITATION, GETTING TO THE HEART OF THE MATTER, AND THEN WHEN I STARTED PREPARING FOR IT, I THOUGHT WHAT THE HELL AM I GOING TO SAY? [LAUGHTER] ANYWAY, I'LL TRY MY BEST. SO I HOPE TO SUMMARIZE FIRST OF ALL NO FINANCIAL DISCLOSURES. IN THE NEXT 25 TO 30 MINUTES I HOPE TO SUMMARIZE FOR YOU WHAT WE KNOW ABOUT THE GENETIC MODIFY S AND WITH THIS KIND OF OBJECTIVES, I WOULD LIKE TO HIGHLIGHT THE IMPORTANCE OF GENETIC BACKGROUND AND ENVIRONMENT THAT CONTRIBUTES TO THE EXTREME PHENOTYPIC VARIANT OF SICKLE CELL DISEASE AND I WANT TO YOU RECOGNIZE THE LIMIT ATIONS OF GENETIC ASSOCIATION STUDIES BUT THEY CAN WORK IF THE STUDY IS WELL DESIGN ED AND THE APPROPRIATE PHENOTYPES ARE DEFINED. SO LASTLY I ALSO WANT TO YOU TO RECOGNIZE THE CONTRIBUTION OF GENETIC FACTORS DIMINISH IN AGE WHEN LIFESTYLE AND ENVIRONMENT PLAYS AN INCREASING ROLE. SO WE'VE HEARD ALREADY THAT SICK LE CELL MUTATION, THE SICKLE CELL DISEASE CAUSED BY SINGLE MUTATION, SINGLE BASE SUBSTITUTION IN THE--IN THE SAME CO DON, IN THE SINGLE GENE AND THIS IS THE SAME IN EVERY EFFECT ED POPULATION. SO YOU CAN GET A MORE SIMPLE MUTATION THAN THAT. AND THIS LIST OF PRODUCTION OF HEMOGLOBIN S, THAT POLYMERIZES WHEN DEOXYGEN GENERATEDDATED RESULTING IN THIS IRREVERSIBLY SICKLE CELLS AND THIS THEN A SET OFF A CASCADE OF DOWN STREAM EVENTS INVOLVING THIS MICROVASC ULAR OCCLUSION, INFLAMM ATION, REMODELING OF THE ENDOTHELIAL CELLS AND VESICLE-OP A THY WHICH UNDERLIES THE DAMAGE IN EVERY ORGAN POSSIBLE IN THE BODY AND SOME OF WHICH ARE SHOWN HERE. AND THE MOST COMMON IS OF COURSE PAIN WHICH YOU'VE HEARD SO MUCH YESTERDAY, WHICH CAN BE ACUTE, CHRONIC AND ACRUIT AND CHRONIC AS THE PATIENTS GET OLDER. WHILE MEAN OF THESE COMPLICATION S ARE RESILIENCE ALATED TO AGE, SO FOR INSTANCE LIKE AVASCULAR NEUROECTODERMALCROSEIS, PREVALENCE INCREASES ISSUES PATIENTS OLDER AND CLEARLY SOME ARE ALSO PREVIOUS POST, BECAUSE YOU'VE HEARD ABOUT CHILDREN CAN DEVELOP ASCHEMIC STROKE EVEN BEFORE THE AGE OF 2, AND THEN I LOOKED UP THE TEENAGER TERRIBL IBLE WITH THE HEBREW RE PLACED FOR THE AGE, AND THEN YOU'VE HAD GALL STONES IN CHILDREN BY THE AGE OF 5. SO THEN OF COURSE, THERE'S ALSO THE INCREASED CONCORDANCE OF STROKE IN SIBLINGS WITH SICKLE CELL DISEASE, SO THE QUESTION THEN IS GENETIC BASIS FOR GENETIC PHENOTYPES AND THE SHORT ANSWER IS YES, FIRST OFF WE KNOW THAT SICKLE CELL SYNDROME S&P COMPOSED OF DIFFERENT GENO TYPES SO BECAUSE THE TENDENCY TO POLYMERIZE IS HIGHLY DEPENDENT ON A CONS TRAIGDZ--CONCENTRATION OF HEMOGLOBIN S, YOU CAN IMAGINE THAT THE PATIENTS WITH SS AND S- 0 WERE ALMOST ALL THE INTRA CELLULAR HEMOGLOBIN S WITH MORE HEMODPLOABIN A-2 AND VARIABLES OF HEMOGLOBIN F WILL HAVE THE MOST SEVERE DISEASE. WELL AS WITH THE PLUS, IT'S THE MILDEST FORM. ONLY FOR AFRICANS THOUGH, BECAUSE [INDISCERNIBLE] IN AFRICANS IS VERY MILD, THE DEFICIT OF THE HEMODPLOBIN IS MINIMAL WHEREAS, AS WITH THE PLUS IN MEDITERRANEANS TEND TO BE AS SEVERE AS ALMOST SS-OR SV0 BECAUSE THE MUTATION THERE IS ONLY ALLOWS A SMALL AMOUNT OF BETA GLOBEIN PRODUCTION. AND THEN ON TOP OF THAT IN AFRICANS OR IN OLDER PATIENTS, CAN YOU CO INHERIT THAT WILLA SEMIA WHICH IS INHERITED INDEPENDENTLY BECAUSE IT'S ON CHROMOSOME 6 C AND THIS CAN AFFAIRS TEAM LEADERRER THE CLINICAL COURSE OF SICKLE CELL DISEASE AND THIS IS REALLY, I THOUGHT SO WELL SUMMARIZED VISUALLY. I FIGURED I'VE TAKEN FROM [INDISCERNIBLE] WHEN I WAS IN KINGS AND I WAS LOOKING AT SICK LE CELL WHERE WE HAVE--CAN YOU SEE AGE DISTRIBUTION--OH MAN , HOW DO I GO BACK? YEAH, SO THE DISTRIBUTION OF THE PATIENT POPULATION BUT IN THE YOUNG ADULTS, THE PREDOMINANT TYPE OF SICKLE CELL DISEASE IS S S, AND AS THEY GROWTH FACTOR OLD ER, THE PROPORTION AS REDUCES 30% TAKEN OVER BY SC AND HEMO GLOBEIN S WHICH IS LIKE 5% IS NOW ALMOST LIKE 20-25%. SO 1 OF THE GENETIC MODIFYS IN TERMS GLOBAL WHERE IT MODIFYS TO ACTUALLY EFFECT THE ROOT CAUSE WHICH IS THE HEMOGLOBIN S- POLYMERIZATION, SO YOU HEARD ABOUT THE GENO TYPE IN THE CELL, THEN HEMODPLOABIN F LEVELS THIS IS SHOWN VERY CLEARLY BUT CLINICAL STUDIES, THAT-- HEMOGLOBIN F A BIG PATIENT S OF HIGH LEVELS HAVE A MILDER DISEASE AND THIS IS BECAUSE YOU KNOW THE HEMOGLOBIN F IN THE CELL NOT ONLY DILUTE OUT CONCENTRATION OF HEMODPLOAB IN S, BUT THE MIXED TETRAMERS HAS INHIBITORY EFFECT ON THE POLYMERIZATION. AND WE ALSO KNOW THAT THERE'S THIS COMMON HEMOGLOBIN FQTLs, 1 IN THE CLUOF THER AND THEN THERE'S 1 IN 6 Q AND B-CELL, AND WITH THE OTHERS COME BACK IT LATER. THEN WE HAVE THE RAG VARIANT ON KLF 1 AND THEN WE HAVE AFULLA TH ALASSEMA, AND IT RELUCS THIS, AND IT REDUCES HEME OLDER PEOPLE --HEME OLYMPIC SIS AND THERE'S RISK OF COMPLICATIONS THAT ARE LISTENED TO HEMOLSIS, BUT THERE'S ALSO AN INCREASED LIKELIHOOD WHERE THERE'S INCREASED BECAUSE OF THE IN CREASE IN ACUTE CHEST SYNDROME , PAIN, RETINAL LOCATION NUMBER OF PATIENTSATHY AND OFTIO NEUROECTODERMALCROSEIS. I WOULD ALSO LIKE TO POINT OUT THAT THE PRESENCE OF THE THALASS EMIA, HAS TO DO WITH THE EFFECT OF THE RESPONSE, THEN THE OTHER 2 GENETIC MODIFIERS, THESE ARE THE SPECIFIC PHENOTYPES OF BILLY RUBEIN AND GAL STONES AND WE ALL KNOW IF YOU HAVE THE GILBERT SYNDROME WHICH IS DO WITH THE REPEATS OF AC1 G AND THE TALS--THALASSEMIA WHICH MENTIONED BCELL LEVEL 8 AND THIS MAY HAVE TO DO WITH THE HEMOGLOBIN LEVEL. AND THEN IN THE 2000S, EARLY 2000S, THERE WAS EVERYBODY ON THE BAND WAGON OF GENERATEDET ASSOCIATION STUDIES AND DHS PROMPTED A COMMENTARY BY MARTY SIGN BERG IN BLOOD WITH A SEXY TITLE, SNIPPING AWAY AT THE SICK LE CELL PHYSIOLOGY AND HERE ARE THE KIND OF SNPs THAT ARE ASSOCIATED WITH THE RISK COMPLICATION AND BAGSED ON THIS CANDIDATE GENES ASSOCIATION STUDIES, MANY GENETICALLY MODIF IERS APPEAR TO BE IN THE TG F BETA FAMILY AND OF COURSE, THIS WE KNOW THE U-D 1 A AND ONLY 1 THAT IS REPLICATED AND VALIDATED AND THERE'S ALSO THIS APL1 WHICH CAME ON LATER AND APL 1 WHICH WAS IN [INDISCERNIBLE] GROUP TOOK THIS TO LOOK AT A SICKLE CELL POP ULATION WHICH IT WAS FIRST DESCRIBED AS GENETIC MODIFIER IN AFRICANS WITHOUT SICKLE CELL DISEASE AS A RISK FACTDOR FOR-- RISK FACTOR FOR END STAGE RENAL FAILURE BUT VERY FEW CAND IDATES REPLICATED. SO, THIS-THIS DIDN'T STOP PEOPLE FROM GOING THROUGH GENOME WIDE AND WHOLE EXOME SEQUENCING AND ALL OF THAT, AND IN THE END THE SENSE IS STILL SERUM LEVELS AND [INDISCERNIBLE] CELLS BUT ALSO ARE THE KIND OF POTENTIAL HEMOGLOBIN FQTLs AND 1 IS SCROAM STUDIES OF MULTIPLE ENDOCRINE 17 AND CHROMOSOME 11 AND THE NFWOBDERFUL--WONDERFUL IN X AND CHROMOSOME 19. BUT, AS FAR AS I KNOW, THESE HAVE NOT BEEN VALIDATED OR REP LICATED. SO YOU KNOW I ANSWER THE CELLS WHERE DID WE GO WRONG? WHAT KIND OF GENETIC ASSOCIATION STUDIES WORK AND WHAT DOES NOT WORK? SO I'M KIND OF LISTED UP THESE CHALLENGES IN THE GENETIC STUDIES OF SICKLE CELL DISEASE WHICH ALLIES NOT JUST TO SICKLE CELL DISEASE BUT TO OTHER GENETIC DISEASES TOO, BUT MORE SO IN SICKLE CELL DISEASE. SO FIRST OF ALL, THE CHOICE AND DEFINITION OF PHENOTYPES MATCHES SO WE HAVE TO CLEAR AND CONSISTENT DEFINITION OF PHENO TYPES WHICH IS CRITICAL TO THE SUCCESS OF GENETIC ASSOCIATION STUDIES. SO WE HAVE IN SICKLE CELL WE HAVE GLOBAL VERSUS THE SUBPHENO TYPES THEN YOU CAN USE CLINICAL AND THE CLINICAL CAN BE ACUTE. SO ACUTE PAIN FOR INSTANCE, CURRENT CHRONIC PAIN, VERSUS LAB ORATORY PARAMETERS AND YOU THINK THAT THE PARAMETERS SHOULD BE EASY BUT IN FACT, IF YOU LOOK AT LGH, WE ALL KNOW THE GENE CRISIS LEVELS CAN GO UP, SO, YOU HAVE TO COME TO THE RIGHT TIME AWLTS TO DO IT, SO PEOPLE SAID MAYBE YOU SHOULD MEASURE INTERMEDIATE PHENOTYPES, SOMETIMES FOR THE END O PHENO TYPES WHICH ARE REPRODUC IBLE AND DISEASE RELATED AND MAY BE MOAGHT SUCCESSFUL THAN CLINICAL END POINTS. THEN WE ARE ALSO TO BUILD A DIS TINGUISHED ASSOCIATION STUDY CLEAR DISTINCTION BETWEEN CASES AND CONTROLS AND IF YOU USE QUANTITATIVE TRAIT, THEN THERE HAS TO BE SUFFICIENT VARIABILITY TO BE ABLE TO GIVE US THE POWER. NEXT THING IS THE SAMPLE SIZE MATTERS AND THIS ALSO DEPENDS ON THE GENETIC ARCHITECTURE OF THE TRAIT OF PHENOTYPE. IS IT CAUSED BY FEW LARGE EFFECT VARIANTS, MANY SMALL EFFECT VARIANTS, FEW COMMON VARIANTS OR MANY, MANY RARE VARIANTS? THE CONTRIBUTION ENVIRONMENT MATTERS. WE KNOW THAT PAIN WITHIN THE SAME INDIVIDUAL, THERE CAN GO TO PERIODS WHEN THEY HAVE INCREASED PAIN AND THIS MAY BE RELATED TO STRESS FROM EXAMS, IN A BRIEF MENT, UNDERGOING DIVORCE AND SO ON AND WE ALSO HEARD ABOUT HOW THE WIND CHILL FACTOR AND THE YOU KNOW THE CHANGES IN TEMPERATURE, CAN BRING INCREASED FREQUENCY IN PAIN AND WE WOULD ALSO LIKE TO POINT OUT THE 3 IDENTICAL TWIN STUDIES AND WE SHOW CONCORDANCY IN THE LABORATORY PARAMETERS BUT DIS CORDANCE IN THE FREQUENCY OF ACUTE PAIN AND OTHER COMPLICATIONS. AND THE GENETIC ANCESTRY MATTERS SO WE KNOW THAT MOST OF THE GWAS HAS BEEN DONE IN POPULATIONS OF EUROPEAN ANCESTRY AND THEY TRY TO TRANSLATE TO AFRICANS AND THERE'S SO MANY RARE VALID AND RELIABLE YABT--VARIANTS THAT ARE NOT FOUND IN THE CAUCASIAN POP ULATION BUT EVEN IN THE AFRICAN ANCESTRY, THERE ARE NUMEROUS TRIES. SO LET ME JUST TAKE PAIN FOR INSTANCE. WE'VE HEARD FROM CATH EXPE SAMIR , ABOUT ALL THESE DIFFERENT PAIN TYPES, I CAME CROSS THE PAPER AND I THOUGHT IT WAS REAL REALLY NICE AND IT LOOKED AT IDENTICAL TWINS AND DID A 12 YEAR FOLLOW UP AND THEY STUDIED CHRONIC PAIN MORE THAN 3 MONTHS KNOWN SOMATIC CAUSESS, ALL OF THIS, I MEAN EXCLUDED AND 961 FEMALE, TWINS, M-ZED AND THIS 1 NONCAUCASIAN EXCLUDED TO TRY TO INSURE AS MUCH HOMOGENERATEDDITY AS THEY COULD AND THEY COLLECT A DATABASE LINE AND T-1 AND 12 YEARS LATER LEAVING THE MAP AND THE THOSE AREAS. SO WHAT THEY FOUND HERITABLE AT BASE LINE WITH 63% BUT REDUCES TO 55 YEARS LATER, AT BASE LINE, THEY GENETIC EFFECT TO EXPLAIN 62% OF THE VARIANCE IN PAIN BUT ONLY AT 11% LATER ON. AND NO ADDITIONAL GENETIC EFFECT ORS EXPLAINED THE VARIANCE IN PAIN. THE TAKE HOME MESSAGE HERE WAS THAT THE PAIN IS MAINLY EXPLAIN ED BY NEW ENVIRONMENTAL FACTORS AND THAT THE SAME GENETIC INFLUENCES ARE OPERATIVE OF TIME BUT THEN HAVE YOU NOVEL EXPERIMENTAL FACTORS AND IMPORTANT TO PAIN MAINTENANCE. SO I COME BACK TO HEMOGLOBIN AS A PROTOTYPE FOR STRATEGY FOR MAP PING COMPLEX TRAITS. SO YOU'VE SEEN, YOU KNOW ONCE THE SICKLE CELL SET OFF THIS PATHWAY, IS, DIFFERENT PEOPLE OF DIFFERENT WAYS TO DEPICTING THIS , AND THIS I PICKED FROM A PEBBLE BECAUSE IT'S KIND OF YOU KNOW A BIT MORE SIMPLIFYIED AND EACH OF THESE KIND OF POINTS IS A QUANTITATIVE TRAIT IN THE CELL AND YOU CAN IMAGINE THEY ALL MAKE UP THE SUMMATION OF WHATEVER WE WANTED FOR PAIN. SO PERHAPS YOU SHOULD STICK TO THE [INDISCERNIBLE] CYCLE AND THEN WE KNOW THAT HEMOGLOBIN IS VERY IMPORTANT AND THEN WE KNOW ALSO THE PSYCHE LYNN COMPONENT AND PLAYS AN IMPORTANT ROLE. SO IF WE LOOK AT IT THIS WAY, IF YOU LOOK AT THE WHOLE KIND OF PHENOTYPE, HEMOGLOBIN IS MORE COMPONENT. THE GENETICS COMPONENTS ARE SMALL, THE LARGE PART IS TO THE ENVIRONMENT AND WITHIN THE GENETICS HEMOGLOBIN CAN INTERVIEW A SMALL COMPONENT. SO PERHAPS YOU SHOULD THEN JUST CONCENTRATE ON THIS SO THAT WE REDUCE THE KIND OF COMPLEXITY OF IT SO THAT THE SMALL COMPONENTS NOW GET AMPLIFIED AND BECOMES EASIER TO DETECT. THIS IS JUST SUCCESS STORY OF HOW WE MANAGE TO MET WITH HEMOGLOBIN IN CASES AND THIS IS REPLICATED IN DIFFERENT POP ULATIONS. THEN YOU THINK THAT THIS WOULD WORK SO THIS WAS A STUDY WHICH IS PUBLISHED IN 2010, THEY CONFIRM AND VALIDATED THE QTLs IN BCL AND WHO ARE THE POSSIBLE REASONS? SO I THINK THAT THE HEMOGLOBIN PHENOTYPE IS EFFECTED BY THE STRESS, SO WE KNOW THAT PATIENT SICKLE CELL DISEASE HAS HIGH HEMOGLOBIN LEVELS THAN UNEFFECT ED ARKTS ULTRAVIOLET B DULTS AND WITHIN SICKLE CELL DISEASE ITSELF THE HEMOGLOBIN IS MUCH HIGHER IN SS COMPARED WITH SC. AND THEN ACTUALLY THE HEMODPLOB AND THE QTLs, BUT IN THIS, EXPANDED WHICH AMPLIFIES EFFECTS , SO THE DISTRIBUTION OF THIS HERE, THE NORMAL CONTROLS IS VERY RESTRICTED BUT IN THE SS -POPULATION IS REALLY VERY ASKEW BECAUSE THE EFFECTS OF THIS QTL ARE TO AMPLIFY THE STRESS, AND IF I WERE TO THEN PLOT SC, USE SOME OF THEM, AND THIS IS EXPLAIN WHY BECAUSE WE SAID HOW IS THIS EXPLAIN THE 50% IN UNAFFECTED PEOPLE WHEREAS IN THE AFRICAN, AFRICAN AMERICAN IN TENSIVE POPULATION, THEY ARE EXPLAINED AT 12-15% SO WE TRY TO KIND OF MAYBE PUT A GENETIC COMPONENT OF THESE QTLs AND THIS IS A STUDY THAT JUST PUBLISHED RECENTLY, WE LOOK AT THE KING'S COHORT, AND TONY WHO IS A STATISTICIAN HELPING US HERE, WE LOOK AT THE GENETIC MOD IFIEDS HERE AND THEN LOOK AT SYNAPSE AND THEY DID LOGISTIC REGRESSION AND JUST DOWN TO 4 SN Ps AND 2 SEMINOLE SNPs AND THE 1 AND 1 OF THE 6 INTERVAL, AND VERY SIMPLE, IF YOU HAVE IT, THE SCORE 1 AND THEN CAN YOU THEN DESIST ILLEGALS IT DOWN TO WAWE CALL G-HEMOGLOBIN FR WHICH IS COMPRISE THE GENETIC COMPONENT OF F, AND WE COULD SEE THAT USING THIS IS EXPLAINS THIS STREAK OF DETAILS EXPLAINS 22% OF THE HEMOGLOBIN VARIABILITY IN SS PAIKETS--PATIENTS AND IN THE SS PATIENTS BUT A HIGHER AMOUNT IN SC. BECAUSE SC IS LESS EFFECTED BY THE HEMATOPOIETIC STRESS. WHAT WE GAIN IS THE ALLELE WHICH IS PRESENT ABOUT THIRD OF AFRICAN POPULATION AND THE RED BLOOD CELLS FROM INDIVIDUALS CARRY THANKSGIVING ALLELE ARE DE HYDRATED AND INITIAL REDUCED PLASMA INFECTION INVITRO. AND OF COURSE, YOU KNOW, IF YOU GET EXCITED COULD THIS EFFECT THE SICKLE CELL PHENOTYPE BECAUSE OF RED CELL DEHYDRATION IS 1 OF THE VERY IMPORTANT FACTORS AND 2 GOES REALLY QUICK OFF THE MARK AND 1 WAS INVOLVES COLLABORATION AND THEN ANOTHER 1 IS SICKLE CELL DISEASE COHORT AND THEY LOOK AT THIS PIEZO DELETION ALLELE, IT'S PRESENT IN ABOUT 22% OF THE AFRICAN POP ULATION AND THEN IT WAS ASSOCIATED WITH THE [INDISCERNIBLE] DEHYDRATION AND ACCOUNTS FOR 2.5 OF THE FIN O TYPIC VARIATION. SO THEN THESE ARE ASSOCIATE WIDE THE DEHYDRATION AND THIS IN CREASES TO 6.2%, THIS ALLELE, WITH THE SICKLE CELL DISEASE PHENOTYPES LIKE [INDISCERNIBLE] CAN THEN THE OTHER GROUP WAS FROM KINGS AND THEY WERE HERE NOW AND ACTUALLY LOOK AT THE BASAL ALLELE, AND FIRST OF ALL THEY CONFIRM THE FREQUENCY IS ABOUT 20% IN THE SICKLE CELL PATIENTS WHICH ARE ALSO MAINLY OF AFRICAN DESCENT BUT IT WAS NOT--IT WAS NOT ASSOCIATED WITH ANY CLINICAL LABORATORY PROBLEMS AND IT WAS NOT ASSOCIATED WITH THE MEAN HOSPITALIZATION RATE AND IT WAS ALSO NO ASSOCIATION WITH THE PIEZOSPADES ACTIVITY. SO THEN WE SAID THAT, I THOUGHT ALSO THERE WAS A BIG PUSH FOR PRECISION MEDICINE AND PARTICULARLY THIS YEAR WHEN GARY GIBBONS LAUNCHED THE CURE SICKLE CELL DISEASE INITIATIVE AND PERHAPS, YOU KNOW HOW CAN WE APPLY PRECISION MEDICINE TO THE SICKLE CELL DISEASE? AND THIS IS FROM A SICKLE CELL PERSPECTIVE. THE CURRENT MODEL IS ACTUALLY ONE-SIZE-FITS-ALL. WHAT I THOUGHT WOULD BE VERY NICE IS WE ECTOMYOSIN WELCOMER OUT THE CAUSAL RISK FACTORS AND THEN TRY TO BRICK DOWN THE EACH OF THESE OF A POLYGENIC RISK SCORE AND THEN STRATIFY THE KIND OF RISK SO THAT THOSE ARE LIKE THE MORE SEVERE DISEASE WOULD BE TRANSPLANTED MUCH EARLIER BECAUSE ONCE YOU HAVE A STROKE, IT'S 1 STROKE TOO LATE. SO, THEN, I THOUGHT THEN, CAN ACTUALLY THEN KNOWING WHAT WE KNOW PUT A FACE TO THIS GENETIC VARIANCE SO I WOULD LIKE TO USE SOME REAL CASES. THIS IS A CASE I BORROWED FROM COURTNEY AND IT'S A 30 YEAR-OLD WOMAN WITH SICKLE CELL DISEASE A NEMIA. HE HAD A VERY SEVERE PHENOTYPE, [INDISCERNIBLE] CRISIS AND AVASC ULAR NEUROECTODERMALCROSEIS BEFORE SHE WAS 30. SHE HAD A HAPPEN LO IDENTICAL TRANSPLANT IN 2010, FAILED GRAPH , AND IN 2013 SHE HAD LEFT KNEE AND LEFT HIP REPLACEMENT IN 2014 SHE DEVELOPED ACS, AND THEN 2015 THEN SHE WAS STARTED ON ANTICO AG CO AGUE LANT AND THEN SHE SUCCUMBED TO CEREBRAL HEMORRHAGE. SO I THOUGHT LET'S ELECTRIC AT WHAT WE KNOW IN TERMS OF GENETIC MODIFYS AND SHE HAS GOT THE HOMO ZYGOUS OR THE HEMODPLOABIN ALLELES IN B-CELL LEVEL A, AND SHE HAS GOT GILBERT'S SYNDROME AND HETEROZYGOUSOUS FOR APOL1 ALLELE. SO, I MEAN DOES THIS ALLOW MOST OF THESE DISEASES, I'M NOT SURE. AND THE NEXT CASE IS A 46 YEAR-OLD MAN WHO ACTUALLY DONE VERY WELL. HYDROXUREIA SINCE 1993 SINCE IT WAS A CLINICAL TRIAL AND NO INTERRUPTION AND YOU KNOW TO DATE, I THINK NOT AT HOSPITAL FOR MORE THAN 15 YEARS UNTIL RECENTLY WHEN HE STARTED GIVEN STEROIDS BECAUSE OF AN ALLERGY AND THAT SET OFF A PAINFUL CRISIS AND WHEN WE LAST EVALUAT ED HIM, HE'S 46, NORMAL BLOOD PRESSURE, HAS DIABETES AND IS METFORMIN BUT DOES HAVE A STRONG FAMILY HISTORY. AND THE THING I WOULD LIKE TO SAY IS THAT WE LOOK AT A GENIC MODIFYS IN THE HETEROGENEOUS LOW ZYGOUS FOR THE B-CELL LEVEL, HOMOSWROIGOUS ON 6 Q HASN'T GOT GILBERTS BUT VERY MUCH VERY SIMILAR TO THE GIRL BEFORE, PATIENT BEFORE, IT'S VERY DIFFICULT TO ASSIGN RISK TO IT BUT MAYBE WHAT I WOULD LIKE TO SAY IS THAT HE APPRECIATES THIS VERY IMPORTANT TO KEEP HEALTHY AND HE WALKS 4-MILES EVERY DAY. SO THEN I COME BACK TO COHORT AND KINGS AND THIS IS IT SHOW YOU THAT THE BURDEN OF MORBIDITY ANDLET GREEN 1 IS THOSE WITHOUT ORGAN DAMAGE AND LOOK AT SS, AND ASSAY, [INDISCERNIBLE] IN THE YOUNG ADULTS, ABOUT 60% OF THEM KNOW KIND OF ORGAN DAMAGE BUT AS THEY GET OLDER THEY ACCUMULATE ORGAN DAMAGE, BUT THERE'S A GROUP WHO'S MORE THAN 6 YEARS OLD AND ACTUALLY HAS NO ORGAN DAMAGE, SO I THOUGHT MAYBE YOU COULD LOOK AT 1 OF THE PEOPLE, 1 OF THE PEOPLE IN THIS GROUP AND SHE ALSO HAPPENED TO HAVE HIGH HEMOGLOBIN THERE. AND THIS IN FACT, SHE WAS 75 YEARS OLD AND THIS WAS LIKE 3 YEARS AGO WITH S S HEMOGLOBIN AND SEEING AND SHOWN ALMOST 30% HEMOGLOBIN F, AND WE--SHE HAS NO ISSUE OF ACUTE SICKLE PAIN, ONLY SINGLE RELATED COMPLICATIONS, NOT REQUIRING MEDICATION, SHE HAS UNDERWENT 3 PREGNANCIES ALL UNEVENTFUL AND WE'VE BEEN SCREEN ING FOR MENELIAN FORMS AND NO DELETIONS AND NO MUTATIONS IN THE GAMMA GAMMA PREMOTOR AND NO HEMOGLOBIN BOOSTING VARIANCEIANT S IN THOSE 3 QTLs. BUT SHE DOES HAVE A VARIANT, A S NP IN THE KLR1 GENE WHICH IS PRESENT IN THE SECOND RING FINGER--OOH, SORRY, I BETTER HURRY UP, THEN WHAT'S INTERESTING IS THAT SHE HAS A DAUGHTER WHO'S HEMOGLOBIN WAS ONLY AT 2%. I KNOW, YEAH, SO SHE ACTUALLY IS A VERY RELATIVELY DISEASE OF PHENOTYPE SO IN FACT HIGH LEVEL OF HEMODPLOABIN IS NOT ONLY PRO TECTING FACTOR IN THIS FAMILY THEN THE OTHER THING IS, I BORTLES BORROWED THIS PICTURE WHO LOOKED AT ACTUALLY 4 PATIENT S WHO ARE IN THE 80S AND TO CUT A LONG STORY SHORT, YOU KNOW 3 OF THEM HAVE SS, 1, 2 SC, THEY HAVE INFREQUENT BASAL INCLUSIVE CRISIS, [INDISCERNIBLE] AND THEY HAVE SOME SICKLE RELATED COMPLICATION S LIKE HIP REPLACE MENT AND ALSO HAVE NON SICKLE CO-MORBIDITIES THAT ARE RELATED TO AGENT BUT IN FACT , THE CONCLUSION WAS THAT MOST OF THEM HAVE IN COMMON A LIFESTYLE OF NO SMOKING, NO OCCASIONAL ALCOHOL, NORMAL VMI AND EXCELLENT FAMILY SUPPORT AND THESE ARE THE KIND OF DAMAGED LIMITING FACTORS THAT WE ALL SHOULD PRACTICE WHETHER WE HAVE SICKLE CELL DISEASE OR NO SICKLE CELL DISEASE. SO I SPOKE OF PRECISION MEDICINE CURRENTLY IT'S TARGETED AT DEVELOPING TARGETING TREATMENTS FOR CANCER BUT WITH PRECISION MEDICINE IS ABOUT YOU KNOW DEVELOPING A PERSONALIZED MEDICINE BASED ON 1'S GENES AND GIVING MATCH BLOOD HAS BEEN PART OF A POSITION FOR A VERY LONG TIME AND I THINK THAT TIME IS RIGHT TO APPLY THIS FOR OUR RE GENOTYPING FOR [INDISCERNIBLE] THOSE OF US WHO LOOK UP [INDISCERNIBLE] WE KNOW THAT AVERAGE ILLIEWMINIZATION IS A BIG PROBLEM WHEN YOU HAVE TO TRANSFUSE PATIENTS SO I THINK WE SHOULD ACTUALLY [INDISCERNIBLE] CYCLE CELL PATIENTS BEFORE THEY WILL RECEIVE PLOOD SO THAT YOU A VOID THIS PROBLEM OF DEVELOPING OLIGMERRIZATION AND IN FACT I SHOWED HER THIS PICTURE WAS SHOWN EARLIER YESTERDAY, AND AND THE TIME WITH THE CELLS CAN IM PROVE AND IT IS FEASIBLE, SO TO SUMMARIZE THE TAKE HOME MESSAGE BECAUSE I'M RUNNING OUT OF TIME, THE TAKE HOME MESSAGE IS THAT MANY--WE HAVE SOME ESTABLISHED MODIFYS BUT CAND IDATE GENES IN THE GWAS VALIDATION AND TO TACKLE THOSE PHENOTYPIC HETEROGENEITY AND IF YOU WANT TO APPLY RISK STRATIFICATION, I THINK THE BEST THING TO EXPLORE WHAT ARE THE CAUSAL RISK FACTORS YOUR OWN RISK OF EACH OF THIS AND THEN YOU CAN DO, YOU KNOW GOOGLE UP A TOTAL SCORE AND THEN APPROPRIATE POLYGENIC RISK SCORE TO THE RISK STRATIFY MANAGEMENT AND THE DE LINEATION OF THESE DIFFERENT CAUSAL RECENT LOCI WILL ALLOW US TO NEED THE BETTER UNDERSTANDING OF THE UNDERLYING MECHANISMS OF THE SICKLE PATHOPHYSIOLOGY AND FINALLY, SICKLE CELL DISEASE SUPPOSEDLY CAUSE BIDE SIMPLE MUTATION IS THAT YOU CONTROL BY A CURRENTLY BIG NETWORK OF REGULATORS AND COMPLEX TRAITS WHICH RESULT IN THIS VARIABLE PHENOTYPE AND ACTUALLY I DON'T THINK THERE'S SUCH THING AS A MENDELIAN DISEASE ANYMORE, THERE'S COMPLEX SUBSTRATE WITH THE MENDELIAN DISEASE.& SO WITH THAT I WOULD LIKE TO THANK PEOPLE FROM MY LAB AND THE CLINICAL TEAM WHO'S REALLY BEEN A STRONG SOURCE OF SUPPORT. THANK YOU VERY MUCH. >> [ APPLAUSE ] >> QUESTIONS, THANK YOU FOR THE WONDERFUL PRESENTATION, NEXT-- >> NEXT WE HAVE GEORGE [INDISCERNIBLE] FROM BROWN UNIVERSITY, PROVIDENCE ROAD ISLAND. HE WILL BE TALKING ABOUT MODEL ING OF SICKLE CELL DISEASE. >> THANK YOU VERY MUCH FOR INVITING HERE AND IN PARTICULAR, I WOULD LIKE TO THANK SWE, LAY, SHE INVITED ME BACK IN MARCH TO VISIT HERE HER BRANCH HERE AT NI H SO HERE I WILL TRY TO PRESENT HOW COMPUTATION TAGGAL SIMULATIONS, MULTISCALE COULD PROVIDE AND ENABLE QUANTITATIVE UNDERSTANDING OF THE DISEASE OF BOTH CELLULAR AND SUBCELLULAR PROCESSES. ALSO, LIKE TO TALK ABOUT THE MACHINE LEARNING AND HEAR A LOT ABOUT MACHINE LEARNING AND HOW PREDICTIVE IT COULD BE AND I HAVE THOUGHTS IN PARTICULAR ON HOW TO INCORPORATE THAT INTO PREDICTING EPISODES IN SICKLE CELL ANEMIA. SO, JUST SO YOU SAW THIS, WE MODEL THINGS FROM FIRST PRINCIPLE, HERE WE'RE MODELING INDIVIDUAL RED BLOOD CELLS AT THE LEVEL, WHAT YOU SEE HERE IS THE HEMOGLOBIN AT THE MIDDLE, MODEL HEMOGLOBIN LAYER BY LAYER, THE CYTOSKELETON AND THE BOTTOM WE SEE THE FIBER THROUGH THE MEMBRANE TO CREATE THE SICKLE CELL, SO MULTISCALE MODELING MEANS YOU'RE MODELING ALL PROCESSES FROM THE NUCLIZATION TO VISUAL OCCLUSION BIOLOG AND IT IS OPEN SOURCE CODE, RBC IS THE FIRST EVER CODE TAKEN--THEY CAN SIMULATE AND THAT SPECTERAL RESOLUTION AS PART OF THE RED BLOOD CELL AS STANDARD DYNAMICS LEVEL INCLUDING ALL PROTEINS RELEVANT TO THE BIOMECHANIC PROPERTIES OF THE RED BLOOD CELL S WHICH PLAY SUCH AN IMPORTANT ROLE FOR THIS DEC, SO 1 CAN FOR EXAMPLE, MODEL VERY COMPLICATED PROCESSES LIKE THIS RED BLOOD CELLS GOING THROUGH THE SPLEEN, THE SPLEEN, THIS IS A RECENT PNAS PAPER WE PUBLISHED I DON'T--I DON'T SHOW HERE A SICKLE BECAUSE BECAUSE IT WON'T GO THROUGH DEPENDING ON THE THICKNESS AND THE LOWER PART YOU CAN SEE A DISEASE IN RED BLOOD CELL THAT BREAKS UP AND GOES THROUGH RIGHT HERE AND FORMS AND AS IT GOES THROUGH THE RED BLOOD CELL, AND THAT'S BECAUSE THERE'S A WEEK COHESION OF THE CYTO SKELETON, SO WE CAN CAPTURE IN THIS THE DETAIL, ALL THIS PHYSICAL MECHANISMS, SO, 1 WOULD WONDER HOW YOU ACTUALLY VALIDATE THIS, SO THAT BEING BE PATIENT SPECIFIC FOR EXAMPLE THERE'S A MOVIE HERE ON THE RIGHT THAT DOESN'T PLAY, BUT WE COULD SAY WE TAKE THE RED BLOOD CELL AND THE STRETCHES IT JUST LIKE IN THIS SKETCH, IN THE PLOT, THAT SHOWS THAT DEPENDING ON THE DIAMETER AND LONGER DIRECTION AND THE COMPRESSED DIRECTION, HAVE YOU DATA, EXPERIMENTAL DATA FROM WHICH YOU CAN EXTRACT THE SHEER MODULE, THE SIEVENESS, BASICALLY THE BIOMECHANICAL PROPERTIES OF THE CELL, WHICH IS DISEASE SPECIFIC AND PATIENT SPECIFIC. SO YOU DO THAT AT THE INDIVIDUAL LEVEL, AND CELL LEVEL, THEN YOU ALSO NEED LOTS OF MICROFLUIDIC EXPERIMENTS WHERE FORTUNATE TO HAVE AS A CO-PI, THE TEAM LED BY MING DAU, AT M. I.T. WHO BUILT U NIQUE FACILITY THERE TO SORT OF MIMIC TRANSIENT HYPOXIA IN THE CHAMBER YOU SEE HERE AND THE FLOW SIGNIFY TOM TERAND THE CELL S WILL FLOW THROUGH THAT AND QUANT EXTRACT QUANTITATIVE FEAT URES THAN USE TO TRAIN THE MODELS AND I WILL SHOW YOU SOME ASPECTS OF IT. OKAY, SO THIS MOVIE IS NOT PLAY ING SO WE HAVEOX GENERATED 8 ED CONDITIONS AND THE CELLS LOOK LIKE THAT BUT FROM THERE, IF THE VIDEO WAS PLAYING YOU COULD SEE ACTUALLY THE GERONTOLOGYSTS LAY TIME WHICH IS VERY IMPORTANT PARAMETER IN OUR MODELS AND THEN THE IRREVERSIBLE CASE. SO IT TURNS OUT, THE VIDEO DOESN'T SHOW IT BUT IT TURNS OUT THAT YOU DON'T JUST HAVE SICKLE CELLS, THE SHAPE AS YOU KNOW HERE, YOU APPRECIATE THAT THE HETEROGENEITY IS 1 OF THE HALLMARKS OF SICKLE CELL ANEME WRA AND WE BUILT THIS CON VOLUNTEERSULATION NEURAL NETWORKS AND THE NEURAL NETWORK TO CLASSIFY ALL THE TYPES OF RED BLOOD CELLS THAT YOU SEE HERE FROM ABOUT 10,000 IMAGES, FROM THE LAB, THAT'S THE SICKLE BLOOD , IN FACT WE FOUND THAT THAT THE SICKLE CELLS ARE ONLY MINORITIES LIKE 10-15% OF THEM, MOST OF THEM HAVE DIFFERENT SHAPES BUT NOT--BUT THEY'RE PRIMARILY NONSICKLE SHAPE AS 1 WOULD THINK AND THE REASON FOR THAT IS THAT THE NUCLEATION PROCESS, THE POLYMERIZATION PROCESSES, SUBCELLULAR PROCESSES , STOIKASTIC PROCESSES THAT 1 COULD NOT PREDICT JUST BY GUESSING. BUT MULTISCALE MODELING INVOLVES ALL SCALES, HERE I SHOW ON THE TOP, THE MODELS FOR IT, BLOOD CELLS, WHITE CELLS AND THE AD HESION PROCESS, I'LL SHOW YOU UP FROM THE MOVIE WE PLAY THERE, AND THEN WE'RE LOOKING AT THE POLYMERIZATION AND THE SIGNALING PROCESS IN THE MIDDLE PANEL AND THEN AT THE BOTTOM WHO CAUSES THAT SO IT'S A MILD KALE PROCESS AS I MENTIONED DOWN TO MOLECULAR LEVEL, DOWN TO HEMOGLOBIN, HOW THE HEMOGLOBIN MOLECULES SELF- ASSEMBLE TO FORM THIS FIBER , FIEPERS FORM THE BUNDLES THAT ACTUALLY PUSH THE CELL, SO THIS IS A TRAINING, THIS IS A-- USING REAL DATA, DEOX GENERATEDDATION ON THE TOP, THE TRAIN IS SINGLE RED BROOD CELL HOW TO BECOME SICKLE AND THEN ALSO TO BE REVERSE AND TO COVER IN THE PRESENCE OF OXYGEN, IN THE BLUE, OXYGEN AND YOU CAN SEE THERE'S ALSO DELAYED TIME, THE GREEN SHOWS THE AMOUNT OF SIGNALING WHICH AS YOU CAN SEE HAS A DIFFERENT PEEK AT THE POINT WHERE OXYGEN GENERATED ACE WILL HAPPEN, SO HERE'S WHAT WE'RE TRYING TO DO, WE'RE TRYING TO TRAIN 1 SICKLE CELL TO BE--1 CELL TO BEHAVIOR HAIF LIKE A SICKLE CELL AND HAVE DIFFERENT SHAPES AND THEN WE WANT TO PREDICT COLLECTIVELY, HOW BLOOD WILL BEHAVE IN FLOW CONDITIONS. SO WE GO BACK TO THE EXPERIMENT, SO THIS IS LOOKING FROM ABOVE AND THE FLOW SIGNIFY TOMETER AND OXYGEN HERE WE STARTED THE OX GENERATEDDATION AS YOU CAN SEE NOW SOME OF THE RED PLOOD CELLS STACK INTO THIS SMALL GATE AND THEN MORE OCCLUSION, THAT'S HOW YOU CAN SORT OF QUANTIFY THIS OCCLUSION IN THE INVITRO THIS, IS AGAIN THE MIT EXPERIMENT AND THEN AS YOU TURN BACK THE OXYGEN GENERATEDDATION WITH THE DELAY TIME, YOU CAN SEE THEY REVIVE ALL THE CELLS AND THEY ARE SWIM MING THROUGH. SO WE WANT TO ACTUALLY USE THIS INFORMATION, NOW HAVING TRAINED A SINGLE CELL, WE WANT TO TEST OUR MODELS AND NOW YOU CAN SEE, THE EXPERIMENT IN THE SIMULATION NEXT TO EACH OTHER, YOU CAN SEE OF COURSE THE STOIKASTIC PROCESS BUT THE AGGREGATE WE SEE HOW MANY CELLS FOR THE SAME BLOOD WOULD GET TRUMPED THEREFORE THE SAME STIFFNESS AND SAME BIO MECHANICAL CHARACTERISTICS SO THERE'S QUANTITATIVE COMPASSION OF THIS IN JOINT PNAS PAWRP WHY PUBLISHED WITH M. I.T. AND OF COURSE DEPENDING ON THE ORGAN OF THIS, OCCLUSION AND [INDISCERNIBLE] ADHESION, SO WE HAVE A STOIKASTIC MODEL BASED ON PROCESSES WHERE WE HAVE A FORM ATION OF THE BONDS AND DIS ASSOCIATION BASED ON EXPERIMENTAL INPUT THAT WE ACQUIRE AGAIN AT THE LAB. NOW I HAVE A MOVIE TO SHOW THAT ON THE TOP, EVEN UNDER SIMPLE FLOW, THE EGULATION--REGULATORY SICKLE CELLS LIKE TO FLAI AWAY FROM THE--FLY AWAY FROM THE WALL S. SO'S MISCONCEPTION THAT THEY CAUSE THE OCCLUSION. THEY LIKE TO--BECAUSE THEY'RE STIFFER THEY FLY AWAY FROM THE WALL, THEY DON'T STICK TO THE WALL. THE YOUNGER CELLS ARE THE 1S THAT THE SOFTER 1S THAT ACTUALLY SPEAK. SO WE QUANTIFY THIS. SO WE BUILD THIS DIGITAL TWIN OF ADHESION, UNFORTUNATELY MY MOVIE S ARE NOT ALL PLAYS BUT WE HAVE ON THE 1 SIDE WE HAVE THE EXPERIMENT,OT OTHER SIDE WE WERE SPOADED TO HAVE THE--LET ME SEE IF I CAN MOVE THIS. OKAY, SO WE HAVE DIGITAL TWINS FOR ALL THIS, THE SICKLE CELLS THAT ARE SOFT, THEY ARE IRREVERSIBLE, MORE DEHYDRATED AS YOU CAN SEE. SO WITH THAT, WE CAME UP WITH QUANTITATIVE ADHESION, ADHESIVE PROCESS FOR SOFT SICKLE CELL AS WELL AS RIGID SICKLE CELLS, AND THE PROCESS IS VERY DIFFERENT. AS CAN YOU SEE IN THE TOP PANEL THERE'S MULTILE POINTS OF AD HESION FOR THE SOFT CELLS AND THEN THERE'S 1 POINT OF DETACH MENT WHICH SORT OF LOOKS LIKE [INDISCERNIBLE] ON THE RIGHT SIDE, I DON'T KNOW IF I CAN POINT WITH IT, YEAH, IT'S RIGHT HERE, SO THERE'S RESEMBLANCE SIMILARLY FOR RE VERSIBLE CELLS, THE ADHESION PROCESS IS VERY DIFFERENT BUT AS WE SAID, WE WILL HAVE CONSTRUCT ED DIGITAL TWIN OUT OF IT. SO TAKING TOGETHER ALL THIS, 1 CAN STUDY VISUAL OCCLUSION, SO FOR EXAMPLE, IF YOU RECALL THE STIFFER 1S THEY GO AWAY FROM THE WALL, THE SOFTER 1S ARE THE 1S THAT STICKS TO THE WALL, THEY CREATE THE STENOSIS AND AS THEY STIFF, SICKLE CELL TYPES THEY GO THROUGH, THERE IS AS CAN YOU SEE HERE, ON THE RIGHT PLOT, THE VELOCITY EVENTUALLY GOES TO 0 WHICH MEANS HAVE YOU A FULL VISUAL OCCLUSION. SO WE IDENTIFY THAT ROLE IN THE QUANTITATE I MANNER, THEY BEFORE MUMBLE, THE CELLS AND SO ON AND THIS PNAS PAPER A FEW YEARS BACK MOVING FORWARD, THERE ARE ALL SORTS OF HETEROGENEOUS ROW GENIUS TYPE OF ADHESION FOR EXAMPLE, WHAT YOU SEE HERE IS THAT THE RETICUE LOW SITES AND WHAT YOU SEE IS A YOUNG SICKLE CELL THAT ATTACHES TO THE WALL WALL AT THE TAME TOO AND IT POLYMERIZES, IT LOOKS LIKE A LOBSTER BECAUSE IT'S VERY SPIKY. SO THESE SPIKES ARE FIBERS THAT PROTRUDE BECAUSE OF THE LARGE SURFACE AREA OF THE YOUNG CELLS, THEY PRODUCE BUT HERE IS A CASE WHERE POLYMERIZATION AND AD HESION WORKS LOGISTICALLY SO THAT HAS TO TAKE INTO ACCOUNT THAT MODEL SO THAT BASAL FILLS ANDS DIFFERENTLY THAN THE CELLS, SO THAT COVERS THE CELLULAR PROCESSES AND IT I WOULD SAY A FEW TINNINGINGS ABOUT SUBCELL ULAR PROCESSES GOING DOWN INTO THE MOLECULE, THE ALPHABET TA TOO, THE BETA 6 MUTATIONS AND HOW YOU DEAL WITH IT AND THE IMPORTANT CONCEPT HERE IS THAT OF NUCLEATION, 1 OF THE MOST DIFFICULT, PHYSICAL PHENOMENON TO ACTUAL MODEL IS NUCLEATION, THINK ABOUT MODELING THINK ABOUT BOILING, THINK ABOUT THE FIRST DROPLET OF VAPOR WHEN YOU BOIL WATER. THAT'S VERY DIFFICULT TO PREDICT , OKAY, SO THE SAME THING HAPPENS HERE, WHAT'S THE FIRST SEED OF POLYMER? THAT'S VERY IMPORTANT BECAUSE THAT STARTS THE HEMOGENIUS NUCLE ACE, AND THEN YOU HAVE THE HETEROGENEOUS ROW GENIUS HERE WHICH IS IN THE LOWER PANEL WHICH IS ON TOP OF THE HEMO GENIUS NUCLEATION, SO 1 IMPORTANT THING IS HOW MUCH IS HOMOGENOUS HETEROGENEOUS ROW GENERATED YIEWS NUCLEOTIDES NUCLEATION, THAT'S REALLY IMPORTANT QUESTION IN TERMS OF OCCLUSION, BUT YOU WANT TO--YOU SAW IN THE MOVIE HOW THE HEMOGLOBIN MOLECULES ARE RECRUIT ED TO PRODUCE FIBERS, SO THERE'S A VERY DETAILED MODEL THAT I WILL NOT BOTHER YOU BUT A MAIN DRIVER HERE IS THE KHIHIGH ERALLITY, AND IT HAS DEFECTIVE IT HAS THIS HYDROPHOBE ICINTERACTION THAT CREATES SELF- ASSEMBLY THAT STARTS THE WHOLE FIBER FORMATION IN FACT THERE ARE 7 STRANDS, DOUBLE STRANDS THAT FORM A FIBER TO BE BIN WITH.& SO WE--WE QUANTIFY THAT AND THERE'S EXPERIMENTAL DATA TO VER IFY THE MODEL BUT WHAT CAN YOU SEE HERE IN FACT IS THE FORM ATION AND WE HAVE THE GRAIN COMPUTATIONALLY TO DO THIS, OFF A SINGLE FIBER THIS IS 1 FIBER AND YOU CAN SEE THIS PILE OF STRUCTURE WHICH IS ALSO OBSERVED IN THE EXPERIMENTS AND THERE'S A VERY GOOD AGREEMENT WITH EXPERIMENTS. SO THIS IS PREDICTIVE WITH THE PRINCIPALS, INTEGRATING ALL THAT POSSIBLE TO DO. NOW YOU SEE FIBER, FIBER INTER ACTION BECAUSE JUST 1 FIBER WILL NOT MAKE THE RED BLOOD CELL SICKLE WITH THE MEMBRANE FLUCTUATION, SO HOW FIBERS INTER ACT ARE VERY IMPORTANT FOR EXAMPLE, THEY ARE PARALLEL, CAN YOU SEE THE FORMER BUNDLE. IF THEY ARE THE 60-DEGREES THEY FORM A DIFFERENT SO THAT WILL GIVE YOU MAPLE LEAVE SHAPE FOR EXAMPLE, SO THIS PROCESS HERE, IS EXACTLY WHAT IS RESPONSIBLE FOR THE HETEROGENEITY WE SEE IN THE DIFFERENT SHAPES THAT I MENTIONED EARLIER ABOUT 10 DIFFERENT CLASSES OF SHAPES IN THE SICKLE CELL ANEMIA. SO HERE WE HAVE A PHASE DEC DIAGRAM--DIAGRAM THAT SHOWS IF THE FIBERS ARE BELOW 50-60- DEGREES THEY ALL BUNDLE UP TO A VERY STRONG FIBER WHICH IS RESPONSIBLE FOR THE SICKLE SHAPE , HOWEVER, IF FIBERS ARE FORMED AND THEY FORM RANDOMLY SO THAT THE ANGLE BETWEEN THEM ARE GREATER THAN 60-DEGREES THEN THEY FORM DIFFERENT SHAPES MORE LIKE A SQUARE, MORE LIKE A MAPLE LEAF BUT YOU MAY HAVE SEEN THIS SOMETIME BUT WE PUT EVERYTHING TOGETHER AND HERE ON THE LEFT YOU WILL SEE A HOMOGENOUS NUCLEATION AND THE OTHER 1 GROWS NEXT TO IT SO THAT'S HOMOGENOUS NUCLEATION AND ON THE RIGHT YOU SEE THE FIBERS ISHT ACTING, AND NUCLEATION, BECAUSE OF THE ANGLE S THEY DON'T ACTUALLY BUNDLE UP AND THEY GIVE YOU RANDOM ORIENTATION SO THIS IS THE CASE WHERE YOU GET THE RED BLOOD CELLS, AND THIS IS A SCHEMATIC OF THIS HAPPENING INSIDE THE RED BLOOD CELL AND YOU CAN SEE IN WHAT DETAIL ACTUALLY, IT'S A VERY DECORATED RED BLOOD CELL HERE, EVERYTHING IS THERE FROM THE BAND 3 PROTEIN S TO SPECTERRING TO BI LAYER, EVERYTHING IS HERE HERE TO REPRESENT THIS PROCESS AND HERE WITH THE--WE HAVE ENLARGED THE FIBER SO JUST SORT OF TO BE VISIBLE WHAT'S HAPPENING AS IT GROWS INSIDE THE RED BLOOD CELL, AND RECRUITS THE MOLECULES IN THE SEMBLE PROCESS THAT WILL PUSH THE RANDOMLY FOLLICULAR MEMBRANE TO CAUSE THE DEFEKS AND SICKLING, SO 5 YEARS OF RESEARCH SUPPORTED BY--THANKS TO NIH FOR DEVELOPING THIS TYPE OF MODELS FOR FIRST TIME, I THINK, SO NOW HOW WE MAKE THIS COMPUTATION MODEL THIS IS IS NOT FOR DOCTORS TO USE IT, MAYBE MORE LIKE PHYSICS TO USE, BUT THEY REQUIRE SUPER COMPUTING AND SO ON, BUT NOW TAKEN TOGETHER THE MICRO FLUIDIC DATA, CLINICAL DAT AND THIS FIRST PRINCE PALES DAT FROM THE MODELS WE IN ONLY TAKES 1 MINUTE TO ACQUIRE ON A LAPTOP AND TAKES ALMOST NO PHYSICS TO ACQUIRE. THE PHYSICS OF WHAT I JUST TOLD YOU ABOUT, THE HOMOGENOUS AND POLYMERIZATION AND NUCLEACE AND PART OF THE MODEL, OKAY, SO WHAT WE HAVE LEFT, THE OXYGEN TENSION , PARTIAL PRESSURE OF THE OXYGEN, OX GENERATEDDATION RATE AND THE TEMPERATURE, THAT OF COURSE YOU CAN HAVE LANGUAGE OX GENERATED RICH OR HAVE A LIVER OF A DIFFERENT ORGAN AND DIFFERENT PARAMETERS AND THEN HAVE YOU PATIENT SPECIFIC HERE, WHERE WE SPECIFY THE HBS CONCENTRATION, HB VARIANTS AND THE RBCs VERY IMPORTANT OF COURSE, THIS IS SORT OF THE MODEL HERE, AND YOU GET THE NUMBER OF NUCLEI GENERATED FROM THE HOMOGENOUS AND THE NUCLEACE AND 1 CUBIC MILLIMETER OF BLOOD IS ABOUT 5 MILLION RED BLOOD CELLS SO I WOULDN'T BE ABLE TO DO THOSE DETAIL SIMULATION SO NOW WE CAPTURE THAT INFORMATION SO HERE, WE CAN SAY, FOR THE WHOLE BODY IN WHATEVER QUANTITY YOU WANT GIVEN THIS INPUT ON THE LEFT, I CAN PRODUCE THE NUMBER OF NUCLEI AND THE FIBER LENGTH AND EVENTUALLY THE NUMBER, THE FRACTION OF CELLS THAT THE SIGNAL IN THE CERTAIN ORGAN, SO I THINK THAT'S PRETTY USEFUL AND PREDICTIVE. IT'S A VERY COMPLICATED MODEL AS I SAID, IT INCLUDES THE DELAY TIME WHICH YOU SAW IN SOME OF THE VIDEOS, FROM THE ONSET OF NUCLEACE AND POLYMERIZATION AND HOMOGENOUS NUCLIZATION, AND THE PROCESS, THE HETEROGENEOUS ROW GENERATED ACE NUCLIZATION AND THE PROCESS AND THEN THE FIBERS. SO FIRST LET'S TEST THIS MODEL, PURIFIED CYCLIC HEMODPLOABIN SOLUTION, HOW MUCH IS--THERE'S LOTS OF EXPERIMENTS FROM THAT AND THEN WE WILL CHANGE THE RATE TO THE OX GENERATEDDATION AND SHOW THE OX GENERATEDDATION, SO THIS PANELS HERE SHOW DIFFERENT TOTAL CONCENTRATION OF HEMOGLOBIN AND THE QUESTION IS WHICH 1 IS MORE IMPORTANT, HOMOGENOUS OR THE HETEROGENEOUS ROW GENIUS, AS CAN YOU SEE HERE IN THIS INSET, IN THE EARLY STAGES OF YOU THIS CLE ACE AND POLYMERIZATION, HOMOGENOUS POLYMERIZATION, ARE ABOUT THE SAME BUT EVENTUALLY HETEROGENEOUS ROW GENERATED YIEWS POLYMERIZATION GROWS EXPONENTIALLY FAST AS OPPOSE TO NUCLEACE DOWN HERE, WHICH AMOUNT S TO JUST A FEW HOMOGENOUS NUCLEI. THE SAME THING IS AS YOU IN CREASE THE TOTAL CONCENTRATION , THAT'S A VERY IMPORTANT PARAMETERS EXCEPT NOW THE CONCENTRATION YOU CAN SEE THE PDF HERE IS [INDISCERNIBLE] BECAUSE YOU HAVE BIG LARGE NUMBERS OPPOSE TO THE DISTRIBUTION AND THAT'S THE NUMBER OF HEMOGENIUS NUCLEI, AS YOU GO FORWARD TO EVEN LARGER CONCENTRATION, 35, YOU SEE THAT YOU GET ABOUT FOR THIS PARTICULAR AMOUNT OF PLOOD, ABOUT 10 HEMOGENIUS NUCLEI, BUT OUT OF THOUSAND SASMYS HERE, I HAVE 3 THAT SHOWS THIS RED AND GREEN AND BLUE LINES THAT SHOW EXPONENTIAL GROWTH OF HETEROGENEOUS ROW GENIUS AND THAT'S VERY ACTUALLY IMPORTANT TO QUANTIFY IN THAT FORM. IN ORDER TO BE PREDICTIVE AND IN TERMS OF THE OX GENERATEDDATION, YOU CAN SEE HERE THAT IN FACT, IF THE SLOW DEOX GENERATEDDATION , YOU CAN SEE HOMOGENOUS NUCLEICE IN THE FAST INATION, THAT CAN BE QUANT IFIED SO NOW HOW DO YOU GO FROM POLYMERIZATION TO THE SOLUTION TO ACTUALLY SIGNALING BECAUSE IT'S SORT OF A HOLY GRAIL, AND THIS WILL BE [INDISCERNIBLE]. SO THAT'S NOW WE CAN BRING IN THE--OUR MECHANISTIC MODEL SO HERE IS THE QUESTION IS HOW MANY FIBERS YOU NEED TO IF YOU HAVE ABOUT A DOZEN FIBERS THEN THAT'S ABOUT THE ONSET OF SIGNALING SO BY THESE NUMBERS THEN WE AND GO FROM POLYMERIZATION TO ACTUALLY SIGNALING AND THAT RESULT IS CONSISTENT WITH SOME DATA THAT WAS PUBLISHED IN THE PNAS BY THE HARVARD GROUP. SO HOW DO YOU VALIDATE THAT, I WILL CHAZ [INDISCERNIBLE] FROM THE LITERATURE. I WILL NOT TWEAK THE PARAMETERS, HOWEVER TAKES INTO ACCOUNT THE POLYMERIZATION PROCESS, AS STOIK ASTIC PROCESS HOW DOES IT PERFORM IN THE VARIOUS EXPERIMENT, SO THE INVIVO EXPERIMENT AS WE COMPARE HERE IS FOR A DEPARTED VAIN, AND HERE WE PLOT THE PROBABILITY OF SICKLING VERSUS--THE POTENTIAL YOU CANNOT GET THE SIGNALING IN B, WHAT WE HAVE IS THE DELAY TIMES IS TOO LONG AS OPPOSE TO TRANSIT TIME IS A FEW SECONDS, AND WE HAVE FIBERS BUT THE FIBERS ARE TOO SHORT AND AT A TURN SOUTH AND ONLY IF BAND D WE HAVE HERE SICK LE CELLS, IT TURNS OUT IF YOU GET THIS CARE HERE, YOU GET 24% AND THE EXPERIMENT WAS 22% IN 4 DIFFERENT PATIENTS IF YOU HAVE SICKLE TRAIT, THE WHOLE THING IS SHIFTED TO THE RIGHT AND YOU DON'T SEE SICKLING SO THE MODEL PREDICTS ALSO A CASE. THERE'S A LOT OF INVITRO EXPERIMENTS FROM OUR M. I.T. COLLEAGUES WHICH COULD ALSO BE USED AND THESE ARE FOR DIFFERENT --7 DIFFERENT PATIENTS SO HERE AGAIN WITHOUT TWEAKING THE MODELS WE CAN FIND THE SING LE FRACTION AS A FUNCTION OF TIME AS YOU CAN SEE WITH A DELAY DOWN HERE, THE DELAY TIME IS VERY IMPORTANT. SO THIS IS A STOIKASTIC MODEL AND THE ONLY THING WE'RE CHANGING IS THE LEVEL OF OXYGEN THAT WE'RE--FINAL OX GENERATED OR 10 OR 3% AND SO ON BECAUSE THAT'S NOT MEASURED DIRECTLY FROM THE PRECISELY FROM THE EXPERIMENT. SO THE EXPERIMENTAL DATA IS THE BLACK HAIR AND BLUE LINE SHOWS THE MEAN AND OF COURSE YOU HAVE THE VARIANTS DUE TO THESE UNCERTAINTIES, THIS IS ALSO TRUE FOR THE OTHER 6 PATIENTS, I WILL NOT SHOW YOU THE RESULTS BUT HERE'S 1 MORE TEST WITH RECENT DATA BY BILL ETON WHO'S WORKING HERE AT NIH AND HE AS I NEW ASSAY FOR USING LASER TO CAUSE CYCLING. THIS IS THE PREDICTED RESULT. SIGNAL FRACTION VERSUS TIME, THE EXPERIMENTAL DATA IS HERE, THE BLUE LINE IS OUR MODEL WITHOUT ANY TWEAKING AS I SAID. IT'S VERY IMPORTANT TO ZOOM IN THIS THE FIRST 102ndS, BECAUSE THIS' WHERE THE ONSET HAPPENS AND YOU CAN SEE IT'S A VERY GOOD AGREEMENT COMPARED TO THE STATE-OF-THE-ART BEFORE THIS MODEL. AND YOU CAN ALSO USE THESE BUPPEDLES TO TEST AND THAT'S VERY IMPORTANT TO TEST THE EVASE Y--EFFICACY TO TEST POTENTIAL DRUGS AND HERE IS 1 THAT WAS TESTED IN THE NIH EXPERIMENT IT'S IN THE A, SO IT SHOWS AGAIN THE NORMALIZED SIGNAL FRACTION AS A FUNCTION OF THE CONCENTRATION OF THE DRUG. THIS DRUG BASICALLY INDUCEED AND THE BLUE, RESULTS FOR 4 HOUR EX POSE AND YOU ARE 24 HOUR EX POSURE ALSO AGREE, SO THERE ARE A LOTS OF DRUGS HERE AND AS YOU KNOW, THIS 1 IS A RECENT 1 YOU DON'T KNOW IF IT WORKS I THINK, MY COLLABORATORS TELL ME AND YOU CAN SEE THERE ARE MANY MECHANISMS AND WHAT I PROPOSE IS THAT SOME OF THIS MODELING CAN BE USED ACTUALLY TO ZOO AM IN FOR SPECIFIC MECHANISMS IN A QUANTITATIVE WAY. SO, SWEE LAY TALK ABOUT QUANT ITATIVE AND GIVE YOU THE PARAMETERS AND SHOWING THE RIGHT DOSAGE OF THE DRUG AND ALSO CAN DISSECT SOME OF THE RESULTS THAT --I WAS LOOKING THIS MORNING ABOUT THE TALK MONICA GAVE ABOUT [INDISCERNIBLE] HEMODYNAMICS AND I REALLY LIKE THIS DATA BECAUSE I COULD INTERPRET IT IN A QUANT ITATIVE WAY BECAUSE OF COURSE, IF YOU HAVE THE BLOOD FLOW, YOU CAN ALSO COMPUTE THE SIMULATE THE OXYGEN AND ALL THIS PROCESSES, AND BE PRODETECTION ANTIBODYIVE IN FACT. SO, I WOULD LIKE TO KIND OF FIN ISH HERE WITH 1 THOUGHT AND THAT IS, THESE DAYS EVERYBODY TRIES TO USE A LOT OF DATA AND SAY, OKAY, WE ARE USING THE NEUR AL NETWORK AND THAT'S LIKE A PANACEA. IT PREDICTS EVERYTHING BUT IT'S NOT STRONG AND NEURAL NETWORK IS REALLY A FUNCTION AND I'M A MATH PROFESSION. AND IT'S AMAZING WITH THIS, SO A NEURAL NETWORK IS NOTHING ELSE BUT AN OPROXIMITYMATION OF A FUNCTION SO IT'S A UNIVERSAL APPROXIMATOR, FOR EXACT, THAT MEANS THAT YOU CAN INTERPOAT ALATE IT'S SOMETHING THAT NOT VERY SO IF YOU WANT TO INFER WITHOUT PHYSICS, THAT'S A REALLY DANGE OROUS PATH TO GO, SO YES, THERE ARE A LOT OF GOOD STORIES IN THE PRESS, THE POPULAR PRESS, THERE'S ABOUT 99% OF STORIES TOO, WHICH WE DON'T HEAR ABOUT, SO I WORK WITH NEUR AL NETWORKS AND SO, RECENTLY , I START THE BIG TRUSTEES WITH THE DEPARTMENT OF ENERGY ON PHYSICS AND FORMULA NETWORKS AND THOSE IN IN THIS CONTEXT HERE AND A NEURAL NETWORK IS WHAT I SHOW HERE ON THE LEFT. YOU HAVE LABEL DATA, X AND T AND PRODUCE THOSE SO YOU NEED TO KNOW THE OUTCOME AND THE CON DITIONS IT CAN BE APPLIED HERE AND IT SHE HAS A LOT OF DATABASES AND DONE A GREAT JOB ORGANIZING IT BUT THE QUESTION IS REQUEST WE PREDICT THE DATA AND CAN WE ALSO ADD CERTIFICATES OF FIDELITY TO OUR PREDICTION BECAUSE THAT'S VERY IMPORTANT. NEURAL NETWORKS BY THEMSELVES WILL NOT GIVE YOU THIS UN CERTAINTY, SO YOU HAVE TO DO SOMETHING EXTRA. SO I KIND OF WORK IN THAT MYSELF , BUT WHAT I HAVE PROPOSED IS THAT, YOU CAN ACTUALLY INTEGRATE THE MODELS AND CODE THE PRIOR KNOWLEDGE, WHATEVER THE KNOWLEDGE IS, COULD BE CONSTRAINTS, BED BE BELIEFS OR PHYSICS HERE TO START. I DON'T KNOW IF ANYBODY CAN RECOGNIZE THIS EQUATION BUT THIS COULD BE FOR EXAMPLE, MY MODEL, DON'T HAVE TO SCRATCH YOUR HEAD BECAUSE IT'S A NONLINEAR THREAD EQUATION I PUT IT HERE WITH LAM DAILY BASIS 1 AND 2 THAT YOU DON'T KNOW. THE POINT IS YOU CAN ACTUAL LYE ENCODE USING GOOGLE INTENSIVE FLOW, CAN YOU ENCODE THE PRIOR KNOWLEDGE IN THE FORM PF OF THE MODELS, MATHEMATICAL MODELS WHO ARE OTHERWISE INTO THE NEURAL NETWORK AND THEN THE NEURAL NETWORK ITSELF, YOU TRY TO FIND THIS STATE, YOU SHARE THIS VERY COMPLICATED GRAPHIC AND I'LL SHOW IT TO YOU, IT'S JUST A SKETCH AND IF YOU KNOW, IF YOU KIND IF PARAMETER, THEN YOU ACTUALLY CAN PREDICT, NOW THERE ARE MANY REASONS HERE WHY THIS IS IMPORTANT. FIRST AS I SAID FROM DATA YOU CAN ONLY INTERPOLATE. YOU CANNOT EXTRAPOLATE. SECOND, THE DATA WOULD NOT NECESSARILY EXPECT PHYSICS AND MECHANISMS FOR EXAMPLE, MASS CON SERVATION, WE WANT TO ALL BELIEVE THAT, WE WANT TO ENCODE THAT INTO THE MODEL, AND INTO THE NEURAL NETWORK, DOESN'T KNOW ABOUT PHYSICS UNLESS YOU TEACH IT. SO IT DOESN'T KNOW ABOUT COAGULATION UNLESS YOU TELL IT SO YOU DON'T NEED TO KNOW EVERYTHING ABOUT IT. IN FACT THAT'S WHAT THE NEURAL NETWORK START WITH, THEY CAN DISCOVER PART OF THE HIDDEN FIDS ICS. IF YOU HAVE AN OBJECTION TO FUSION REACTION SYSTEM, YOU KNOW THE REACTION IS VERY COMPLICATED THROUGH THE DATA YOU CAN DISCOVER THE REACTION SO HAVE YOU ACTUALLY A NEW PATHWAY, WHICH YOU CAN TEST. SO AS CAN YOU SEE HERE FOR THOSE WHO READ SOME MATH IS THE LOSS FUNCTION WHICH IS THE OPTIMIZATION ENCLUEDS THE MISFIT TING DATA AND THAT'S A STANDARD NEURAL NETWORK AS WELL AS THE PENNALLIZING THE RESIDUAL IN THE CONSERVATION LAW IN YOUR BELIEF OR THE PRIOR KNOWLEDGE. SO I THINK GOING FORWARD AND BECAUSE NOW YOU HAVE THIS, THE LANDSCAPE YOU ARE TRYING TO OPTIMIZE IS NOT AS ROUGH, IT'S SORT OF REGULARIZING THIS OPTIMIZATION PROBLEM NEURAL NETWORKS ARE GOOD FOR, YOU CAN OBTAIN TAIN AN ANSWER AND AN ANSWER WITH A CERTIFICATES OF IT SO I THINK I WILL STOP HERE. THANK YOU VERY MUCH FOR YOUR TIME. I HAVE 1 MORE MINUTE SO I'M GLAD I FINISHED. THANK YOU. [ APPLAUSE ] >> FRANK FROM DREKSLE UNIVERSITY , GEORGIA IT'S A BEAUTIFUL MODEL THAT YOU HAVE. I WOULD JUST CAUTION YOU THAT A LOT OF THE TWEEZER WORK HAS TO BE DONE IN OX GENERATEDDATED--OX GENERATEDDATED ENVIRONMENT AND SO YOU MAY WANT TO BE CAREFUL ABOUT BUILDING INTO DEOX GENERATED 8ED CELL MEMBRANES WHERE YOU HAVE BAND 3 ISSUES AND DPG AND ALL THAT SORT OF STUFF THAT COMPLIATES THE STORY. AND I ADMIRE THE FACT THAT YOU ARE TRYING TO BUILD IN THE FUND AMENTAL EXPERIMENTS, BUT I WOULD CAUTION YOU THAT THAT WAS 1 PARTICULAR THING THAT LEFT OUT THE OTHER 1 IS ALSO THAT THE GENIUS NUCLEATION BUILDS ON THE SURFACE BETA 6 VALINES THAT APPEAR IN THE FIBER SO THE ANGLE TURNS OUT TO BE FIXED. IT'S RATHER THAN BEING VARIED AND YOU WERE SHOWING A VARIETY OF CROSSES BUT IT'S NOT OBVIOUS THAT THOSE CROSSES ARE ALSO PHYSICAL. SO COUPLE OF THINGS TO KEEP IN MIND AS YOU DEVELOP THIS ELEGANT MODEL. >> I WANT TO MENTION THAT I HAVE USED A LOT YOUR PHYSICAL INSIGHT S IN BUILDING THOSE MODEL S MYSELF. >> I RECOGNIZE THOSE PICTURES. >> BUT YOU POINTING OUT PHYSICS WHICH WOULD COME INTO THE MODEL s AS THEY COME IN, THE MODELS ARE EVOLVING AND IT'S A PLATFORM, BUT AS YOU KNOW, JUST 3 OR 4 YEARS AGO, WE DO HAVE ALL THIS FIDELITY SO DIFFERENT MASS SPECS WOULD COME IN AS NEW DATA COME IN, BUT THE OX GENERATED DATED STATUS IN THE AD HESION I DON'T KNOW IF YOU SAW THE RECENT PAPER, WE ARE ACTUAL LY QUANTIFY BOTH THEOX GENERATED 8ED STATE AND THE DEOX GENERATEDDATED STATES AND BOTH WERE YOUNG AND AGE SICKLE CELLS AND THE DIFFERENCES COULD BE VERY LARGE AS YOU POINT OUT. >> --THEORY BUT VERY TRICKY ABOUT YOU TO ACTUALLY BE ABLE TO CAPTURE IT TO SIMPLIFIED MODEL WHICH I DON'T THINK YOU CAN JUST ON ITS OWN BUT TOGETHER WITH DATA, TOGETHER WITH MECH MECHANISTIC MODELS COULD GIVE YOU QUANTITATIVE UNDERSTANDING. POINT WELL TAKEN. >> ELLO HELLO? SORRY. I'M [INDISCERNIBLE] FROM FLORIDA AG RICULTURE AND MECHANICAL UNIVERSITY AND I'M A PHEAR D CANDIDATE AND MY QUESTION IS NOT TO FAR FETCHED BUT I'M JUST CURIOUS AS TO NOW THAT YOU ARE ABLE TO SIMULATE THE PROCESS OF SICKLING THE RED BLOOD CELLS IS IT LIKE MAYBE IN THE NEAR FUTURE OR SOMETHING THAT CAN TRANSFER INTO A TECHNOLOGICAL FORM OR WHERE MAYBE LIKE AN APP OR SOMETHING LIKE THAT IT--BE DEVELOPED AND THE PATIENTS CAN BE DO A LOT IF THEY'RE DOING SOMETHING WRONG TO PREVENT HOSPITALIZATION FOR [INDISCERNIBLE] OR ANY OTHER HEALTH PROBLEM? AND IN ADDITION TO THAT, YOU ALSO MENTIONED I BELIEVE YOU SAID VALIDITY BUT WHAT ABOUT RELIABILITY OF, YOU KNOW, THE MODEL? >> I DIDN'T CATCH ALL THE QUESTION, I THINK YOU WERE ASKING SOMETHING ABOUT SICKLING AND INVIVO SICKLING, YEAH. >> YEAH, LIKE THE RED BLOOD CELL S SICKLING CAN BE LIKE A MONITOR OR SOMETHING IN THE NEAR FUTURE MAYBE THAT MIGHT CONNECT AND PREVENT HOSPITALIZATION. >> YEAH, SICKLE SUGGEST A VERY COMPLICATED PROCESS AS YOU APPRECIATE AND JUST SMALL CHANGE S COULD CHANGE THE OUTCOME , I WOULDN'T--THIS IS SORT OF BUILT MOSTLY ON LABORATORY EXPERIMENTS. THE SIMPLER MODEL I SHOW YOU INVIVO COMPARISON, WE ARE WORK ING WITH A GROUP OF GREG CAT O WHO USED TO BE HERE BUT NOW AT [INDISCERNIBLE] HE HAS A MOUSE MODEL FOR WHICH WE CAN HAVE INVIVO COMPARISONS IT'S VERY DIFFICULT TO ASSESS BUT WE'RE TRYING TO DO THAT WITH ALL OF OUR SERVICES HAVE CERTAIN QUANTIFICATION AND BASED ON THE PARAMETERS THE MODELS HAVE, SO THAT'S WHY I CALL CERTIFICATES OF FIDELITY THAT I SHOW IN MY MODELS THEY'RE NOT INTERNISTIC MODELS THEY'RE STOIKASTIC MODEL ASTIC MODELS SO I QUANTIFY THEM MYSELF BUT I COULD NONAPOPTOTIC THE TELL YOU I PRO DUCE INVIVO DAT EXCEPT IN SOME CASES SMGHT. >> THANK YOU. [ APPLAUSE ] >> THANK YOU AGAIN. >> OKAY, OUR NEXT SPEAKER IS VAN DANA, SACHDEV WHO IS A RESEARCHER AT NIH WHO PUBLISHED EXTENSIVELY ON CARDIOVASCULAR DISEASE IN SICKLE CELL AND SHE WILL TALK ABOUT CARDIOVASCULAR PHENOTYPES IN SICKLE CELL. >> HELLO, GOOD MORNING AND GOOD AFTERNOON, I WANT TO THANK EVERYONE FOR ASKING ME TO PARTICIPATE. THE TITLE OF THIS TALK USED TO BE PREDICTING MACHINE TYPES BUT BACK WITH WE WERE PLANNING AND TALKING ABOUT THIS DISCUSSION, WE WERE VERY EXCITED TO BE START ING A PROJECT OF MACHINE LEARNING AND LESSON NUMBER 1 THAT WE REALIZED IS THAT WHEN YOU DO MACHINE LEARNING PROJECTS YOU'RE DEALING WITH A HUGE A MOUNT OF DATA AND TO PUT THAT DATA TOGETHER TO ANALYZE THE VARIABLES AND ALIGN THEM TO CLEAN THE DATA AND TO COLLECT OUTCOME VARIABLES, IT TAKES A LOT MORE TIME THAN YOU MIGHT THINK. SO, THAT ACTUALLY IS NOT A TYPICAL FOR MACHINE LEARNING PROJECTS DURING THAT WHOLE PROCESS OF PREPARING THE DATA FOR THE MACHINE, TAKING LONGER THAN BUILDING THE ALGORITHMS SO FIRST OF ALL IN ORDER TO PRE DETECTED A CARDIOVASCULAR PHENOTYPE, YOU WANT TO BED IT A BIT BETTER AND SO I'M GOING TO START TO GIVE YOU A TOUR OF THE CARDIOVASCULAR FINDINGS IN SICK LE CELL DISEASE. LUKELY WE'VE BEEN THROUGH A DAY AND A HALF OF TALKS O A LOT OF THE PATHOPHYSIOLOGY HAS BEEN DISCUSSED. I WILL SKIP OVER A LOT OF THAT AND I WILL TALK ABOUT INVIVO AND TESTING AND MEASUREMENTS THAT WE USE TO LOOK AT CARDIOVASCULAR CHANGES AND I WILL WILL TALK ABOUT REVERSIBILITY. I HAVEN'T HEARD MUCH ABOUT THAT IN TERMS OF PHENOTYPES SO WE WILL TALK ABOUT WHAT MIGHT BE RE VERSIBLE AND IN THE VERY END I WILL GO INTO MACHINE LEARNING AND TELL WHAT YOU WE'RE DOING IS BY THE TIME THERE'S ANOTHER MEET ING IN THE NEAR FUTURE WE WILL HAVE RESULTS TO SHARE WITH YOU. SO FORTUNATELY I HAVE NO FINANCIAL CONFLICTS. I DO WORK WITH HEMEATOLOGYSTS. HAVE I FRIEND WHO IS ARE HEMEAT OLOGYSTS BUT I'M NOT A HEMEATOLOGYST SO PLEASE REMEMBER THAT AND AS SIMILARLY I WORK WITH DATA SCIENTISTS BUT I'M NOT A DATA SCIENTISTS AND I THINK THAT THEME YOU HEARD MANY TIMES IT GOES TO MULTISYSTEMIC MULTI DISCIPLINARY NATURE OF THIS TYPE OF WO, AND I THINK WE'RE LEARNING IN OTHER DISEASE STATES AS WELL THAT THAT'S THE TYPE OF THING THAT'S NECESSARY IN ORDER TO MAKE PROGRESS. SO THIS YOU HEARD A LOT ABOUT BUT I WANT TO POINT OUT A FEW SPECIFIC THINGS RELATED TO CARDIOVASCULAR CHANGES. SO THE APEOPLIA AND SICKLE CELL DISEASE REALLY LEADS TO A HIGH OUTPUT STATE LET ME FIND MY POINTER. THAT BY ITSELF CAN LEAD TO CARDIOVASCULAR DISEASE, THIS RE VIEW ACTUALLY IS FROM A EUROPEAN JOURNAL AND IT USED TO BE PATHOPHYSIOLOGY OF HEART FAIL AND YOU ARE HEMOGLOBIN OPERATING GLOBALLYATHY SO I ADOPTED IT FOR THIS TALK AND REALLY HIGH OUTPUT FAILURE IS SOMETHING THAT WE ANEMIA BY ITSELF CAN GIVE YOUND- THAT, THIS REALLY DOESN'T REFER TO SICKLE CELL, IT REFERS MORE TO THALASSEMIA AND WE WILL GO INTO THAT AND THAT'S MORE PER INENT TO THIS DISCUSSION. I DON'T HAVE ANY COOL 3D ANIMATIONS LIKE GEORGE DID SO I'M GOING TO STICK TO THE ONLINE CARTOONS TO KEEP YOU AWAKE DURING THIS. YOU HEARD A LOT ABOUT THE EFFECT S OF ANEMIA, YOU GET A LOW SYSTEMIC VASCULAR RESISTANCE, LOW PVR, LOWER THAN IN PEOPLE WITHOUT ANEMIA, AND LEADS TO EXPANSION OF THE PLASMA VOLUME AND BASAL DILATION AND RESULT OF INCREASE IN CARDIAC OUTPUT. WE SAW A LOT ABOUT ENTRAPMENT ABOUT THE MICROVASCULATURE LEAD ING TO INFLAMMATORY STATE AND HYPE OR CO AGUEILABLE STATE AND YOU'VE ALREADY HEARD ABOUT REPROFUSION INJURY. HOW DO WE MEASURE THESE INVIVO? WELL WE THINK WOO CAN MEASURE ENDOTHELIAL DYSFUNCTION BY LOOK ING AT BRACHIAL ARTERY TEST ING AND FLOW MEDIATED DILATION, DAMAGED ERYTHROCYTES TO RELEASE THE HEMOGLOBIN AND IF YOU BELIEVE IN BIOMARKERS CAN YOU MEASURE THE EFFECTS OF THAT, THE CYTOKINES, ADHESION MOLECULE S, ET CETERA AS YOU HEARD. WE CAN MEASURE BLOOD PRESSURE AND IT'S LOWENER SICKLE CELL DISEASE IN THE GENERAL POP ULATION, WE HEARD SOMETHING ABOUT THIS YESTERDAY, SO PATIENT S DO DEVELOP THIS REG GATIVE SYSTEMIC HYPER TENSION AND THE VASCULAR STIFFNESS THAT THEY DO DEVELOP CAUSES HIGHER SIS TOLL-LIKE RECEPTORIC PRESSURES AND THE HIGHER PULSE PRESSURES. SO HOW DO WE MEASURE OUR ARE--ADMINISTRATIVE TERIOLE STIFFNESS? WELL THERE ARE 2 MEASUREMENTS, POST WAVE AND AUGMENTATION INDEX IN THE WAY IT'S DONE IS WITH EVERY CARD CARDIAC CONTRACTION THERE'S A FORWARD WAVE OF BLOOD FLOW WHICH IF YOU PUT A TENOMEAT ER AND ON THE FELPSORAL ARTERY AND LOOK AT THE DISTANCE BETWEEN THEM AND THE TIME THAT& IT TAKES TO REACH AND VELOCITY THAT'S INCREASED WITH CARDIOVASCULAR DISORDERS AND INCREASED RISK OF AND PEOPLE THAT FORWARD WAVE IS THE PRIMARY REASON THAT DRIVES THE INCREASE IN SIS TOLL-LIKE RECEPTORIC PRESSURE AND THAT'S NOT THE ONLY THING. WHAT HAPPENS IS WHEN BLOOD MOVES FORWARD, EVERY TIME THE AORTA BIFURCATES THERE'S AN IMPEDE ENSEL MISMATCH AND THERE'S A REFLECTION THATADS TO THESE WAVE S THAT GETS YOU HIGHER SIS TOLL-LIKE RECEPTOR INCREASE IN BODY PRESSURE SO IF YOU LOOK AT MACHINE WHE'S YOUNG AND HAS VERY COMPLIANT BLOOD VESSELS IT'S MOSTLY THE PRIMARY WAVE WE'RE MEASURING AND A BIT OF THE SECONDARY WAVE THAT AUGMENTS THE INITIAL WAVE TO GET YOU A PRESSURE WAVE FORM. IN OLDER PEOPLE WITH SICHER WEST VESSELS THAT SECONDARY REFLECTED WAVE CARRIES A LOT MORE AMP LIAISON FEUDITUDE AND SO YOU GET HIGHER SYSTEMIC PRESSURES. THE DIFFERENCE BETWEEN THE PRIMARY AND THE AUGMENTED WAVE IS THE AUGMENTATION INDEX WHICH WE ALSO MEASURE, AND THAT'S INCREASED IN OTHER CARDIAC DIS ORDERS. WHAT'S INTERESTING IS THAT IN SICKLE CELL PATIENTS AND THIS IS A LARGE STUDY IN 5 COUNTRIES IN SUB-SAHARAN AFRICA, THEY DID SEE THE STIFFNESS WAS IMPAIR INDEED SICKLE CELL DISEASE AND IT WAS ASSOCIATE WIDE CHRONIC VASCULAR COMPLICATIONS AND THE FUNNY THING WAS THAT INSTEAD OF THE PULSE WAVE VELOCITY BEING INCREASED THESE PATIENTS HAVE A HIGHER PULSE WAVE VELOCITY BECAUSE THEY'RE ALREADY BASAL DILATED AND THE SICKER THEY WERE THE LOWER THE PULSE WAVE VELOC ITY BUT THEY DID HAVE HIGH ER UGMENTATION INDEX SOCIET IED WITH END ORGAN COMPLICATION SIMILAR TO OTHER CARDIAC EVENTS. WELL THAT'S HA HAPPENS IN THE LARGE VESSELS CAN WE MEASURE WHAT HAPPENS IN THE SMALL VESSEL S IN THE MICROVASCULATURE, UNLESS HAVE YOU PET IMAGING OR SOMETHING THAT YOU'VE--SOMETHING LIKE THAT TO MEASURE MICROVASC ULAR FLOW, IT'S DIFFICULT TO DO WHAT WE TRY TO DO IS A SMALL STUDY IN WHICH WE USED A COMMERCIALLY AVAILABLE AGENT USING CONTRAST ENHANCEDAST- ULTRA SOUND IMAGING AND ESSENT IALLY WHAT WE SAW IS THAT MICRO VASCULATURE FLOW, AT LEAST IN THE FOREARM WAS SIMILAR TO CONTROLS. IF YOU REMEMBER THE TALK FROM EARLIER, THOUGH, ABOUT THE CEREBRAL BLOOD FLOW BEING INCREASED YOU COULD INTERPRET THIS A BIT DIFFERENTLY. IF YOU SO THE FLOW IS THE SAME AS CONTROLS THAT MIGHT NOT BE A GOOD THING BECAUSE I WOULD HAVE EXPECTED THE FLOW TO BE INCREASE INDEED THE SICKLE CELL PATIENT IN A HIGH OUTPUT CARDIAC PATIENT WE DID NOTICE THAT PEOPLE ON HYDROXURIA, DID HAVE HIGHER LEVELS SO IN A SMALL OBSERVATION AL STUDY WE WERE ABLE TO MEASURE MICROVASCULAR FLOW. ARE THESE ABNORMALITIES REVERS IBLE, SO THIS IS WORK OUT OF CHILDRENS IN LA AND THEY LOOK ED AT BRACHIAL FORUM FLOW AND PULL MONITORARY VASC LOPATHY AND FOUND WITH CHRONIC TRANS FUSIONS THERE WAS IMPROVE MENT IN THE FLOW MEDIATED DILATION. SO THIS IS ALSO FROM ONLINE BUT I'M GOING TO GO THROUGH AND TALK ABOUT A COUPLE OTHER COMPLICATIONS SO PULL MONITORARY HYPER TENSION, I THINK MOST OF YOU KNOW A LOT ABOUT. YOU NEED A HARD CATH TO MAKE THE DIAGNOSIS, HERE'S THE DEFINITION : A MEAN P. A. PRESSURE OFAST LEAST 25 OR ABOVE AND THE WORLD HEALTH ORGANIZATION HAS GROUPED IT INTO MANY DIFFERENT ETIOLOGIES. SO PULL MONITORARY GROUP TENSION , GROUP 2 IS HEART DISEASE, GROUP 3 LUNG DISEASE OR OTHER COMPLICATIONS LIKE SMOKING OR GROUP 4 FROM CHRONIC EMBOLISM AND I THINK YOU GET THE PICTURE THAT MANY OF THESE ETIOLOGIES CAN EXIST IN OUR SICKLE CELL PATIENTS. AND YOU'VE HEARD EARLIER TODAY, AND TODAY, AND LEADING CAUSE OF PULL MONITORARY PRESSURES AND A FEW PATIENTS THEY DEVELOP A PULL MONITORARY VASC LOPATHY, AT LEAST HALF OF THEM HAVE LEFT HEART DISEASE AND THAT LEADS TO PULL MONITORARY HYPER TENSION. AND AND WHAT DEFINITIONS WE USE, WE USE ECHO TO SCREEN FOR PULL MONITORARY HYPER TENSION AND YOU KNOW THAT WE USE THE TR-VELOCITY SO THIS IS A WHOLE SERIES OF STT STUDIES FROM 2004 TO A COUPLE OF YEARS AGO AND YOU CAN SEE THAT THE HAZARD RATIOS ARE HIGH IN TERMS OF PREDICTING MORTALITY BASED ON THE INCREASE WITH ELEVATED T. R. AS WE SAID PULL MONITORARY VENUS HYPER TENSION EXISTS IN MANY OF THESE PATIENTS SOPHISTICATED THEY HAVE AN ELEVATED WEDGE PRESSURE. THIS IS A QUESTION THAT'S BEEN ASKED OVER AND OVER, WHAT IS THE PREVALENCE OF I THINK WE LEARNED OVERTIME THAT IT DEPENDS WHICH PATIENTS YOU INCLUDE IN THIS TYPE OF A SCREENING AND WHAT CRITERIA, YOU USE AND WHAT TEST YOU USE, SO IF YOU USE AN ECHO AND YOU USE A T. R. CUT OFF OF 2.5, IT TELLS WHICH PATIENTS ARE HIGHER RISK, YOU MIGHT GET A THIRD OF THE POPULATION SO THESE ARE NOT PERFECTLY TO SCALE BUT HOPEFULLY CLOSE, IF YOU USE A HIGHER CUT OFF, OF 2.3, IT'S HIGHER OR SMALLER POPULATION AND IF YOU TAKE THE GENERAL DEFINITION OF PH BY RIGHT HEART CATH, IT MAY BE 10 OR 12% OF THE POPULATION. THIS IS AN IMPORTANT QUESTION: IS THIS SOMETHING THAT'S REVERS IBLE? THIS IS UNPUBLISHED WORK BUT HOPEFULLY SOON TO BE IMPRESS. THIS IS THIS IS BY COURTNEY AND JOHN THAT YOU HEARD A LOT ABOUT THIS MORNING. SO WHEN WE LOOK AT PATIENTS AS A GROUP, THE 1S THAT HAVE HAD SUCCESSFUL TRANSPLANTS IF WE LOOK AT TR VELOCITY THERE ISN'T MUCH CHANGE BEFORE AND AFTER AND WHAT WE DID IN THIS GRAPH IS WE TOOK 24 PATIENTS THAT HAD ABNORMAL T. R. MEANING OVER 2.5 TO BEGIN WITH AND THEY DID HAVE A SIGNIFICANT IMPROVEMENT IN THEIR TR VELOCITIES IN THE FIRST COUPLE OF MONTHS OUR STATISTICIAN TELLS US THAT IS JUST REGRESSION TO THE MEAN BUT I WANTED TO SHOW YOU WHAT WE SEE EARLY ON. MOVING ON TO CARDIOMYOPATHY. THIS IS SOMETHING THAT'S AN IMPORTANT PART OF SICKLE CELL PATHOPHYSIOLOGY BECAUSE IT LEADS TO A SIGNIFICANT MORTALITY IN THESE PATIENTS. IF YOU SPEAK TO CARDIOLOGYSTS WE THINK ABOUT CARDIO MY OPERATING GLOBALLYATHY AS 3 DIFFERENT TYPE S HYPER TROAPIC WHICH IS WHAT YOU HEAR ABOUT IN YOUNG ATHLETES, SUDDEN DEATH, THICK HEARTS, DILATED CARDIO MIRROR IMAGE OPERATING GLOBALLYATHY, THEY HAVE ASEEMIC HEART DISEASE- -ASCHEMIC HEART DISEASE AND LOWER REFRACTION, AND RE PSYCHIATRICKIVE CARDIOMYOPATHY , SO WHICH OF THESE DOES SICKLE CELL FIT INTO? ANY GUESSES? WELL, REALLY NONE OF THEM. THERE HAVE BEEN A FEW GROUPS THAT ARE STARTING TO CALL SICKLE CELL RESTRICTIVE. THAT'S NOT SOMETHING THAT FITS IN WELL AND I WILL TELL YOU WHY. WHAT I WANT TO DO IS PROPOSE A TERM CALLED A REILLOGGIC CARDIOMYOPATHY BECAUSE THAT DESCRIBES SICKLE CELL DISEASE A BIT BETTER, WE SIGH DILATION OF ALL CARDIAC CHAMBERS, WE DO SEE LEFT VENTRICULAR HYPER TROPHY AND WE SEE HYPER FLOW ABNORMALITIES AND I'M GOING TO SKIP OVER SOME OF THE PATHO PHYSIOLOGY WE TALKED ABOUT IT, AND START WITH THE EJECTION FRACTION FIRST OF ALL. WE KNOW THAT SIS TOLL-LIKE RECEPTORIC FUNCTION IS PRESERVED , IT'S NORMAL IN MOST OF OUR PATIENTS AND EVEN USING MORE FANCY MEASURES OF SUB CLINICAL DYSFUNCTION OR CONTRACTTILITY, WE KNOW MOST OF THE TIME OUR PATIENTS HAVE PRE SERVED MY O CARDIAL CONTRACT TILITY. THEY DO GET DIASTOOL DNAIC FUNCTION AND THIS YOU HEARD ABOUT A LOT, IT'S INDEPENDENT PREDICTOR OF MORTALITY AND IT'S BEEN SEEN IN BOTH CHILDREN AND ADULTS AND IT'S A MARKER OF A HIGH RISK PATIENT. THE DIFFICULT PART THOUGH IS HOW TO DEFINE THE DIASTOOL DNAIC FUNCTION AND FOR EVERY STUDY, THERE'S PROBABLY A DIFFERENT DEFINITION. THE AMERICAN SOCIETY OF ECOCAME OUT WITH GUIDELINES 2 YEARS AGO FOR PATIENTS WITH NORMAL EJECTION FRACTION, HOW DO YOU MAKE THE DIAGNOSIS OF DIASTOOL DNAIC FUNCTION AND IF YOU LOOK AT THE BOX HERE, THESE ARE THE 4 VARMIS VARIABLES WE USE THE ONLY PROBLEM IS IF YOU GO THROUGH EACH OF THESE, THE E-PRIME, WE USE IT BECAUSE IN A GENERAL POP ULATION IF THAT RATIO IS OVER 15, IT'S ASSOCIATED WITH A HIGH WEDGE PRESSURE OF OVER 15. BUT THAT'S NOT VALIDATED IN SICK LE CELL PATIENTS WITH THE HIGH CARDIAC OUTPUT SO THAT DOESN'T REALLY WORK. NUMBER 2 IS A MEASURE OF TISSUE MY O CARDIAL RELAX AITIONZ, THAT MAY BE A GOOD MEASURE OF DIA STOOL DNAIC FUNCTION. T. R. VELOCITY AS WE TALKED ABOUT CAN HAVE MANY DIFFERENT ETIOLOGIES IN SICKLE CELL PATIENTS AND LEFT ATRIOLE VOLUME INDEX WHICH IS A MEASURE OF HOW BIG THE LEFT ATRIUM IS, AND IN MANY OTHER POPULATIONS IT'S A GOOD MARKER OF DIASTOOL DNAIC DYSFUNCTION. IN SICKLE CELL ALL THE CHAMBERS ARE DILATED SO THAT'S NOT THE BEST MEASURE, SO AT LEAST 3 OUT OF THE 4 MUST BE MEASURES RECOMMENDED FOR EVALUATION OF THIS DON'T REALLY WORK IN SICKLE CELL DISEASE. WELL CAN ANY OF THE FINDINGS THAT WE'VE TALKED ABOUT BE RE VERSED AND AGAIN THIS IS DATA AND THE POPULATION HERE THAT UNDERWENT TRANSPLANT THIS IS 44 PATIENTS, AND WE'RE MEASURING LEFT VENTRICULAR AND DIASTOOL DNAIC INDEX SO BASICALLY DILATION OF THE LEFT VENTRICLE. YOU CAN SEE SIGNIFICANT IMPROVE MENT AND IT HAPPENS WITHIN THE FIRST COUPLE OF MONTH S AFTER THE TRANSPLANT. WELL THAT'S THE STRUCTURAL CHANGE. WHAT HAPPENS AT THE MICROVASC ULAR LEVEL. ONE THING WE NOTED AND THIS IS THE SAME STUDY THAT I MENTIONED EARLIER, IS IF WE CAN MEASURE MY O CARDIAL MICROVASCULAR FLOW USING THE SAME ULTRA SOUND TECHNIQUE THAT WE USE INDEED SKEL TOLL-LIKE RECEPTOR MUSCLE, WE FIND NATHE FLOW IS LOWER IN CONTROLS, LOW IN SICKLE CELL COMPARED TO CONTROLS BUT PATIENT S THAT ARE ON HYDROXURIA, THE LEVELS ARE HIGHER SO MAYBE THIS' SOME IMPROVEMENT IN MICRO VASCULAR FLOW WITH THE HYDROXURIA. USING ANOTHER TYPE OF MODALITY TO TEST MICROVASCULAR FLOW, IF WE LOOK AT STRESS NRI PROFUSION, THIS IS WORK OUT OF CHICAGO WHERE THEY MEASURED MY O CARDIAL PROFUSION RESERVE INDEX SO THAT 'S BASICALLY BLOOD FLOW WITH STRESS DIVIDED BY BLOOD FLOW AT REST AND THEY FOUND IT WAS MUCH LOWER IN SICKLE CELL COMPARED TO CONTROLS SUGGESTING AGAIN THAT THE MICROVASCULAR DYSFUNCTION IS A PROBLEM THIS IS TO SHOW YOU JUST AN EXAMPLE OF WHAT CARDIO MIRROR IMAGE OPERATING GLOBALLY ATHY LOOKS LIKE IN SICK LE CELL PATIENTS AND I'M SURE ALL OF THE CLINICAL PEOPLE KNOW THAT THEY GENERALLY DON'T SEE CORINARY BLOCKAGES IN THEIR SICKLE CELL PATIENTS BUT WHAT WE DO SEE IS THICK HEARTS, YOU CAN SEE REGIONAL RAW MOTION ABNORMALITIES IT'S A BITE OUT OF THE BASAL SEPTUM THERE, THERE'S THICKENING, BRIGHTNESS AND SOME HYPOKINESIS HERE, A FLATTENED SEPTUM AND IMPOSSIBLE TO BUILD RALATERAL HYPOKENESIS, THOSE ARE ALL AREAS WHERE THERE'S PROBABLY REGIONAL FIBROSIS AND PROBABLY AREAS OF INFARCTION. THIS PATIENT HAD SEVERE RENAL FAIL AND YOU ARE COULDN'T UNDER GO MRI. BUT I'LL SHOW YOU WHAT WE LOOK FOR IN THE MRI SCANS. THE CONTENT IS GENERALLY NORMAL, THIS WAS WELL COVERED YESTERDAY SO I WILL KEEP MOVING. ONE THING WE KNOW FROM THE CHICAGO GROUP THAT DID A STUDY MY MRI SCANS WITH LATE GAB LYNN IUM HYPER ENHANCEMENT AND THAT WE CAN SEE THIS IN THE SICK LE PATIENTS AND THAT LOOKS LIKE THIS--THIS IS THE MYOCARDIUM IN BLACK. GATTA LYNNIUM IS SEEN IN THE WHITE SPOTS SHOWN BY THE ARROWS AND IN THIS POPULATION OF 38 ADULTS THAT I SAW GATTA LYNNIUM ENHANCEMENT IN A QUARTER OF THE PATIENTS MOSTLY THE SICKER PATIENTS BECAUSE THIS WAS A POP ULATION WITH VERY DILATED VENTRICLES AND BORDER LINE EJECTION FRACTION. O ANOTHER THING THAT'S RECEIVED INTEREST IS IF WE ARE INTERESTED IN MORE THAN FOCAL FIBROSIS, HOW CAN THAT BE MEASURED. AND MRI CAN BE USED IN TERMS OF T1 RELAXATION TIMES TO LOOK AT THE EXTRA CELLULAR VOLUME FRACTION. SO THIS IS WHAT THE T-1 MAPS LOOK LIKE. IN A NORMAL HEALTHY CONTROL. THE BLUE IS THE LEFT VENTRICLE, THIS IS SOMEONE WITH SOME LEFT VENTRICULAR MYOPATHY AND THIS IS SOMEONE WITH AN INN FARCTION AND SOMEONE WITH AN AMYLOID, CAN YOU SEE THE CHANGES IN THE CELLULAR FRACTIONS INDICATED BY THE MAPS AND YOU THE LEVEL FIST YOU HAVE EXTRA CELLULAR VOLUME FRACTION, THE DIFFUSE FIBROSIS IS HIGHER THAN NORMAL IN BETWEEN FOCAL FIBROSIS AND INFARCTION AND THE HIGHEST BEING SOMETHING LIKE AMYLOID, THAT'S JUST BACKGROUND TO SHOW YOU WHAT HAS BEEN MEASURED IN SICKLE CELL PATIENTS THIS WAS A NICE STUDY OUT OF SIN SEN ILLEGALSEN ATY WHERE THEY LOOKED AT MRI MEASURES OF EXTRA CELLULAR VOLUME FRACTION. SO LOOKING FOR DIFFUSE MYOCARD IAL FIBROSIS AND YOU CAN SEE IN CONTROLS IN BLUE HERE AND SICKLE CELL PATIENTS EVERY PATIENT IN THIS STUDY HAD HIGH PRESSURES OF ECV INDICATING DIFFUSE MY O CARDIAL FIBROSIS, THE GREEN WAS FROM OTHER STUDIES IN THE LITERATURE, YOU CAN SEE THAT THE DIFFUSE FIBROSIS IS LESS THAN A FOCAL INFARCT AND IT WOULD BE A LOT LESS THAN IN AMYLOID PATIENT FOR EXAMPLE. SO IS SOME OF THAT REVERSIBLE? THE DIFFUSE FIBROSIS? DOES IT HAVE TO DO WITH IMPROVING THE MY O CARDIAL PHENO TYPE? THIS IS NOT A SICKLE CELL STUDY BUT SUFFICE IT TO SAY IN THIS STUDY JUST CAME OUT THIS YEAR AND PATIENTS WITH ATRIOLE FIBRILLATION THAT UNDERWENT ABLATION THERE SHOULD WAS SOME IMPROVEMENT IN THE RELAXATION TIMES WITH INTERVENTION. SO MOVING ON TO DISRYTH METRICSA S THIS IS A BIG PROBLEM IN SICKLE CELL PATIENTS WE REAL LY DONE KNOW WHY MANY OF THEM HAVE SUDDEN DEATH. I SUSPECT IT MAY BE BRADY ARITH MIRROR IMAGIAS, OR ATTACK A REEGHT MIRROR IMAGIAS, WE KNOW IN OTHER POPULATIONS QTC PROLONG ATION IS LINKED TO SUDDEN DEATH AND VENTRICULAR ARITH MIRROR IMAGIAS, SO THIS IS A STUDY IN THE CHICAGO COHORT WHY THEY FOUND LONG QT IN THEIR GROUP OF SICKLE CELL PATIENTS AND THEY DID FIND AN INCREASED HAZARD RATIO FOR MORTALITY ALTHOUGH THE SIGNIFICANCE WAS BORDER LINE AND AGAIN NOT SURPRISINGLY WHAT THEY NOTICED T LEVELS AND SOME PATIENTS HAD HIGHER QTC, PROBABLY INTERACTION S WITH MEDICATION AND SOME ASSOCIATION WITH MARKERS OF HOM OLDER PEOPLE SIS AND INTERESTINGLY THERE WAS NO CORRELATION AFTER ADJUSTMENT FOR TRB. SO IN THE LAST COUPLE MINUTES I WANT TO TALK ABOUT MACHINE LEARN ING. SWEE LAY TALKED TO YOU ABOUT THE PHENOTYPIC HETEROGENEITY AND SOME OF THE REASONS FOR IT. WHY IS IT IMPORTANT TO LOOK AT THE HETEROGENEITY OF THE PHENO TYPE. WELL WE MAY NEED TO DECIDE WHAT PATIENTS NEED MORE FREQUENT SCREENING. WE MAY WANT TO INTENSIFY MEDICAL THERAPY IN CERTAIN PATIENTS, THIS MAY BE HELPFUL IN DETERMIN ING TIMING OF INTER VENTIONS AND MOST IMPORTANT LY, MAYBE THE SELECTION OF CANDIDATES FOR A CHANCE, MAYBE BASED ON SOMETHING LIKE THIS. ONE THING WE'VE LEARNED FROM LOOKING AT CARDIAC PHENOTYPES AND OTHER DISEASES IS THAT WE'RE INTERESTED IN SUBTYPES WITHIN THE DISEASE THAT MAY BE ETIOLOGICALLY SIMILAR OR PROGNOSTICLY DIFFERENT BECAUSE THAT MAY HELP US LOOK AT DIFFERENT TARGETED TREATMENTS AND CLINICAL TRIALS FOR THOSE SPECIFIC PHENOGROUPS. THIS WAS AN EDITORIAL FOR A MOUSE STUDY IN SICKLE CELL DISEASE SAYING THAT THE HEART AND SICKLE CELL DISEASE MAY BE A MODEL FOR HEART FAILURE WITH RE SERVED CERTAINLY--CERTAINLY JEKS FRACTION, NOW CO SINCE DENT ALLY I DO SPEND SOME TIME WITH OUR HEART FAILURE GROUP AND EXTRA MURAL AND WE THINK ABOUT A LOT ABOUT FF HORMONE HEART FAIL WUR PRESERVED EJECTION FRACTION. SO WE HAVE SIMILARITIES BETWEEN THE CARDIAC PHENOTYPING AND THESE 2 DISEASES, AND SO WHAT I'M GOING TO DO IS TURN THIS A ROUND AND TELL YOU ABOUT THE WORK THAT'S BEEN DONE AND USING MACHINE LEARNING AND WHAT WE'VE LEARNED BECAUSE WE HOPE TO AMRI THAT TO THE SICKLE CELL POP ULATION THIS WAS VERY NICE WORK OUT OF CHICAGO. SANJEEV, SHAW HAS DONE A LOT OF WORK ON SICKLE SEPROJECTION FRACTION. AND IN THIS FIRST STUDY HE TOOK HIS WHOLE HALF PATH CLINIC SO 400-SOMETHING PATIENTS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION AND WHAT HE DID IS YOU PROBABLY CAN'T READ ALL THIS BUT HE TOOK MANY DIFFERENT PHENOTYPING VARIABLES FROM HIS ECHOES. HE TOOK LAB VARIABLES AND SOME DEMOGRAPHIC VARIABLES AND PUT EACH OF THEM ALONG THE ROSE HERE , EACH OF THESE COLUMNS REPRESENTS A PATIENT AND THEN REPRESENTED VISUALLY AS THE HEAT MAP IN WHICH THE VARIABLES THAT ALIGNED CLOSELY WITH OTHERS WERE GROUPED TOGETHER, BOTH IN TERMS OF THE ROWS AND THE COMUMKCS SO WHAT THE COLORS MEAN HERE IS THAT THE RED INDICATES WHICH VARIABLES GROUP TOGETHER NICELY AND THE BLUE INDICATES THERE WAS N'T AS MUCH SIMILARITY BETWEEN THE DIFFERENT VARIABLES. SO WHAT THIS IS SUPPOSED TO SHOW YOU IS WHETHER THERE ARE ANY PATTERNS OR CLUSTERS WITHIN ALL THESE PATIENTS LOOKING AT AT ALL OF THESE DIFFERENT VARIABLES BECAUSE THIS IS NOT VERY EASY TO INTERPRET, THEY USE SOME COMPLICATED MODELING. THEY NEEDED SOMEONE LIKE GEORGE TO INTERPRET THIS, BUT WHAT THEY LOOKEDDA THE IS HOW MANY CLUSTER S OF USEFUL CLINICAL DATA COULD THEY FIND IN THIS HEAT MAP AND THEY CAME UP WITH 3 DIFFERENT PHENOGROUPS. SO 1 OF THEM AND THESE ARE THE ECHO IMAGES TO SHOW YOU WHAT PATIENTS IN THESE 1 GROUP HAD NORMAL BMPEXPZ YOU WILL KNOW THAT IN HEART FAILURE A HIGH BMP IS 1 OF THE DIAGNOSTIC FEATURES OF THE DISEASE, SO THERE WAS 1 GROUP THAT HAD BORDER LINE NORM AL BMP LEVELS, THERE WAS A SECOND GROUP THAT WAS MORE THE OBESE CARDIO METABOLIC PHENOTYPE AND THERE WAS A THIRD GROUP THAT HAD RIGHT VENTRICULAR FAIL AND YOU ARE SIGNIFICANT RENAL DISEASE. AND WHAT WAS MORE INTERESTING IS THAT OF THESE 3 PHENOGROUPS THEY HAD DIFFERENT MORTALITY OUTCOMES SO WHAT DID WE LEARN TRUSTEES THAT? COUPLE OF CAVEATS. FIRST OF ALL IF YOU LOOK AT THOSE PHENOGROUPS AND IF YOU WERE SOMEONE LIKE SWE, LAY OR CATHER OR ANY OF THE MASTER CLINICIANS HERE, YOU WOULDN'T LEARN MUCH FROM THIS MACHINE ALGORITHM, IT'S A DIAGNOSTIC APPROACH BUT IT CAN COMPLEMENT COMPLEMENT THE WORK BUT IF YOU HAVE PROGNOSTICLY SIMILAR SUB TYPES THEY DON'T NECESSARILY HAVE THE SAME ETIOLOGY AND MAY NOT RESPOND TO THE SAME TREATMENTS BUT THAT'S OUR HOPE IS THAT WE'RE LOOKING FOR GROUPS THAT PATTERNS THAT GO TOGETHER AND HOPEFULLY, INSTEAD OF USING A ONE-SIZE-FITS-ALL APPROACH FOR TREATING THEM, WE CAN USE SPECIFIC APPROACHES FOR DIFFERENT GROUPS. THE OTHER CAVEAT THAT I'M GOING TO MENTION HERE AT THE END HERE IS THAT MACHINE LEARNING ANALYSIS ARE GENERALLY OVERFIT FITTED TO THE DATA THAT YOU LOOK AT. SO THAT SPECIFIC ANALYSIS THAT I SHOWED YOU WORKED VERY WELL IN THAT POPULATION OF PATIENTS FROM CHICAGO BUT DEPENDING ON WHETHER WE USE IMAGING DATA ONLY, IMAGING PLUS LABS, PLUS LABS PLUS GENETIC DATA YOU MAY NOT BE ABLE TO USE THIS SAME ALGORITHMS FOR DIFFERENT DATA SETS. SO I WILL STOP THERE. THANK YOU FOR YOUR ATTENTION. I'LL TAKE QUESTIONS. ANY QUESTIONS? I HAD A QUESTION. SO WITH PROLONGED QT IT SEEMS LIKE IT'S A FAIRLY COMMON PHENOMENON. BUT, WE DON'T SEE SEEM TO KNOW EXACTLY WHY IT OCCURS. I THINK YOU KNOW, LIKE BASED ON THE JACKSON HEART STUDY WHERE THEY HAD LIKE 4000 PATIENTS FROM MISSISSIPPI THEY FOUND ENVIRONMENTAL FACTORS LIKE HYPER CO LEEMIA, CAN YOU COMMENT ON MAYBE MEDICATIONS LIKE METHADONE OR OXYCO DONE OR SOMETHING LIKE THAT AS FAR AS MAY RISK--IN CREASE THE RISK FOR PRO LONGED QT POPULATION? SO, SNE SOPHISTICATED ANALYSIS OF QT PROLONGATION HAS A LOT OF PROBLEMS WITH CONFOUNDERS AS YOU MENTIONED. MEDICATION IS A BIG 1 WITH SICK LE CELL PATIENTS BECAUSE OF THE NARCOTICS THEY RECEIVE, 1 IN WAS IN AN IN-HOSPITAL SETTING SO MAISHT PATIENTS MAY HAVE BEEN GETTING MORE MEDICATIONS INCLUDING ANTIBIOTICS AND OTHER PAIN MEDICATION THAN WHAT THEY RECEIVE AT HOME. THE OTHER ISSUE IS THAT THERE'S A LOT OF ELECTROLYTE ABNORMALITIES IN THE HOSPITAL SO THAT CAN EFFECT A LOT OF THE EKG MEASUREMENTS AND BASAL O CLUBHOUSIVE CRISIS, MANY OF THESE THINGS CAN ALSO EFFECT SOME OF THE EKG FINDINGS, SO, THERE'S NO EASY WAY TO DEAL WITH THEM. BUT I THINK IT'S JUST IMPORTANT TO DEFINE WHAT POPULATIONS AND WHETHER YOU'RE LOOKING AT REST, YOU KNOW STRESS AND WHAT THE ELECTROLYTE VARIABLES ARE WHEN THESE MEASUREMENTS ARE MADE. >> I THINK WE HAVE ANOTHER QUESTION. >> GREAT TALK. SO I THINK YOU WERE TALKING A BIT ABOUT FIBROSIS IN PATIENTS WITH SICKLE CELL DISEASE AND CARDIOVASCULAR ILLNESS SO I WAS WONDERING DO HAVE A SENSE OF THIS BEING DRIVEN BY ASCHEMIA AND WE FIND THIS HARD TO INTERPRET WITH ENTROAPINS SO IS IT DRIVEN BY INFLAMMATION OR ANY SPECULATION ABOUT THIS? >> SO, NOW I KNOW WHY PEOPLE HAVE A HARD TIME HEARING UP HERE , I THINK WHAT YOU ASKED ME IS DO WE KNOW MUCH ABOUT THE MY O CARDIAL FIBROSIS AND WHETHER IT'S DRIIVE BY ASCHEMIA, PRO FUSION, INFLAMMATION, COAGULATION? THE ANSWER IS PROBABLY ALL OF THE ABOVE. I CAN'T THINK OF A GOOD WAY TO TEASE OUT THAT ANSWER. BUT, WE--WE DO KNOW THAT THE FIBROSIS HAS HISTOLOGIC VALIDATION IF WE THINK ABOUT IN FARCTIONS AND YOU KNOW MEASURE MENTS THAT HAVE BEEN MADE IN COMPARING THE MRI FINDING WITH HISTOPATHOLOGY, THE DIFFUSE FIBROSIS IS HARDER BECAUSE THERE'S NO NORMAL AREAS TO COMPARE TO. SO ... >> OKAY, THANK YOU AGAIN. FOR A VERY THOUGHT-PROVOKING TALK. OKAY. [ APPLAUSE ] WE WILL GET STARTED FOR OUR FINAL SESSION OF THE CONFERENCE. THANKS EVERYONE FOR STAYING. I THINK THIS IS GOING TO BE A REAL EXCITING WHY--WAY TO CLOSE OUT THE CONFERENCE. SO THIS MORNING WE HEARD ABOUT DIFFERENT GENE THERAPEUTIC APPROACHES AND THEN THIS AFTERNOON WE ALSO HEARD ABOUT DIFFERENT INFLAMMATORY ABNORMALITIES IN SICKLE CELL DISEASE THAT ARE TARGETABLE, SO I THINK THIS IS A REAL NICE BACKGROUND TO OUR KIND OF FINAL TOPIC TODAY THAT WE'RE GOING TO DEBATE AND THAT'S DEBATING THIS STATEMENT THAT IN DEVELOPING THERAPIES FOR SICKLE CELL DISEASE, IT MAKES MORE SENSE TO TARGET THE ROOT CAUSE RATHER THAN ALL THE DOWN STREAM EVENTS. SO BEFORE WE GET TO OUR 2 SPEAK ERS I WANT TO SEE WHERE WE'RE STARTING FROM BY PULLING POLLING THE AUDIENCE TO SEE WHERE YOU ARE AT THIS POINT FROM THIS STATEMENT THAT IT MAKES MORE SENSE TO TARGET THE ROOT CAUSE. SO IF YOU THINK WE SHOULD TARGET THE ROOT CAUSE RIGHT NOW BEFORE YOU KIND OF HEAR OUR SPEAK ARES, RAISE YOUR HAND. YEAH. OKAY. OKAY AND CONIF YOU DISAGREE TARGET ALL THE DOWN STREAM EFFECTS SICKLE CELL. ALL RIGHT. SO, I THINK WE'VE GOT A LITTLE BIT OF A WAY TO GO IN EACH SIDE, SO WE'LL START OUT WITH THE PRO ARGUMENT. SO DR. YOGEN SAUNTHARARAJAH FROM THE CLEVELAND CLINIC WILL BE PRESENTING FIRST. >> THANK YOU SO MUCH ALL YOU PRO S. SO THESE ARE MY DISCLOSURE. WE HEARD A LOT ABOUT THIS, THE PATH OF PHYSIOLOGICAL CELLS OF IN THE DISEASE AND FOR DECADES WE KNOW IT ALL STARTS WITH THIS, SO ALL THIS PATHOPHYSIOLOGY CAN BE EFFECTED BY ENUMMERRABLE OTHER FACTORS WE HEARD FROM GENETIC FACTORS, WE HEARD FROM OTHERS ABOUT ENVIRONMENTAL FACTORS, BUT, IF I GET COLD, I DON'T GET A SICKLE CELL CRISIS, OKAY? SO THERE'S 1 GENE THAT'S BY FAR RULES THEM ALL AND THAT'S THE SICKLE CELL GENE. THIS IS NOT CANCER. IT'S NOT A DISEASE WHERE ANY OF 20,000 GENES COULD BE INVOLVED IN DRIVING THE PATHOPHYSIOLOGY IN A MEANINGFUL WAY. IT'S A SINGLE GENE DISORDER. WE EVEN KNOW WHAT HAPPENS, THE POLYMERIZATION OF THIS MOLECULE AND THEN WE HAVE ALL THIS MAYHEM IN THE SIDEWALK AND AT A MODEL CITIZEN MOLECULAR LEVEL, THERE ARE 10S OF THOUSANDS OF THINGS GOING ON, WE HEARD THAT FROM 1 OF THE SPEAKERS TO DO, THOUSANDS OF CYTOKINES AND INFLAMMATORY BIOMARKERS AND SO IF WE HIT 1, THERE'S STILL 999, I'M QUOTING JOHN TISDALE SO YOU BETTER VOTE FOR ME JOHN. AND OF COURSE ALL OF THIS EFFECT S EVERY SINGLE ORGAN IN THE BODY AS YOU SAW FROM THAT BEAUTIFUL FIGURE IN SWEE LAY'S TALK. SO IT'S OBVIOUS, OKAY? IT'S EACH IN OUR CULTURAL LAW, THE DUTCH BOY AND THE DIKE, YOU STICK THE FINGER IN THE HOLE OF THE DIEK, THIS IS THE WHOLE UP HERE SO WHAT DO WE ACTUALLY HAVE WHAT ARE WITH WE DOING TO ADDRESS THIS ROOT CAUSE OF ALL THE BADNESS THAT IS--THAT OCCURS IN OUR PATIENTS. THIS IS IT, WE HAVE 4 MAJOR EFFORTS IN DRUG DEVELOPMENT TO AN AGENT DEVELOPMENT TO ADDRESS THE ROOT CAUSE, OKAY? SO, YOU CAN COMPLAIN THAT I'M GROUPING ALL THE GENE THERAPY IN 1 CATEGORY BUT FRANKLY TO ME IT ALL SEEMS LIKE 1 CATEGORIES. AND THEN WE HAVE FREE DRUGS. SO GBD, STUFF THAT I'M INVOLVED AND INSIGHT HAS AN LSD 1 INHIBIT OR. IT'S PRETTY SAD AND WHAT ABOUT DOWN STREAM STUFF THAT'S ACTUAL LY TRYING TO MODIFY A DISEASE? SO NOT JUST SYMPTOMATIC, ACTUAL LY TRYING TO INTERDICT BASAL OCCLUSION, THERE ARE A NUMBER OF EFFORTS, MAYBE THERE'S 1 OR 2 OTHERS, NOTICE THAT A LOT OF THESE ARE INTRA VENOUS AND THEY COULD BE AN ACTUAL DELIBERATE REASON FOR THIS AND WE WILL COME TO THAT LATER, AS WE ANALYZE THE REASONS FOR--FOR THIS ACTUALLY PALTRY LANDSCAPE, OKAY, OF ACTUAL EFFORTS BY US TO DEVELOP DISEASE MODIFYING THERAPIES THAT ADDRESS PATHO PHYSIOLOGY AND NOT JUST IN TERMS. BY CONTRAST, THESE ARE EFFORTS UNDER WAY TO DEVELOP ROOT CAUSE MODIFYING THERAPIES FOR CYSTIC FIBROSIS, ALL RIGHT? THIS IS A FRACTION OF THE PATIENTS WITH SICKLE CELL DISEASE AND I'M NOT INCLUDING ALL THE DOWN STREAM--THIS IS TRULY THE ROOT CAUSE ADDRESSING APPROX MALEVENTS IN THE PATHO PHYSIOLOGY OF THE CYSTIC FIBROSIS, SO WHAT'S WRONG WITH US? THIS IS US WHO ARE DOING THIS 8 OF WHICH ONLY 4 OR ROOT CAUSE FOR DISEASE MODIFICATION. SO SOME OF YOU ARE PROBABLY THINKING WHO IS THIS SELF- RIGHTEOUS, SO AND SO? WHO CARE WHAT IS HE THINKS? WELL WHAT ABOUT THE PATIENTS? WHAT DO THE PATIENTS WANT? ALL RIGHT? SO THE FDA ACTUALLY LOOKED INTO THAT AND THESE ARE THE HIGHLIGHT S IN THE REPORT FROM THE VOICE OF THE PATIENT MEANING THE FDA CYTOCONDUCTING IN 2014 AND EXTENDED INTO 2017 AND PARTICIPANTS YOUNG AND OLD EXPRESS THEIR FEAR ABOUT DYING EARLY FROM THEIR DISEASE. IT'S ALMOST A NO BRAINER AND THEY--THEY HIGHLIGHTED THE NEED FOR TREATMENTS THAT BETTER ADDRESS THE UPSTREAM CAUSES OF SICKLING AND ANEMIA. AND THE LONG-TERM PROGRESSIVE DAMAGE OF SICKLE CELL DISEASE. ARE YOU GOING TO HANDLE LISTEN ING? SO OF COURSE THEY DON'T WANT TO DIE AND EVEN IN THE WEST, WE SEE A FEW EXAMPLES, A FEW SCATTERED EXAMPLES OF PATIENTS THAT HAVE LIVED THROUGH 80, LIVED TO 60 AND IT'S SO EXCEPTIONAL THAT IT'S WARRANTIED, PUBLICATIONS AND HIGH IMPACT JOURNALS, OKAY, AND SO THE ROUTINE IS FOR THESE- -FOR OUR PATIENTS EVEN IN AMERICA, EVEN IN WESTERN EUROPE, TO HAVE THEIR LIVES SHORTENED BY SEVERAL DECADES AND THIS IS DESPITE THE INTRODUCTION OF-- THIS DATA OBVIOUSLY IS PRE DATES HYDROXURIA ERA BUT EVEN WITH MORE RECENT ANALYSIS, THERE'S NOT BEEN A CLEAR EVIDENCE OF AN IMPACT ON HYDROX URIA, ON THIS SORT OF SURVIVAL OUTCOME FOR OUR PATIENT S SO HOW CAN WE PREVENT THESE EARLY DEATHS. SO IT'S OBVIOUS, RIGHT? THAT WE SHOULD BE ADDRESSING THE ROOT CAUSE, BUT NATURE ON TOP OF , YOU KNOW ALL OUR DECADES ALL UNDERSTANDING OF THE NATURE HAS GIIVE US THE ANSWER FOR HOW WE CAN ADDRESS ROOT CAUSE PHYSIOLOGY, AND INCREASED IN FETAL HEMOGLOBIN SO THIS IS FROM THE ASSEMBLE COHORT AND PATIENTS WITH SICKLE CELL--I MEAN NEWLY BORN SICKLE CELL THE MORTALITY INITIATES AS IT SWITCHES FROM SICKLE TO FETAL HEMOGLOBIN AND WE KNOW THIS, RIGHT? THEY--THEY DEVOTE--ONLY DEVOTE THE PROBLEMS AFTER THE SWITCH AND WE KNOW SOME OF THOSE PATIENTS THAT ARE LIVING FROM 60 S TO 80S OOTH BECAUSE THEY HAD VERY, VERY HIGH FETALEM O GLOBE IN, WE DON'T NEED TO RECAP ITULATE THE WHOLE PERSISTENCE OF HOMOGLOBEIN TO PREVENT IT, EVEN A SMALL ELEVATION CAN MAKE A BIG DIFFERENCE OR SUBSTANTIAL DIFFERENCE IN OVER ALL SURVIVAL. WE EACH KNOW THE MECHANISM, IT PREVENTS POLYMERIZATION, WE ALL KNOW ALL THIS STUFF AND WE EVEN KNOW THAT HYDROXURIA BENEFITS COME FROM THE INDUCTION OF FETAL HEMOGLOBIN, AND I'M SURE SOME OF YOU WOULD LIKE TO DEBATE THIS, HAPPY TO DEBATE IT SOME MORE. THE FOLLOW UP OF THE PATIENTS FROM THE 55ITAL TRIAL OF HYDROX URIA, AGAIN THERE WAS A SIGNIFICANT DIFFERENCE IN DEATH RATE, DEPENDING ON FEIGNAL HEMOGLOBIN LEVELS, BUT WHAT'S KEY ABOUT THIS ANALYSIS, IS THAT IT WAS UNCLEAR IF THESE FETAL HEMOGLOBIN DIFFERENCES WERE INDUCE BY HYDROXURIA, BECAUSE IT'S MORE LIKELY TO INDUCE FETAL HEMODPLOABIN IN THE PATIENT WHO IS HAVE HIGHER FETALEM O GLOBIN TO BEGIN WITH, THE TRULY DISEASE MODIFYING AGENT IS THAT IT HELPS THOSE WHO ARE DESTINED TO DO BET TER ANYWAY, EVEN WITH THIS BUILT IN ADVANTAGE IT'S BEEN UN CLEAR AND DIFFICULT TO SHOW THAT HYDROXURIA, HAS IMPROVED SURVIVAL AS SUSY HAS POINTED OUT . WHY IS THIS? WELL WHEN IT COMES TO RECAPIT ULATING THE EXPERIMENT, THE FETAL GLOBEIN INDUCTIONS ARE MOSTLY NOT SUSTAINED, SO THIS IS AGAIN DATA FROM THE PIVOTAL STUDY FROM MARTY STEINBERG AND HE DIVIDED THE PATIENTS WHO QUAR TILES ACCORDING TO THE SETTLEMENTS AND THE BOTTOM 3 QUA RTILES WERE NOT SUSTAINED FOR THE 2 YEARS OF THE PIVOTAL STUDY DURATION AND IN OTHER STUDIES THIS IS FROM DEEPER AND SHE SHOW ED THAT THE EVEN IN THE PEDIATRIC POPULATION, FOR MOST OF THESE PATIENTS THE FETAL HEMOGLOBIN INDUCTIONS WERE NOT SUSTAINED. AND SO WHY IS THAT, SO HYDROXUR IA, ONLY, YOU KNOW TRULY DISEASE MODIFYING INTERVENTION OR ATTEMPT AT IT, IT WORKS IN A VERY ROUND ABOUT WAY, AND SO ON AT THE END WE'RE TRYING TO ACHIEVE THIS, WHICH IS CHROMATIN REMODELING AND EPIGENETIC MOD IFYING--MODIFICATION OF THE FETAL HEMOGLOBIN LOCUST BUT WE'RE DOING IT IN THIS CIRCUM LOCULAR FASHION AND NASTY OFF-TARGET MECHANISMS AND EFFECT S. SO, AND THESE ARE THE ACTUAL TARGETS THAT WE ARE TRYING TO HIT. AND THAT ROUND ABOUT MECHANISM OF ACTION, INVOLVING CYTOTOXIC ITY, THAT'S NOT GOOD BECAUSE ANEMIA IS PART OF THE PATHOPHYSIOLOGY AS YOU SAW FROM THE PATHOPHYSIOLOGICAL CASCADE OOTH NOT JUST BASAL ACLIEWGZ AND 1 OF THE MAJOR PREDICTORS OF EARLY DEATH IN OUR ADULT PATIENT S IN WESTERN EUROPE AND THE UNITED STATES IS THE LOSS IN THE ABILITY TO SUSTAIN 10 FOLD, 15 FOLD RETICUE LOW SIGNIFYITOSE IS TO KEEP THE COM PATIBLE WITH LIFE, AND THAT-- THAT WAS ALSO QUITE EVIDENT IN THE A LOT OF THE DATA BASICALLY ANEMIA IS BAD AND PROGRESSIVE ANEMIA IS WORSE AND WE KNOW THIS AND WE KNOW THIS, SO IT'S NOT JUST BASAL OCCLUSION IT'S ALSO ANEMIA CONTRIBUTING TO THE TISSUE HYPOXIA AND MULTI ORGAN DAMAGE AND THE MA HEM , SO WHY DID I GO THROUGH THAT STUFF ABOUT THE ROUND ABOUT MECHANISM OF ACTION OF HYDROXUR IA, BECAUSE EVERYTHING YOU NEED TO REMEMBER ABOUT EVERY EFFORT WE ENGAGE IN WHETHER IT'S GENE THERAPY, DEVELOPING WHAT I DO, OR WHAT ANYBODY ELSE DOES, IS OF COURSE, THERE'S NO SUCH THING AS A MAGIC MEDICINE, EVERYTHING IS GOING TO HAVE SOME OFF TARGET EFFECTS AND UNINTEND ED CONSEQUENCES AND WE HAVE TO NOT JUST LOOK AT WHAT WE'RE TRYING TO ACHIEVE WITH INTERVENTION OR AGENT, WE HAVE TO LACK AT OFFTARGET EFFECTS AND THINK ABOUT HOW MUCH MOZ OFF TARGET EFFECTS INTERVENE BASIC RULES ABOUT WHAT WE'RE TRY ING TO DO. SO I WOULD ARGUE KILLING A LOT OF CELLS IS NEVER GOOD FOR LIVING CREATURE. ENTROPYS IS IN THE FABRIC OF THE COSMOS, THE WAY WE SURVIVE MINUTE TO MINUTE IS BY RE GENERATING AND REPLENISHING AND TO GIVE AGENTS THAT DESTROY, IT RUNS COUNTER TO THIS FUND AMENTAL ASPECT OF LIFE AND CREATION. SO KISPEAK LIKE THIS BECAUSE IT'S A DEBATE RIGHT? JANE? TAKE THAT. ALL RIGHT. AND [LAUGHTER] --OKAY, SO WHY, WHY IS THIS DIS CONNECT THERE? WHY IS IT THAT WE'RE SPENDING HUNDREDS OF MILLIONS OF DOLLARS ON DRUG DEVELOPMENT EFFORTS THAT ARE YOU KNOW SORT OF PERIPHERAL, ATTACKING 1 MOLECULE OUT OF A THOUSAND THAT ARE UPREGULATED AND ARE MEDIATING SOME OF THE DOWN STREAM CONSEQUENCES, OF THE ROOT CAUSE OF PHYSIOLOGY THEY ARE UNLIKELY TO REALLY MAKE A SUBSTANTIAL IMPACT ON LIFE SPAN FOR OUR PATIENTS AND HOW IS IT THAT THIS HAPPENS, THIS DIS CONNECT. HOW COME EVEN THOUGH WE KNOW SO MUCH IN SUCH EXCRUCIATING DETAIL , THE ROOT CAUSE OF THIS DISEASE WE'VE KNOWN IT FOR DECADES, WE'VE KNOWN HOW TO FIX IT YET WE HAVE 4 LOUSY EFFORTS, OKAY? TWO OF WHICH ARE SORT OF STRUG GLING, MINE, YOU KNOW LACK OF MONEY, LACK OF WHATEVER, AND INSIGHT IS A PHASE 1 A. AND OF COURSE GB T IS KIND OF ADVANCED BUT WE WILL HAVE TO SEE WHAT HAPPENS WITH THAT. AND THEN WE HAVE GENE THERAPY AND ALSO IN EARLY PHASES. WHY, WHY IS IT SO KIND OF SAD? BECAUSE THIS IS HOW DRUG DEVELOP MENT WORKS, IT'S COMPLICATED, IT GOES TO MULTIPLE STEPS AND WITH MANY DOMAINS OF EXPERTISE AND YOU NEED TO GET MONEY TO DO IT AND SO MUCH OF THAT MONEY IS DRIVEN NOT BY--OF COURSE IT PLAYS INTO IT, RIGHT? , THE IMPACT, THE POTENTIAL FOR CLINICAL IMPACT BUT MUCH MORE IT'S DRIVEN BY OUR HUMAN INFAT UATION WITH WHAT IS NEW. OKAY? WE ALL WATCH THE SAME MOVIE AGAIN AND AGAIN, WE LOOK FOR A NEW MOVIE, NEW SERIES ON NETFLIX , WE'RE OBSESSED NOVELTY TO BUT TO SUSTAIN THE EFFORT NEEDED TO DEVELOP A DRUG ALL THE WAY, SO THAT IT CAN ADDRESS ROOT CAUSE, IT TAKES PAINFUL ATTENTION TO BORING DETAILS. THEY'RE HARD TO GET FUNDED. JOHN, I LOVED YOUR TALK EARLIER, YOU LOOK AT CD11 B AND CD--CAN YOU IMAGINE PUTTING THAT STUFF IN A GRANT, YOU KNOW? YOU WON'T GET FUNDED. YOU WOULD BE THE GUY THAT HAS SOME FANCY NEW TECHNOLOGY THAT'S GOT A MACHINE AND IT'S GOT LIGHT S AND IT'S GOT MACHINE LEARNING YOU KNOW? THAT'S WHAT'S GOING TO GET FUND ED BUT TO GET ALL THE WAY, YOU NEED TO PAY ATTENTION TO PAINFUL DETAILS THAT BECOME LESS AND LESS GLAMOROUS, LESS GLAMOROUS, EPIGENETICS LESS GLAMOROUS AS THE DECADES GO BY AND PEOPLE ARE LOOKING FOR SOMETHING NEW AND THE OTHER BIG PROBLEM IS YOU GET TO THIS PART OVER HERE, YOU START TO HAVE THE INVOLVEMENT OF PEOPLE WHO DON'T REALLY UNDERSTAND THE SCIENCE OR THE PATIENTS. ALL THE UNDERSTAND IS MONEY AND HE WHO HAS GOLD RULES. THE DECISION MAKERS AS YOU GET OVER HERE HAVE NO LONGER THE GUISE TO SEE PATIENTS, IT'S NO LONGER YOU AND ME, AS WELL MEAN ING AS WE MIGHT WANT TO BE. THE GUYS WITH THE MONEY, THEY RULE, I BOW AND SCRAPE, THE GUY WITH THE MONEY THAT I'M BEGGING, YES, SIR, YES, SIR, YOU KNOW? WHATEVER. I HAVE NO CHOICE, OTHERWISE I CAN'T GET ANYWHERE. THIS IS THE PERVERSION THAT IS AT THE END AND ONCE MONEY GOES IN, THE FICTION HAS TO BE SUSTAINED EVEN IF THE RESULTS DON'T MAKE SENSE AND THERE'S OFF -TARGET EEVENGHTS WHICH ARE COUNTER TOINATE AND YOU ARE BIOLOGY, THE FICTION GETS SUSTAINED. AND TEN YOU KNOW WHO THE REAL ARBITER OF TRUTH IS IT'S NO THINK US IT'S THE FDA AND IF GET S PAST THE FDA WHEN IT COMES BA BEING TO US, AGAIN IT'S ABOUT MONEY AND WE CAN--WE CAN COME TO THAT AND IT REALLY IS, JUST 1 QUICK BEFORE I HAND IT OVER TO JANE, 1 QUICK ANECDOTE TO HIGHLIGHT THAT POINT THAT REALLY IT'S THE FDA THAT WE HAVE TO THANK FOR FOR TRUTH, NOTES NOT US, NOT THE MONEY GUYS, MEDICAID THE LARGEST EXPENSE IN MEDICARE USED TO BE ERYTH ROUGH ATOM POE ETIN UNLESS THEY FUNDED DIALYSIS AND NOW MOST DIALYSIS PATIENTS WILL RUN HEMOGLOBINS 7 AND 8 AND KRO CRATE AND NO LONG LONGER THE LARGEST EXPERIENCE. SO IT WAS REALLY DRIVEN BY DOCTORS WANTINGINGING DO THE BEST FOR THE DIALYSIS PATIENTS NOTHING SHOULD HAVE CHANGED BUT IT DIDN'T. IT CHANGED REALLY DRAMATICALLY SO I'M JUST POINTING OUT THAT WE SHOULDN'T TRUST TOO MUCH OUR OWN PROFESSIONAL ETHICS, ET CETERA, ET CETERA. IT'S A PRETTY DIRTY WORLD OUT THERE. THANK YOU VERY MUCH. [ APPLAUSE ] >> ALL RIGHT, THANK YOU VERY MUCH TO TRY TO REFUTE FIEWT YOGE N, WE HAVE DR. JANE LITTLE COMING FROM CLEVELAND BUT FROM THE UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER AND SHE WILL ARGUE THE OPPOSING VIEW, THE CON-VIEW THAT THE DOWN STREAM EVENTS ARE VERY IMPORTANT TO TARGET. >> IT MUST SOUND LIKE ALL WE DO IN CLEVELAND IS FIGHT. IT'S TRUE. SO I WOULD LIKE TO START BY FOLD ING BUT ENTIRELY, IF THE ROOT CAUSE CAN BE FIXED THIS SECOND, I'M THERE, LIKE I'M ALL FOR IT BUT UNFORTUNATELY THAT'S NOT QUITE TRUE I'LL SO SPEND THE NEXT IF YOU MINUTES SUGGESTING WHY WE NEED TO FECUS ON THESE TIRESOME DOWN STREAM EVENTS ACTUALLY IF WE WANT TO FIX THE UPTREME EVENT WE WOULD HAVE GOTTEN HOLD OF THAT PERSON 7000 YEARS AGO FOR THE 1 MUTATION THAT DRAGGED ALL OVER AFRICA AND CAUSED ALL THIS PROBLEM BUT WE CAN'T DO THAT SO OUR THIS IS WHAT I WOULD HAVE CALLED THIS TALK, I THINK YOU DO HAVE TO FOCUS ON THE ROOT CAUSE OF SICK LE CELL DISEASE BECAUSE THAT WILL GET RID OF THE DOWN STREAM CAUSES BUT IT'S NOT SUFFICIENT YET, ONCE IT'S SUFFICIENT, I THINK IT WILL HAPPEN AND WE GALLON AWAY AND WE WILL NEVER HAVE THIS DISCUSSION AGAIN. THIS IS A WORD FROM OUR SPONSOR TO REMIND YOU THAT YOU SOONT SEE A DISEASE, CANNOT CURE IT WITHOUT NEW BORN SCREENING NONE& OF THIS MATTERS ASK WHICH IS WHY , A LOT OF THIS DISCUSSION IS REALLY AND LIMITED SETTINGS WHERE IT'S NOT YET UNIVERSAL. I'M GOING TO CONTINUE WITH THAT THEME OF WHY NIEWB ORNAMENT SCREENING MATTERS BECAUSE I LOVE THESE OLD DATA THAT YOU HEARDLY KNOW UNTIL YOU GO BACK AND LOOK AT THEM. THIS WAS ELLIOTT AND COLLEAGUES FROM OUT WEST. THEY HAD A COHORT OF PATIENT WHO IS HAD NOT BEEN SCREENED SO THEY WERE DIAGNOSED LATE AND ANOTHER COHORT THAT WERE LATE BEING AFTER 3 MONTHS OF AGE AND ANOTHER COHORT THAT WERE DIAGNOSED LESS THAN 3 MONTHS OF AGE AND THE MORTALITY YOU CAN SEE IS 4 TIMES FOR CHILDREN IN THIS REALLY QUITE SMALL COHORT OF CALIFORNIA, WHO WERE DIAGNOS ED LATE BEING 3 MONTHS OLD. AND IN A BEAUTIFUL SORT OF RE MINDER OF WHAT MATTERS IS THE OTHER THINGS THAT MATTER IN SICK LE CELL DISEASE, THEY SAID IT WAS REALLY THE EDUCATION OF THE PARENTS THAT MADE THE DIFFERENCE. THESE DAYS WE CALL THEM HAPLO- IDENTICAL DONORS, THOSE DAYS THEY WERE PARENTS. AND TO TEACHING THE PARENTS TO WATCH FOR INFECTIONS AND WATCH FOR SIGNS OF ANEMIA IS HA THEY FELT MADE THE BIG DIFFERENCE WHICH I BELIEVE IS STILL TRUE IN MANY THINGS WE TROO I ON DO NOW TO MAKE OUR PATIENTS BETTER. SO DIAGNOSIS IS THE ULTIMATE IN UPSTREAM EVENTS. THE SECOND POINT I WILL MAKE IS THAT UNDERSTANDING DOWN STREAM EVENTS CAN REALLY HAVE AN IMPACT ON LIFE EXPECTANCY AND CAN CHANGE THE WAY THE DISEASE LOOKS MANY OF HAVE YOU SEEN THE CURVES BUT IT ALSO SHORTENED THE DROWN STREAM EVENTS, RIGHT? IF PEOPLE WERE DYING AT 10 YEARS OF AGE, THERE WERE THING THEY COULD BE AIR TO, VASC LOP ATY THAT CAUSED THE STROKES, INFECTIONS AND ANEMIA, THOSE WERE THE DOWN STREAM EVENTS WE WERE TALKING ABOUT AND PAIN AND SUFFERING HAVE ALWAYS BEEN PART OF THIS DISEASE. AGAIN ELLIOTT IS TO THIS PAPER, SO IT'S SORT OF AMAZING TOO, THESE PEOPLE WHO DID ALL THIS WORK 30 YEARS AGO. SHOWED THAT IF YOU IDENTIFIED NOT THE FOUNDING MUTATION, NOT THE ROOT CAUSE, AS IMPORTANT AS IT IS BUT IF YOU IDENTIFY KIDS THAT HAVE THAT AND YOU GAVE THEM SOMETHING SIMPLE LIKE BEN SILLIN IT HAD A PROFOUND ON THEIR RISK OF INFECTIONS AND THEY HADN'T LOOKED ON THE STUDY IN DOGS AGE AND ALTERNATES A YEAR THEY'RE FOLLOWING THESE KIDS AND JUST AS THEY START TO SPLIT SO DRAMATICALLY OVER KRIST YEAR BETWEEN THE KIDS THAT GOT PENICILLIN AND THOSE THAT DID NOT AND THAT'S JUST IDENTIFYING WHAT'S DOWN STREAM OF THE DIAGNOSIS. AND YOU KNOW THIS WAS--I'M GLAD RUSSELL ISN'T HERE ANYMORE BUT THIS IS WHEN THEY USED TO CALL THESE STUDIES INSTEAD OF SWITCH OR TWITCH OR STOP. IT WAS JUST A STUDY BUT THEY IDENTIFIED CHILDREN WITH SICKLE CELL DISEASE ASK HAD HIGH TCD AND THEY TRANSFUSE THEM AND AGAIN, YOU KNOW IT WAS QUITE PRO FOUND OVER 2 YEARS, THE DIFFERENCE IN THE CENTRAL NERVOUS SYSTEM OF IMPACT OF TRANSFUSING THESE KIDS, IT IS SO PROFOUND, YOU NOW IT'S SO COMMON PLACE I DON'T THINK WE FEEL IT AS MUCH. AND AGAIN, THIS IS AN OLD CHEST NUT BUT I LOVE IT. BECAUSE YOU BEGIN TO SAY, THE EXPANSION AND LIFE EXPECTANCY REALLY HAPPENS BEFORE WE IN ANY WAY ADDRESS THE ROOT CAUSE, SO HYDROXURIA, IT DOES TRY TO STOP THE POLYMER FORMATION AT THE CRUX. IT'S NOT GENE THERAPY BUT IT DOES HELP WITH THE BALMER PORM ATION WHICH IS THE ROOT CAUSE BUT EVEN BUYER THAT WHEN R OLAND SCOTT AT HOWARD PUSHED FOR THE NATIONAL SICKLE CELL ACT WHICH FORMED THE COMPREHENSIVE SICKLE CELL CENTERS WHICH REALLY PUSHED FOR UNIVERSAL SCREENING AND THEN YOU GET PENICILLIN AND TRANSFUSIONS AND THEN HIDDURIA STARTS TO SHOW BAH BEFORE YOU ADDRESS THE ROOT CAUSE PAYING CAREFUL ATTENTION TO WHAT IS S&P MAKING PEOPLE SICK COULD LECTEN THEIR LIVES. WE'RE IN THE DEVELOPING WORLD WE ARE IN THE SITUATION WHERE THERE'S NOT ENOUGH MONEY OR NOT ENOUGH INFRASTRUCTURE TO REALLY DO WIDE SPREAD NEW BORN SCREEN ING YET AND IT'S SORT OF SHOCKING TO REALIZE THAT YOU KNOW WE'RE THE U.S. WE'RE IN THAT LITTLE 2% WEDGE OF THE EN TIRE ESTIMATED WORLD POP ULATION IN 2010 OF CHILDREN BORN WITH SICKLE CELL DISEASE. AND AT THAT TIME THEY ESTIMATE THAD 90% CHILDREN WITH SICKLE CELL DISEASE STILL IN SUB-SAHARANAC 46A BECAUSE WE CAN'T ADDRESS THE ROOT KUZ OR DROWN STREAM EFFECTS THEY'RE STILL DYING UNDER 5 YEARS OLD. 50 SWRS GOOD RATE OF SURVIVAL. SO MY SEBLGD POINT IS THAT IT COULD LENGTHEN LIFE AND UNTIL WE CAN REALLY FIX THE PROBLEM IN A SIGNIFICANT WAY, CONTINUING TO TROY TO IMPROVE THE DOWN STREAM EVENTS THAT WE CAN HAVE AN IMPACT ON IS REALLY IMPORTANT. THE NEXT THING I'M GOING TO ARGUE IS THE DOWN STREAM EVENTS HAVE REALLY CHANGED AS WE'VE GOTTEN BETTER AT TREATING THE DOWN STREAM EVENTS AND CHILDREN ARE NOW GETTING OLDER, THE DOWN STREAM EVENTS ARE EVOLVING AND WE HAVE TO KEEP TRACK OF THEM, AND WE HAVE TO UNDERSTAND WHAT'S HAPPENING IN WE'RE GOING TO HELP PEOPLE SUFFER LESS FROM THIS DISEASE, BECAUSE THIS IS WHERE PEOPLE ARE LIVING RIGHT NOW AS MUCH AS WE PAY BE ASPIRATIONAL OVER WHAT WILL HAPPEN OVER THE NEXT FEW DECADES MOST PEOPLE AREN'T THERE, SO PEOPLE ARE STILL EXPERIENCING MEMORY RESPONSE BREAN DAMAGE, HOM OLDER PEOPLE SIS, NORMAL ADHESION, THROMO FEELIA, YOU'VE HEARD IT ALL, AND THIS WEEK AND PAIN, AND YOU CAN THINK OF IT IN OTHER TERMS OF DOWN STREAM EVENTS OF BRAIN DAMAGE, STROKE, CEREBRAL HEMORRHAGES, CARDIAC STUFF THAT VANDANA JUST BEAUTIFULLY DESCRIBED, HYPER TENSION, END STAGE RENAL DISEASE, CKD, LIVER DISEASE, REPRODUCTIVE RISK AND THE PAIN AND SUFFERING THAT ARE STILL MAJOR (--PROBLEMS SO DOWN STREAM EVENTS ARE NOT DOWN STREAM WITH THOSE WHO ARE LIVING WITH SICKLE CELL DISEASE RIGHT NOW. THEY'RE WHERE THEY'RE LIVING RIGHT NOW SO WE CAN'T IGNORE THEM BECAUSE THE PATIENTS CAN'T IGNORE THEM SO IF YOU WANT TO HELP PEOPLE NOW, WE HAVE TO FOCUS ON DOWN STREAM EVENTS, I'M AFRAID. THE FOURTH AT SOME POINT THAT WE REALLY AGAIN, THE DOWN STREAM EVENTS ARE CHANGING. WE HAVE A NEW POPULATION, WE HAVE THIS, YOU KNOW IN THE DEVELOPED WORLD, NOWHERE IN THE WORLD DID WE HAVE A POPULATION THAT HAD SICKLE CELL AS SEVERELY AS THEY HAD WHO ARE NOW SURVIVE AG. THEY ALL USED TO DIE BECAUSE WE DIDN'T GIVE THEM THE PENICILLIN AND WE DIDN'T TRANSFUSE THEM SO NOWEE HAVE A POPULATION THAT US ED TO DIE AND IT'S EXPANDING WHICH IS TERRIFIC AND PEOPLE ARE LIVING AND THEY'RE SURVIVING THROUGH CHILDHOOD AND SO WE HAD THIS NEW CURVE OF SURVIVAL AND SICKLE CELL DISEASE BUT WE REAL LY DON'T KNOW WHAT'S UNDER THE CURVE LIKE WHAT ARE THE PROBLEMS WHAT ARE THE PROBLEMS THAT ARE EMERGING IN THIS POP ULATION AND I WOULD CALL THEM CHRONIC ORGAN DAMAGE BUT YOU CAN ALSO CALL THEM DOWN STREAM EVENT S. SO THIS WAS THE PAPER OUT OF TENNESSEE WHERE THEY JUST LOOKED AT LUNG DISEASE, OBJECT STRUCTURALLYIVE LUNG DISEASE, ELEVATED TRB AND CKD WITH A PRETTY STRICT DEFINITION, IT WAS PRETTY BAD CKD AND THEY REPORTED ON 150 ADULTS FOLLOWED FOR 9 YEARS AND THIS IS WHAT THE ORGAN INVOLVEMENT WAS THAT WE LOOK AT EACH INDIVIDUALLY AND IF YOU LOOKED AT PEOPLE WHO HAD COMBIN ATIONS OF YOU KNOW CKD PLUS LUNG DISEASE OR CKD PLUS HEART DISEASE, YOU COULD SEE THAT THE MORTALITY GOES UP AND 4.7% OF THE POPULATION HAD 3 OTHER ORGANS INSOLVED, 21% HAD 2 ORGANS INVOLVED AND THEY HAD TWEBT% IN THEIR MORTALITY AND MEDIAN AGE WAS 25 YEARS SO THAT 'S PRETTY SIGNIFICANT MORTAL ITY FOR A YOUNG GROUP OF PATIENTS. AND ALSO THE CLINICAL SYMPTOMS HAVE SHIFTED AND WE RECOGNIZE THAT THEIR SIM TOMS OR DOWN STREAM EVENTS ARE QUITE DIFFERENT FROM CHILDRENS, RIGHT? LIKE CHILDREN DON'T HAVE MUCH CHRONIC PAIN, ADULT VS A LOT OF IT, AND IN THIS RECENT STUDY THAT WE DID WITH SOFY [INDISCERNIBLE] SHE HAD A BIG MULTICENTERRED STUDY OUT OF BALTIMORE THAT INCLUDED CLEVELAND AND INCLUDED A SITE IN WISCONSIN AND A SITE IN LOUISIANA OVER 2/3RDS OF PATIENT S REPORT CHRONIC PAIN IN THAT PROSPECTIVE STUDY. AND THE THREATS HAVE SHIFTED SO IF YOU DON'T UNDERSTAND WHAT'S HAPPENING DOWN STREAM OF THE POLYMERIZATION IN THE NEW POP ULATION THAT EMERGING THEN YOU DON'T UNDERSTAND WHAT PROBLEMS PEOPLE ARE FATES--FAC ING, INFECTION USED TO BE THE WHAT PEOPLE WERE FACING ABOUT YOU NOW IT'S ORGAN DAMAGE THAT'S THE BIGGEST PROBLEM FOR PATIENTS THIS IS SS PATIENTS AND THE BLUE IS HYPER RESPONDISM AND YOU DON'T SEE THAT IN ADULTS WITH SS, YOU SEE IT IN VARIANT SICKLE CELL BUT NOT THOSE ADULTS WITH HOMOZYG OUTS SS. SO THERE'S A CHANGE AS LIFE EXPECTANCY INCREASES, RIGHT? SO AS YOU GO FROM--THIS IS NOT COMPLICATED AS YOU GO FROM LIVING 10-15 YEARS TO LIVING 40- 50 YEARS THE KINDS OF PROBLEM S YOU ARE FACING ARE SHIFTING AND WE NEED TO UNDERSTAND THOSE IF WE ARE GOING TO TAKE CARE OF PEOPLE WHO ARE LIVING NOW. I REALLY LIKE THIS FIGURE FROM ENRICO AND SUE AT PITTSBURGH AND IT DESCRIBES AGAIN THE SORT OF CIRCLE OF PROBLEMS YOU CAN GET INTO WITH THE CIRC SICKLES CELL BUT WITH THE ROOT CAUSE ASK AND THEN THE INFLAMMATION, BASAL A CLIEWGZ, THE ENDOTHELIAL FUNCTION WHICH WE TALKED ABOUT TODAY AND THESE DOWN STREAM EVENTS WHICH I WOULD CONSIDER THESE DOWN STREAM EVENTS REALLY DO GUIDE EMERGING THERAPIES THAT WILL MAKE PEOPLE'S LIVES BETTER. IT WILL NOT BE A HOME BUN BUT SOMETIMES YOU DON'T GET A HOME RUN. SOMETIMES YOU HAVE TO GO BASE BY BASE, AS WE WILL SEE THIS EVEN ING. YOU CAN'T JUST ALWAYS HIT IT OUT OF THE PARK AND FOR PEOPLE, THAT MAKES A DIFFERENCE, RIGHT? IF YOU ARE FEELING BETTER, EVEN IF YOU CAN'T FIX EVERYTHING, THAT'S REALLY AN IMPORTANT THING FOR THE PATIENT'S LIVES. SO IDENTIFYING AND TREATING DOWN STREAM EVENTS CHANGE DISEASE PHENOTYPE AND CAN IMPROVE SYMPTOMS, CAN ALLOW YOU TO TARGET SYMPTOMS SPECIFICALLY SO I THINK THAT'S REALLY IMPORTANT AND THEN MY LAST 2-POINTS REALLY ARE THAT I THINK CURE IS VITALLY IMPORTANT AND I THINK IT WILL BE TRICKY. DOESN'T MEAN WE DON'T FOCUS ON IT BUT I THINK IT WILL TAKE LONG ENOUGH THAT WE NEED TO KEEP OUR EYE ALSO ON THE DOWN STREAM EVENTS. CML, EVERYONE WITH THE TKI INHIBITORS HAVE BEEN FANTASTIC, BUT IT'S NOT A CURE, BUT THE DOWN STREAM EVENTS WHICH AREN'T THAT SIGNIFICANT. THEY ARE MORE FROM THE MEDICINE THAN FROM THE DISEASE AND IN RE SOURCE LIMITED SETTINGS IT'S STILL NOT IDENTIFIED AND TREATED HIV AGAIN, THE MANAGEMENT HAS BEEN REVOLUTIONIZED BUT IT'S FOCUS ON THE A CURE, IT'S STILL BEING TRANSMITTED AND THE DOWN STREAM EVENTS HAVE SHIFTED LIKE IN SICKLE TO CHRONIC MASCULINIZED CUE LOPATHY AND YOU CAN SEE THE PHENOTYPE IS SHIFT ING AS YOU TREAT THE APPROXIMATE DOWN STREAM EVENTS YOU HAVEN'T CURED HIV BUT YOU'VE MANAGED IT, YOU GET NEW DOWN STREAM EVENTS. THERE'S BEEN A LOT OF EFFORT PUT THERE BUT IT'S NOT--IT'S NOT YTS COMPLETED. THE MOST INTERESTING 1 WHEN YOU THINK ABOUT CURE AND HOW TO CURE THINGS AND WHAT IT MEANS TO CURE THINGS IS STREP RIGHT, SO IF YOU IDENTIFY STREP AND YOU TREAT IT IN THE U.S., THERE'S ALMOST NO 1 WHO HAS POST STREP NECK ROP ALGT Y, THERE'S IT'S THE ULTIMATE IN ROOT CAUSE AND AGAIN ALMOST NO 1 IN THE U.S. HAS RHEUMATIC FEVER OR CARD O MYOPATHY FROM STREP. BUT AREAS OF RURAL INDIA, A THOUSAND PEOPLE OUT OF A THOUSAND THOUSAND HAVE BEEN EST MADED TO HAVE POST TREPT O COCKAL GLUE MARRIAL CARDIOMYOPATHY AND THE POST STREP GM IS STILL PREVALENT IN SOME PARTS OF THE WORLD SO EVEN THOUGH WE KNOW HOW TO KILL STREPT O CALKAL BACTERIA THERE ARE DOWN STREAM SEEVENTS THAT MATTER BECAUSE THE CURE ISN'T HIGHLY PENETRANT. YOU MAY BE ABLE TO CURE IT IN 1 SPOT BUT IF YOU DON'T CURE IT A ROUND THE WORLD. YOU CAN'T CALL IT A COMPLETE CURE. SO I THINK I WILL GO THROW THIS QUICKLY THAT--ARGUING THAT PROBABLY 30% OR MORE IS WHAT WE'LL NEED. IT SOUNDS LIKE A IF WE'RE LUCKY WE'LL GET THAT, SECOND, TAKING MEDICATIONS FOR PROLONGED PERIOD S IS DIFFICULT. SO, ORAL MEDICATIONS ARE GOING TO BE A CHALLENGE IN THE SAME WAY THAT HIDURIA IS A CHALLENGE. THIS IS A STUDY FROM GENE HENKIN S WHERE THEY FAMILIAR UP THE 28 BABIES WHO WENT INTO HU- SOFT AND ONLY 8 OF THEM AND THE KIDS DROPPED OUT--NEED FOR ALTASD MATE DONORS AND FRAGILE GRAPHS AND GENE THERAPY WILL GET AROUND THAT BUT AS WE HEARD WE'RE NOT QUITE READY FOR PRIME TIME YET EITHER. THEY'RE GETTING THERE WHICH IS VERY EXCITING AND MOST PEOPLE WITH SCD ARE IN A RESOURCE LIMITED SETTING WHICH I SHOWED YOU THAT BEFORE. AND I'VE SHOWED YOU ALL THESE PYRAMIDS ALL THE WAY THROUGH LIKE THE ROOT CAUSE AND DOWN STREAM EFFECTS BUT IF YOU THINK ABOUT IT,--IF YOU THINK ABOUT IT IT'S NOT REALLY A TRIANGLE IT'S REALLY A PYRAMID WITH 15- 20 MILLION PEOPLE WORLD WIDE, POSSIBLY ESTIMATED TO HAVE SICK LE CELL DISEASE AND WE HAVEN'T EACH TOUCHED ON HOW TO DEAL WITH VARIANT DISEASE HONEST LY, I DON'T KNOW WHAT THESE GENE THERAPY--WHAT GENE THERAPY WILL DO FOR VARIANT DISEASE, IT'S NOT AS LIFE THREAT ENING BUT IT HAS A LOT OF DOWN STREAM EFFECTS THAT ARE VERY SIGNIFICANT CANT FOR PEOPLE WHO HAVE THOSE DISEASES. AND WE ALREADY ARE SEEING A LOT OF COMPLICATIONS IN THE DEVELOP ED WORLD. AS SOME SIDE EFFECTS ARE BEING MANAGED, YOU ARE HAVING A YOUNG WOMEN IMETTING PREGNANT AND THERE'S MORE INFORMATION ABOUT HOW COMPLICATED THOSE PREGNANCIES CAN BE AND LAST WEEK AT THE FDA ASH PANEL, THEY ESTIMATED 7500 CHILDREN IN SSIN NIGORIA HAVE A STROKE EVERY YEAR , SO THERE'S STILL A LOT OF- -OR DAMAGE GOING ON AROUND THE WORLD THAT YOU KNOW IT'S HARD TO SEE HOW WE'LL ADDRESS THAT IN THE NEXT 2-3 DECADES AND IF YOU THINK ABOUT HOW TO SURVIVE ON A DESERT ISLAND WITH NO HELP IN SIGHT, THERE'S A WICK PEDIA WEBSITE AND HOW TO SURVIVE ON A DESERT ISLAND, SOME CROWDFUNDING THING, I DON'T UNDERSTAND IT, BUT IT LISTS ALL THESE VARIOUS THINGS ALL THESE VARIOUS ANIMALS AND WHERE TO GET WATER AND SO FORTH. AND SO IN MY LITTLE YOU'RE STRANDED, YOU'VE GOT ISOLATION HUNGER IN THE THIRSTED, EXPOSURE , VULNERABILITY, DOWN STREAM EVENTS SOPHISTICATED WHAT DO YOU DO WHILE YOU WAIT FOR RESCUE, RIGHT? LIKE THAT'S ADDRESSING THE ROOT CAUSE, WHEN YOU STOP SKINNING THE AGUDI, WHICH IS A TROPICAL RODENT THAT THEY SHOW YOU HOW TO SKIN, WHEN DO YOU STOP DOING THINGS TO MANAGE DOWN STREAM EVENTS IS IT HERE WHEN YOU SEE A BOAT ON THE--WAY ON THE HORIZON OR IS IT HERE WHEN THEY'RE ACTUALLY THERE AND THEY'RE COM ING TO PICK YOU UP, OR IS IT POSSIBLE THAT IT WILL BE, YOU KNOW MAYBE RISKY, EXPENSIVE AND MAYBE NOT EVERYONE CAN FIT ON THE BOAT, LIKE WHAT DO YOU DO THEN. SO I THINK IN THE MEAN TIME WE'RE SORT OF STUCK WITH THESE EVENTS AND I THINK FOR US NOT TO PAY ATTENTION TO THEM AT LOS ANGELESA ROOT CAUSE, IT MEAN S WE'RE NOT PAYING ATTENTION TOTS DISEASE SO, YOU KNOW CURING DISEASE AND INDIVIDUAL IS REALLY IMPORTANT BUT CURING DISEASE IN A POPULATION WILL BE A MIRACLE AND IT'S A HIGHLY DESIRABLE MIRAKAAC WILL BUT IT WILL TAKE A LOT OF WORK AND SO I WOULD SAY, UNTIL WE HAVE SO UNTIL WIEW A WAY TO CURE THE POPULATION, AND HE SAID EVERYONE PUT YOUR PADDLE IN THE WATER AND ROW, IF YOU STUDY MEMBRANES, DO IT, IF WHAT YOU LOVE IS HEMOGLOBIN F YOGEN SAUNTHARARAJAHIN DO IT, IF YOU WANT TO DO TRAN PLANT, DO IT , IF YOUR AREA OF EXPERTISE WILL HELP SOMEBODY WITH SICKLE CELL DISEASE, YOU BETTER DO IT JUST PUT YOUR PADDLE IN THE WATER AND ROW. SO THAT'S WHAT I HAVE TO SAY. [ APPLAUSE ] >> ALL RIGHT, THANK YOU VERY MUCH. TOAZ WERE 2 EXCELLENT PRESENT ATIONS TO INTRODUCE THIS TOPIC NOW TO CONTINUE THE HEALTH Y DEBATE, I WILL LET EACH OF OF THE SPEAKERS SPEAK FOR A MINUTE TO. >> I WOULD LIKE TO AND--FRAMING MY ARGUMENT AND ACTUALLY, YOU KNOW I'M JUST SAYING WE SHOULD ADDRESS THE ROOT CAUSE WITH THE CURRENT SPAN OF HUNDREDS OF SITUATIONS, AND THE RESOURCES BECAUSE TO SOME EXTENT IT IS NOT THAT WE ALL GET TO ROLE, IT'S ONLY SOME OF US THAT GET HANDED A PADDLE, RIGHT? BECAUSE THERE'S ONLY SO MANY SOURCES OF FUNDING AND INSTEAD OF SPENDING A HUNDRED MILLION DOLLARS INHIBITING 1 MOLECULE OUTED OF A THOUSAND MEDIATING INFLAMMATION, WHY DON'T WE SPEND A HUNDRED MILLION DOLLARS ON DEVELOPING DRUGS TO ADDRESS THE ROOT CAUSE PATHOPHYSIOLOGY. ALL STATED IN THE FRIEND LIAISON NEST SPIRIT OF DEBATE. >> I'D LIKE TO PUT A MATCH TO THAT AND SAY THAT I THINK C-MAIL IS A GOOD MODEL FOR THIS BECAUSE I WAS A MINNESOTA WHEN BEFORE TK Is WERE WIDELY ADOPTED AND THERE WAS A LOT OF RESEARCH ABOUT HOW PLATELETS ACTED IN CML AND HOW WHITE CELLS ACTED IN CML AND YOU KNOW ALL THAT WAS BUBBL ING UP IN AN ATTEMPT TO HELP PEOPLE GET BETTER AND THEN WHEN THE TKIs CAME IN THAT ALL WENT AWAY SO I DON'T THINK WE HAVE TO REGULATE THAT, I THINK WHEN THE CURE COMES, IT WILL GO AWAY. BUT IN THE MEAN TIME WE ARE SEE ING PATIENTS WHO ARE SUFFER ING FOR THE DOWN STREAM EVENTS AND FOR US TO PRETEND IS NOT FAIR TO THE POPULATION AND IT DOES COME UP, LIKE FUNDING AGENCIES DO SAY TO US, WHY SHOULD WE GIVE ANYTHING TO ANYTHING OTHER THAN LIKE GENE THERAPY AND I THINK THE ANSWER IS BECAUSE PEOPLE HAVE TO LIVE DAY-TO-DAY AND WE'RE SORT OF STUCK WITH THE SIDE EFFECTS. >> I'LL ALLOW THE SPEAKERS TO ASK THE OPPOSING SPEAKER A QUESTION TO CHALLENGE THEIR THINKING. >> SO JANE, HOW DO WE HANDLE THIS FUNDAMENTAL PROBLEM THAT THERE ARE ONLY A FEW PADDLES AND A HUNDRED OF US WHO WANT TO PAD DLE? >> IT'S A GOOD QUESTION, I THINK --I DON'T THINK THERE'S A GOOD ANSWER FOR IT, I WOULD SAY THAT THE MONEY FOR SICKLE CELL DISEASE HAS REALLY INCREASED IN THE LAST DECADE, IT DOES SEEM LIKE MORE COMPANIES ARE INTEREST ED AND I AGREE IT'S CORRUPTING IN A FUNNY WAY BECAUSE IT STEERS THE BOAT 1 WAY MORE THAN THE OTHER BUT I THINK- -IT'S HARD TO IMAGINE THAT A REAL CURE IS BEING SUPPRESSED SOMEWHERE, LIKE, TRUE ADVANCE MENTS THAT WE HEARD ABOUT THIS MORNING, I THINK ARE MAKING THEIR WAY, THROUGH THE SYSTEM, AND ARE GOING TO PREDOMINATE, THE 1S THAT REALLY WORK AND DON'T MAKE PEOPLE SICK, I THINK THERE'S ENOUGH CRITICAL THINKERS AT THESE MEETINGS THAT THEY WILL HELP US TRY TO FIND THE THINGS THAT REALLY MAKE A DIFFERENCE FOR OUR PATIENTS. >> YOU GET TO IS ASK'S QUESTION. >> DO YOU THINK LEBRON SHOULD HAVE GONE TO LOS ANGELES? [LAUGHTER] >> BY THE WAY HE'S A GENIUS I DO THINK THAT THE ADVANCES THAT WERE MADE IN BOTH HIV AND CML WERE A RESULT OF FOCUS THOSE LED TO DRUGS THAT HAD THOSE TRANSFORMATIVE CAPABILITY IN OUR MANAGEMENT OF THESE 2 DISEASES AND SO, TO CONFLATE CURE WITH FOCUSING ON THE ROOT CAUSE, I THINK IS NOT QUITE FAIR BECAUSE FOCUSING ON THE ROOT CAUSE COULD SAY SO WE KNOW THERE'S CONCENTRATION IN THE RED CELL IS VERY IMPORTANT AND IF WE GET BACK TOWARDS THINKING ABOUT THAT HEMOGLOBIN S, WE MIGHT WANT COME UP WITH. >> I JUST WANT TO POINT OUT AND AND AND ADQUAITDLY SERVED BY FOR MANY, MANY AND MORE MANY NONAPOPTOTIC THE PIPELINE AND TRYING TO ADDRESS THE ROOT CAUSE ,. SO DON'T GET ME WRONG. I THINK IT'S IMPORTANT--CIPH 5 H MF-REPORTING SO WE'LL SEE WA HAPPENS. AND IN ORDER TO TREAT EVERYBODY, GENE THERAPY. THE FOCUS NOT LOOKING AT THE ROOT CAUSE OR AND PROBLEM WITH THE DOWN STREAM IS MONEY. THIS IS AN ISSUE VERY SIMPLE THAT IT'S MUCH EASIER TO LOOK WHERE THE LIGHT IS BEST, AND FOR YOUR KEYS, IT'S THE SAME STORY. PHARMACEUTICAL COMPANIES HAVE DRUGS THAT TREAT INFLAMMATION, AND HAVE DRUGS THAT TREAT AD HESION TO SICKLE CELL, IT'S A COMPLIANCE PROBLEM ANYMORE THAT YOU BRUTE UP THAT PEOPLE WILL GET THE DRUG, SO THIS IS PARTLY ABOUT WHERE MONEY IS IF THE DRUG COMPANIES ARE GOING WHERE THE MONEY IS AND IT'S NOT ORAL DRUGS TO TREAT EVERYBODY, IT'S SOMETHING ELSE AND SO, SOMEONE ELSE IS GOING TO HAVE TO FUND THE KIND OF BASIC RESEARCH WE'RE TALKING ABOUT, NHLBI IS CERTAIN LY SUPPORTED SICKLE CELL RESEARCH AND SUPPORTS 1 OF THE DRUGS SCD 101. IT'S JUST THAT KIND OF BASIC RESEARCH TO LOOK FOR DRUGS THAT INTERFERE WITH POLYMERIZATION SOME WAY IS HARDER WORK. AND THAT'S WHY YOU DON'T SEE IT BEING DONE. >> MOST DRUG COMPANIES HAVE BENEFITED FROM NIH FUNDED RESEARCH AND I THINK IT WOULD DO THEM WELL TO THINK ABOUT DOING PILOT FUNDING. YOU KNOW, I THINK THEY SHOULD GIVE SOME BACK, AND YOU KNOW THEY USED TO DO NAIN EUROPE AND I THINK THEY SPAWNED A LOT OF GOOD SCIENCE AND I THINK IT BEHOOVES THE DRUG COMPANIES TO KIND OF KICK IT UP A NOTCH HONESTLY BECAUSE THEY DO MAKE MONEY. THEY MAKE A TON OF MONEY FROM THESE PRODUCTS IF THEY GO, IF THEY DON'T GO, I MEAN THEY PUT THEMSELVES AT RISK. I UNDERSTAND THAT. I ADMIRE THEM FOR DOING IT BUT THEY SHOULD GIVE SOME BACK. I WOULD LIKE TO--I MENTIONED 1 OF MY SLIDES, I SHOWED HOW THE V OC DIRECTED AGENTS ARE INTRA VENOUS, I DON'T THINK THAT'S-- THAT'S YOU KNOW BECAUSE THEY HAD TO OR WHATEVER, IT'S A DELIBERATE REGISTRATION AND REEM BUSKERMENT STRATEGY. IT'S NOT BEING DRIVEN BY WHAT IS MOST COST EFFECTIVE, WHAT'S-- WHAT THE PATIENTS NEED THE MOST, IT'S DRIVEN BY WHAT WILL MAKE THE MOST MONEY NOT JUST FOR THE DRUG COMPANY BUT ALSO FOR THE HOSPITAL, ALSO FOR THE PHYSICIANS BECAUSE AT THE END OF THE DAY, THE ACTUAL CUSTOMER FOR ALL OF THESE DRUG DEVELOPMENT EFFORTS IS THE DOCTOR. IT'S THE KOLs AND ALL THE OTHER DOCTORS THAT ARE GOING TO LISTEN AND THESE ARE THE--WE CAN USE THE WORD CORRUPTIONS MAYBE THAT'S TOO STRONG BUT THESE ARE THE REALITIES OF HOW DRUG DEVELOPMENT OCCURS AND IS DRIVEN AND WE SHOULD BE EXPLICIT IN APPRECIATING AND ACKNOWLEDGING THESE REALITIES BECAUSE THEY DRIVE US--THEY DRIVE WHAT ACTUAL LY HAPPENS IN TERMS OF DRUG DEVELOPMENT, FURTHER AND FURTHER AWAY, FROM WHAT AND WHAT TO DO AND BECAUSE THESE ARE ACTUALLY THE MORE POWERFUL DRIVERS OF WHAT ACTUALLY GETS DONE IN TERMS OF ACTUAL DRUG DEVELOPMENT. DON'T YOU WONDER WHAT GOES ON IN CLEVELAND? >> ONE THING ABOUT DROWN STREAM THOUGH, HOWEVER, FOR DOWN STREAM , THERE IS SOME NEED FOR THAT, BECAUSE AS PATIENTS GET OLDER SOME OF THESE DRUGS THAT MIGHT EFFECT THE EARLY EVENTS, THE ROOT CAUSE THEM AS MUCH FRANKLY AND FOR THOSE THERE MAY BE STILL A NEED FOR SOME OF THESE DROWN STREAM TREATMENTS. >> ONE FINAL QUESTION? >> CALIFORNIA AND I'M A MOM, AND SOME OF YOU HAVE HEARD ME SPEAK BEFORE, ON FIFTH GENERATION OF MOTHERS IN MY FAMILY TO HAVE A CHILD WITH SICKLE CELL. AND GENETIC CAUSE, MY MOM KNEW TO HAVE US TESTED AND HIT THE JACKPOT WITH THE DAUGHTER WITH SICKLE CELL. AND WHEN YOU--WHEN YOU--WHEN YOU FIRST STARTED TALKING, I HAD BEEN THINKING BEFORE I STARTED THIS JOURNEY 3 YEARS AGO INTO ADVOCACY THAT THAT WAS REALLY KIND OF HOW I FELT, I FELT OH IT'S REALLY SIMPLE AND IF THEY COULD JUST FIX THAT 1 THING IF THEY COULD FIX THAT 1 THING IT WILL BE OKAY, BUT NOW I UNDERSTAND MORE ABOUT THE COMPLEXITY OF PEOPLE AND LIFE AND CULTURE AND NONE OF IT IS SIMPLE. RIGHT? THEY'RE GOING TO PACIFY US BUT IN THE MEAN TIME THERE ARE MILLIONS AND CHILDREN BORN AND LIVING WITH THIS DISEASE THAT ARE GOING TO NEED CURATIVE THERAPIES. AND SO, AS MUCH AS I WOULD SAY BEFORE, THAT YOU KNOW WHY OR YOU CAN MEASURE THIS OR WHATEVER, NOW I HAVE A TRUE APPRECIATION AND I ALSO THINK THAT UNLIKE ANY- OTHER TIME IN THE WORLD MEDICINE AND CURATIVE THERAPIES ARE CLOSE LY ALIGNED WITH TECHNOLOGY. CAN BE APPLIED DOWN STREAM TO USE THAT WORD FOR OTHER CON DITIONS AND I ALSO THINK THAT FOR THE FIRST TIME FOR THE FIRST TIME SCIENTISTS ARE LISTENING TO THE MOTHERS AS I HEAR YOU TALK ABOUT WHAT YOU'RE FINDINGS AND I THINK ABOUT, YOU KNOW 30 YEARS AGO WHEN I SAID, NO, MY CHILD'S HAVING DIFFERENT KIND OF PAINS, BECAUSE SHE MAKES THESE DIFFERENT SOUNDS, THEREYA A SOUND FOR EACH TYPE OF PAIN OR WHEN SHE TURNS 15 AND I SAID THERE'S SOMETHING WRONG WITH HER BRAIN AND YOU KNOW I DIDN'T EAT MEAT SO I COULD PAY FOR AN MRI BECAUSE I WAS CONVINCED THERE WAS SOMETHING WRONG WITH HER BRAIN AND TECHNOLOGY COULDN'T SEE IT THEN. BUT NOW YOU CAN. SO I THINK WHEN WE HAVE THESE DISCUSSIONS, WE NEED TO TAKE IN ACCOUNT THE WHOLE EFTHIMIOS HISTORIC CONTEXT. I STAND HERE THERE WERE MILLIONS AND MILLIONS OF MOTHERS AND CHILDREN DYING SO IN OUR CONVERSATIONS I WOULD LIKE TO KEEP OUR HUMANITY AND THE ADVANCES THAT WE HAVE, UNDERSTAND THAT SCIENCE IS DEAL ING WITH HUMANITY AND WE'RE ALL UNDERSTANDING THAT WE'RE COLLECTED. SO, THANK YOU, THANK YOU FOR LET TING ME SPEAK. >> OKAY, LET ME JUST--I THINK WE'VE HEARD A NICE DISCUSSION AND A NICE DEBATE SO I WANT TO POSE IT BACK TO THE AUDIENCE WITH THE INITIAL QUESTION AGAIN, FIRST WITH THE PRO ARGUMENT THAT IT MAKES MORE SENSE TO TARGET THE ROOT CAUSE, PLEASE RAISE YOUR HAND? AND THE OPPOSING CON, THE DOWN STREAM EVENTS ARE STILL IMPORTANT, OH? MIGHT HAVE PERSUADED SOME PEOPLE SO I THINK IT'S STILL A VERY, VERY HEATED TOPIC SO THANKS FOR THE SPEAKERS FOR ELUC DATING GOOD POINTS ON BOTH SIDES. [ APPLAUSE ] >> CAN I JUST SAY A FEW WORDS, SO THANK YOU FOR STAYING TO THE BITTER END, UNFORTUNATELY MOST OF YOU HAVE LEFT, BUT I THINK YOU WOULD AGREE WITH ME THAT YOU KNOW THIS HAS GONE VERY SEAMLESS LY AND I REALLY HAVE JESSICA AND THE TEAM TO THANK FOR MAKING SURE THAT THIS STAYS ON LIKE CLOCK WORK SO LET'S GIVE HER A BIG HAND.