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Introduction to Translational Medicine (TM) – Part 1: Translational Medicine

Author and Curator: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN 

 

This document in the Series A: Cardiovascular Diseases e-Series Volume 4: Translational and Regenerative Medicine,  is a measure of the postgenomic and proteomic advances in the laboratory to the practice of clinical medicine.  The Chapters are preceded by several videos by prominent figures in the emergence of this transformative change.  When I was a medical student, a large body of the current language and technology that has extended the practice of medicine did not exist, but a new foundation, predicated on the principles of modern medical education set forth by Abraham Flexner, was sprouting.  The highlights of this evolution were:

• Requirement for premedical education in biology, organic chemistry, physics, and genetics.
• Medical education included two years of basic science education in anatomy, physiology, pharmacology, and pathology prior to introduction into the clinical course sequence of the last two years.
• Post medical graduate education was an internship year followed by residency in pediatrics, OBGyn, internal medicine, general surgery, psychiatry, neurology, neurosurgery, pathology, radiology, and anesthesiology, emergency medicine.
• Academic teaching centers were developing subspecialty centers in ophthalmology, ENT and head and neck surgery, cardiology and cardiothoracic surgery, and hematology, hematology/oncology, and neurology.
• The expansion of postgraduate medical programs included significant postgraduate funding for programs by the National Institutes of Health, and the NIH had faculty development support in a system of peer-reviewed research grant programs in medical and allied sciences.

The period after the late 1980s saw a rapid expansion of research in genomics and drug development to treat emerging threats of infectious diseases as US had a large worldwide involvement after the end of the Vietnam War, and drug resistance was increasingly encountered (malaria, tick borne diseases, salmonellosis, pseudomonas aeruginosa, staphylococcus aureus, etc.).

Moreover, the post-millenium found a large, dwindling population of veterans who had served in WWII and Vietnam, and cardiovascular, musculoskeletal,  dementias, and cancer were now more common.  The Human Genome Project was undertaken to realign the existing knowledge of gene structure and genetic regulation with the needs for drug development, which was languishing in development failures due to unexpected toxicities.

A substantial disconnect existed between diagnostics and pharmaceutical development, which had been over-reliant on modification of known organic structures to increase potency and reduce toxicity.  This was about to change with changes in medical curricula, changes in residency programs and physicians cross-training in disciplines, and the emergence of bio-pharma, based on the emerging knowledge of the cell function, and at the same time, the medical profession was developing an evidence-base for therapeutics, and more pressure was placed on informed decision-making.

The great improvement in proteomics came from GCLC/MS-MS and is described in the video interview with Dr. Gyorgy Marko-Varga, Sweden, in video 1 of 3 (Advancing Translational Medicine).  This is a discussion that is focused on functional proteomics role in future diagnostics and therapy, involving a greater degree of accuracy in mass spectrometry (MS) than can be obtained by antibody-ligand binding, and is illustrated below, the last emphasizing the importance of information technology and predictive analytics

Thermo ScientificImmunoassays and LC–MS/MS have emerged as the two main approaches for quantifying peptides and proteins in biological samples. ELISA kits are available for quantification, but inherently lack the discriminative power to resolve isoforms and PTMs.

To address this issue we have developed and applied a mass spectrometry immunoassay–selected reaction monitoring (Thermo Scientific™ MSIA™ SRM technology) research method to quantify PCSK9 (and PTMs), a key player in the regulation of circulating low density lipoprotein cholesterol (LDL-C).

A Day in the (Future) Life of a Predictive Analytics Scientist

 

By Lars Rinnan, CEO, NextBridge   April 22, 2014

A look into a normal day in the near future, where predictive analytics is everywhere, incorporated in everything from household appliances to wearable computing devices.

During the test drive (of an automobile), the extreme acceleration makes your heart beat so fast that your personal health data sensor triggers an alarm. The health data sensor is integrated into the strap of your wrist watch. This data is transferred to your health insurance company, so you say a prayer that their data scientists are clever enough to exclude these abnormal values from your otherwise impressive health data. Based on such data, your health insurance company’s consulting unit regularly gives you advice about diet, exercise, and sleep. You have followed their advice in the past, and your performance has increased, which automatically reduced your insurance premiums. Win-win, you think to yourself, as you park the car, and decide to buy it.

In the clinical presentation at Harlan Krumholtz’ Yale Symposium, Prof. Robert Califf, Director of the Duke University Translational medicine Clinical Research Institute, defines translational medicine as effective translation of science to clinical medicine in two segments:

1. Adherence to current standards
2. Improving the enterprise by translating knowledge

He says that discrepancies between outcomes and medical science will bridge a gap in translation by traversing two parallel systems.

1. Physician-health organization
2. Personalized medicine

He emphasizes that the new basis for physician standards will be legitimized in the following:

1. Comparative effectiveness (Krumholtz)
2. Accountability

Some of these points are repeated below:

WATCH VIDEOS ON YOUTUBE

https://www.youtube.com/watch?v=JFdJRh9ZPps#t=678  Harlan Krumholtz

https://www.youtube.com/watch?v=JFdJRh9ZPps#t=678  complexity

https://www.youtube.com/watch?v=JFdJRh9ZPps#t=678  integration map

https://www.youtube.com/watch?v=JFdJRh9ZPps#t=678  progression

https://www.youtube.com/watch?v=JFdJRh9ZPps#t=678  informatics

An interesting sidebar to the scientific medical advances is the huge shift in pressure on an insurance system that has coexisted with a public system in Medicare and Medicaid, initially introduced by the health insurance industry for worker benefits (Kaiser, IBM, Rockefeller), and we are undertaking a formidable change in the ACA.

The current reality is that actuarially, the twin system that has existed was unsustainable in the long term because it is necessary to have a very large pool of the population to spread the costs, and in addition, the cost of pharmaceutical development has driven consolidation in the industry, and has relied on the successes from public and privately funded research.

https://www.youtube.com/watch?v=X6J_7PvWoMw#t=57  Corbett Report Nov 2013

(1979 ER Brown)  UCPress  Rockefeller Medicine Men

https://www.youtube.com/watch?v=X6J_7PvWoMw#t=57   Liz Fowler VP of Wellpoint (designed ACA)

I shall digress for a moment and insert a video history of DNA, that hits the high points very well, and is quite explanatory of the genomic revolution in medical science, biology, infectious disease and microbial antibiotic resistance, virology, stem cell biology, and the undeniability of evolution.

DNA History

https://www.youtube.com/watch?v=UUDzN4w8mKI&list=UUoHRSQ0ahscV14hlmPabkVQ

As I have noted above, genomics is necessary, but not sufficient.  The story began as replication of the genetic code, which accounted for variation, but the accounting for regulation of the cell and for metabolic processes was, and remains in the domain of an essential library of proteins. Moreover, the functional activity of proteins, at least but not only if they are catalytic, shows structural variants that is characterized by small differences in some amino acids that allow for separation by net charge and have an effect on protein-protein and other interactions.

Protein chemistry is so different from DNA chemistry that it is quite safe to consider that DNA in the nucleotide sequence does no more than establish the order of amino acids in proteins. On the other hand, proteins that we know so little about their function and regulation, do everything that matters including to set what and when to read something in the DNA.

Jose Eduardo de Salles Roselino

Chapters 2, 3, and 4 sequentially examine:

• The causes and etiologies of cardiovascular diseases
• The diagnosis, prognosis and risks determined by – biomarkers in serum, circulating cells, and solid tissue by contrast radiography
• Treatment of cardiovascular diseases by translation of science from bench to bedside, including interventional cardiology and surgical repair

These are systematically examined within a framework of:

• Genomics
• Proteomics
• Cardiac and Vascular Signaling
• Platelet and Endothelial Signaling
• Cell-protein interactions
• Protein-protein interactions
• Post-Translational Modifications (PTMs)
• Epigenetics
• Noncoding RNAs and regulatory considerations
• Metabolomics (the metabolome)
• Mitochondria and oxidative stress