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Archive for the ‘Population Health Management, Genetics & Pharmaceutical’ Category

Reporter: Aviva Lev-Ari, PhD, RN

Centers of Excellence in Genomic Sciences (CEGS): NHGRI to Fund New Center (CEGS) on the Brain: Mental Disorders and the Nervous System

April 16, 2013

NEW YORK (GenomeWeb News) – The National Human Genome Research Institute plans to fund new Centers of Excellence in Genomic Sciences, or CEGS, to create interdisciplinary teams that pursue innovative genome-based approaches to address biomedical problems and to understanding the basis of biological systems.

NHGRI, along with support from the National Institute of Mental Health, expects to provide up to $2 million per year for each of the new CEGS it funds, and plans to award up to four new awards each year.

Although these CEGS may pursue a wide range of research objectives, NIMH will support the program because it wants to fund research using novel genomic approaches that can accelerate the understanding of the genetic basis of mental disorders and the nervous systemNHGRI said on Friday.

The CEGS program was created to use the new knowledge and technologies that resulted from the Human Genome Project and subsequent genomics research to develop new tools, methods, and concepts that apply to human biology and disease.
CEGS grantees are expected to be innovative, to focus on a critical issue in genomic science, to use multiple investigators working under one leader, to work toward a specific outcome, and to tackle challenging aspects of problems that may have impeded previous research efforts.

Further, they are supposed to bolster the pool of professional scientists and engineers who are trained in genomics through offering educational programs, and they are expected to address the shortage of scientists from underrepresented minority communities by developing recruiting programs that encourage minority community members to become independent genomics investigators.

The technologies and methods the CEGS investigators develop should be applicable to a wide range of cell types and organisms, and they should be scalable and expandable so they may apply to other model systems, according to NHGRI’s funding opportunity announcement.

Recent CEGS centers include

  • Caltech’s Center for In Toto Genomic Analysis of Vertebrate Development;
  • Harvard University’s Center for Transcriptional Consequences of Human Genetic Variation;
  • Johns Hopkins University’s Center for the Epigenetics of Common Human Disease;
  • Stanford University’s Center for the Genomic Basis of Vertebrate Diversity;
  • Arizona State University’s Microscale Life Sciences Center;
  • Medical College of Wisconsin, Milwaukee’s Center of Excellence in Genomics Science;
  • The University of North Carolina at Chapel Hill‘s CISGen center;
  • The Broad Institute’s Center for Cell Circuits;
  • Yale University’s Center for the Analysis of Human Genome Using Integrated Technologies; and
  • Dana-Farber Cancer Institute‘s Center for Genomic Analysis of Network Perturbations in Human Disease.

 http://www.genomeweb.com/nhgri-fund-new-centers-excellence-genomic-sciences

Center for In Toto Genomic Analysis of Vertebrate Development

P50 HG004071
Marianne Bronner-Fraser
California Institute of Technology, Pasadena, Calif.

This Center of Excellence in Genomic Science (CEGS) assembles a multidisciplinary group of investigators to develop innovative technologies with the goal of imaging and mutating every developmentally important vertebrate gene. Novel “in toto imaging” tools make it possible to use a systems-based approach for analysis of gene function in developing vertebrate embryos in real time and space. These tools can digitize in vivo data in a systematic, high-throughput, and quantitative fashion. Combining in toto imaging with novel gene traps permits a means to rapidly screen for developmentally relevant expression patterns, followed by the ability to immediately mutagenize genes of interest. Initially, key technologies will be developed and tested in the zebrafish embryo due to its transparency and the ability to obtain rapid feedback. Once validated, these techniques will be applied to an amniote, the avian embryo, due to several advantages including accessibility and similarity to human embryogenesis. Finally, to monitor alterations in gene expression in normal and mutant embryos, we will develop new techniques for in situ hybridization that permit simultaneous analysis of multiple marker genes in a sensitive and potentially quantitative manner. Our goal is to combine real time analysis of gene expression on a genome-wide scale coupled with the ability to mutate genes of interest and examine global alterations in gene expression as a result of gene loss. Much of the value will come from the development of new and broadly applicable technologies. In contrast to a typical technology development grant, however, there will be experimental fruit emerging from at least two vertebrate systems (zebrafish and avian). The following aims will be pursued: Specific Aim 1: Real-time “in toto” image analysis of reporter gene expression; Specific Aim 2: Comprehensive spatiotemporal analysis of gene function of the developing vertebrate embryo using the FlipTrap approach for gene trapping; Specific Aim 3: Design of quantitative, multiplexed ‘hybridization chain reaction’ (HCR) amplifiers for in vivo imaging with active background suppression; Specific Aim 4: Data analysis and integration of data sets to produce a “digital” fish and a “digital” bird. The technologies and the resulting atlases will be made broadly available via electronic publication.

Center Web Site: California Institute of Technology Center of Excellence in Genomic Science

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Causal Transcriptional Consequences of Human Genetic Variation

P50 HG005550
George M. Church
Harvard University, Cambridge, Mass.

The Center for Transcriptional Consequences of Human Genetic Variation (CTCHGV) will develop innovative and powerful genetic engineering methods and use them to identify genetic variations that causally control gene transcription levels. Genome Wide Association Studies (GWAS) find many variations associated with disease and other phenotypes, but the variations that may actually cause these conditions are hard to identify because nearby variations in the same haplotype blocks consistently co-occur with them in human populations, so that specifically causative ones cannot be distinguished. About 95% of GWAS variations are not in gene coding regions, and many of these presumably associate with altered gene expression levels. CTCHGV will identify the variations that directly control gene expression by engineering precise combinations of changes to gene regulatory regions that break down the haplotype blocks, allowing each variations’ effect on gene expression to be discerned independently of the others. To perform this analysis, CTCHGV will extract ~100kbps gene regulatory regions from human cell samples, create precise variations in them in E. coli, and re-introduce the altered regions back into human cells, using zinc finger nucleases (ZFNs) to efficiently induce recombination. CTCHGV will target 1000 genes for this analysis (Aim 1), and will use human induced Pluripotent Stem cells (iPS) to study the effects of variations in diverse human cell types (Aim 2). To explore the effects of variations in complex human tissues, CTCHGV will develop methods of measuring gene expression at transcriptome-wide levels in many single cells, including in situ in structured tissues (Aim 3). Finally, CTCHGV will develop novel advanced technologies that integrate DNA sequencing and synthesis to construct thousands of large DNA constructs from oligonucleotides, that enable very precise targeting and highly efficient performance of ZFNs, and that enable cells to be sorted on the basis of morphology as well as fluorescence and labeling (Aim 4). CTCHGV will also develop direct oligo-mediated engineering of human cells, and create “marked allele” iPS that will enable easy ascertainment of complete exon distributions for many pairs of gene alleles in many cell types.

Center Web Site: Center for Causal Transcriptional Consequences of Human Genetic Variation (CTCHGV)

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Center for the Epigenetics of Common Human Disease

P50 HG003233
Andrew P. Feinberg
Johns Hopkins University, Baltimore
(co-funded by National Institute of Mental Health)

Epigenetics, the study of non-DNA sequence-related heredity, is at the epicenter of modern medicine because it can help to explain the relationship between an individual’s genetic background, the environment, aging, and disease. The Center for the Epigenetics of Common Human Disease was created in 2004 to begin to develop the interface between epigenetics and epidemiologic-based phenotype studies, recognizing that epigenetics requires new ways of thinking about disease. We created a highly interdisciplinary group of faculty and trainees, including molecular biologists, biostatisticians, epidemiologists, and clinical investigators. We developed novel approaches to genome-wide DNA methylation (DNAm) analysis, allele-specific expression, and new statistical epigenetic tools. Using these tools, we discovered that most variable DNAm is in neither CpG islands nor promoters, but in what we term “CpG island shores,” regions of lower CpG density up to several kb from islands, and we have found altered DNAm in these regions in cancer, depression and autism. In the renewal period, we will develop the novel field of epigenetic epidemiology, the relationship between epigenetic variation, genetic variation, environment and phenotype. We will continue to pioneer genome-wide epigenetic technology that is cost effective for large scale analysis of population-based samples, applying our knowledge from the current period to second-generation sequencing for epigenetic measurement, including DNAm and allele-specific methylation. We will continue to pioneer new statistical approaches for quantitative and binary DNAm assessment in populations, including an Epigenetic Barcode. We will develop Foundational Epigenetic Epidemiology, examining: time-dependence, heritability and environmental relationship of epigenetic marks; heritability in MZ and DZ twins; and develop an epigenetic transmission disequilibrium test. We will then pioneer Etiologic Epigenetic Epidemiology, by integrating novel genome-wide methylation scans (GWMs) with existing Genome-Wide Association Study (GWAS) and epidemiologic phenotype data, a design we term Genome-Wide Integrated Susceptibility (GWIS), focusing on bipolar disorder, aging, and autism as paradigms for epigenetic studies of family-based samples, longitudinal analyses, and parent-of-origin effects, respectively. This work will be critical to realizing the full value of previous genetic and phenotypic studies, by developing and applying molecular and statistical tools necessary to integrate DNA sequence with epigenetic and environmental causes of disease.

Center Web Site: Center of Excellence in Genomic Science at Johns Hopkins

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Genomic Basis of Vertebrate Diversity

P50 HG002568
David M. Kingsley
Stanford University, Stanford, Calif.

The long-term goal of this project is to understand the genomic mechanisms that generate phenotypic diversity in vertebrates. Rapid progress in genomics has provided nearly complete sequences for several organisms. Comparative analysis suggests many fundamental pathways and gene networks are conserved between organisms. And yet, the morphology, physiology, and behavior of different species are obviously and profoundly different. What are the mechanisms that generate these key differences? Are unique traits controlled by few or many genetic changes? What kinds of changes? Are there particular genes and mechanisms that are used repeatedly when organisms adapt to new environments? Can better understanding of these mechanisms help explain dramatic differences in disease susceptibility that also exist between groups? The Stanford CEGS will use an innovative combination of approaches in fish, mice, and humans to identify the molecular basis of major phenotypic change in natural populations of vertebrates. Specific aims include: 1) cross stickleback fish and develop a genome wide map of the chromosomes, genes, and mutations that control a broad range of new morphological, physiological, and behavioral traits in natural environments; 2) test which population genetic measures provide the most reliable “signatures of selection” surrounding genes that are known to have served as the basis of parallel adaptive change in many different natural populations around the world; 3) assemble the stickleback proto Y chromosome and test whether either sex or autosomal rearrangements play an important role in generating phenotypic diversity, or are enriched in genomic regions that control phenotypic change; 4) test whether particular genes and mechanisms are used repeatedly to control phenotypic change in many different vertebrates. Preliminary data suggests that mechanisms identified as the basis of adaptive change in natural fish populations may be broadly predictive of adaptive mechanisms across a surprisingly large range of animals, including humans. Genetic regions hypothesized to be under selection in humans will be compared to genetic regions under selection in fish. Regions predicted to play an important role in natural human variation and disease susceptibility will be modeled in mice, generating new model systems for confirming functional variants predicted from human population genetics and comparative genomics.

Center Web Site: Stanford Genome Evolution Center

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Microscale Life Sciences Center

P50 HG002360
Deirdre R. Meldrum
Arizona State University, Tempe

Increasingly, it is becoming apparent that understanding, predicting, and diagnosing disease states is confounded by the inherent heterogeneity of in situ cell populations. This variation in cell fate can be dramatic, for instance, one cell living while an adjacent cell dies. Thus, in order to understand fundamental pathways involved in disease states, it is necessary to link preexisting cell state to cell fate in the disease process at the individual cell level.

The Microscale Life Sciences Center (MLSC) at the University of Washington is focused on solving this problem, by developing cutting-edge microscale technology for high throughput genomic-level and multi-parameter single-cell analysis, and applying that technology to fundamental problems of biology and health. Our vision is to address pathways to disease states directly at the individual cell level, at increasing levels of complexity that progressively move to an in vivo understanding of disease. We propose to apply MLSC technological innovations to questions that focus on the balance between cell proliferation and cell death. The top three killers in the United States, cancer, heart disease and stroke, all involve an imbalance in this cellular decision-making process. Because of intrinsic cellular heterogeneity in the live/die decision, this fundamental cellular biology problem is an example of one for which analysis of individual cells is essential for developing the link between genomics, cell function, and disease. The specific systems to be studied are proinflammatory cell death (pyroptosis) in a mouse macrophage model, and neoplastic progression in the Barrett’s Esophagus (BE) precancerous model. In each case, diagnostic signatures for specific cell states will be determined by measuring both physiological (cell cycle, ploidy, respiration rate, membrane potential) and genomic (gene expression profiles by single-cell proteomics, qRT-PCR and transcriptomics; LOH by LATE-PCR) parameters. These will then be correlated with cell fate via the same sets of measurements after a challenge is administered, for instance, a cell death stimulus for pyroptosis or a predisposing risk factor challenge (acid reflux) for BE. Ultimately, time series will be taken to map out the pathways that underlie the live/die decision.

Finally, this information will be used as a platform to define cell-cell interactions at the single-cell level, to move information on disease pathways towards greater in vivo relevance. New technology will be developed and integrated into the existing MLSC Living Cell Analysis cassette system to support these ambitious biological goals including 1) automated systems for cell placement, off-chip device interconnects, and high throughput data analysis with user friendly interfaces; 2) new optical and electronic sensors based on a new detection platform, new dyes and nanowires; and 3) new micromodules for single-cell qRT-PCR, LATE-PCR for LOH including single-cell pyrosequencing, on-chip single-cell proteomics, and single-cell transcriptomics using barcoded nanobeads.

Collaborating InstitutionsFred Hutchison Cancer Research Center, Brandeis University, University of Washington.

Center Web Site: Microscale Life Sciences Center

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Wisconsin Center of Excellence in Genomics Science

P50 HG004952
Michael Olivier
Medical College of Wisconsin, Milwaukee

The successful completion of the human genome and model organism sequences has ushered in a new era in biological research, with attention now focused on understanding the way in which genome sequence information is expressed and controlled. The focus of this proposed Wisconsin Center of Excellence in Genomics Science is to facilitate understanding of the complex and integrated regulatory mechanisms affecting gene transcription by developing novel technology for the comprehensive characterization and quantitative analysis of proteins interacting with DNA. This new technology will help provide for a genome-wide functional interpretation of the underlying mechanisms by which gene transcriptional regulation is altered during biological processes, development, disease, and in response to physiological, pharmacological, or environmental stressors. The development of chromatin immunoprecipitation approaches has allowed identification of the specific DNA sequences bound by proteins of interest. We propose to reverse this strategy and develop an entirely novel technology that will use oligonucleotide capture to pull down DNA sequences of interest, and mass spectrometry to identify and characterize the proteins and protein complexes bound and associated with particular DNA regions. This new approach will create an invaluable tool for deciphering the critical control processes regulating an essential biological function. The proposed interdisciplinary and multi-institutional Center of Excellence in Genomics Science combines specific expertise at the Medical College of Wisconsin, the University of Wisconsin Madison, and Marquette University. Technological developments in four specific areas will be pursued to develop this new approach: (1) cross-linking of proteins to DNA and fragmentation of chromatin; (2) capture of the protein-DNA complexes in a DNA sequence-specific manner; (3) mass spectrometry analysis to identify and quantify bound proteins; and (4) informatics to develop tools enabling the global analysis of the relationship between changes in protein-DNA interactions and gene expression. The Center will use carefully selected biological systems to develop and test the technology in an integrated genome-wide analysis platform that includes efficient data management and analysis tools. As part of the Center mission, we will combine our technology development efforts with an interdisciplinary training program for students and fellows designed to train qualified scientists experienced in cutting-edge genomics technology. Data, technology, and software will be widely disseminated by multiple mechanisms including licensing and commercialization activities.

Collaborating InstitutionsUniversity of Wisconsin-Madison, Marquette University

Center Web Site: Wisconsin Center of Excellence in Genomic Science

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CISGen

P50 MH090338
Fernando Pardo-Manuel de Villena
University of North Carolina, Chapel Hill

p>In this application, we propose a highly ambitious yet realistically attainable goal: to align existing expertise at UNC-Chapel Hill into a CEGS called CISGen. The overarching purpose of CISGen is to develop as a resource and to exploit the utility of the murine Collaborative Cross (CC) mouse model of the heterogeneous human population to delineate genetic and environmental determinants of complex phenotypes drawn from psychiatry, which are among the most intractable set of problems in all of biomedicine. Psychiatric disorders present a paradox – the associated morbidity, mortality, and costs are enormous and yet, despite over a century of scientific study, there are few hard facts about the etiology of the core diseases. Although our GWAS meta- analyses are in progress, early results suggest that strong and replicable findings may be elusive. Therefore, our proposal provides a complementary approach to the study of fundamental psychiatric phenotypes.

We propose a particularly challenging definition of success – we will identify high probability etiological models (which can be realistically complex) and then prove the predictive capacity of these models by generating novel strains of mice predicted to be at very high risk for the phenotype. Once validated, these high confidence models can then be tested in subsequent human studies – we do not propose human extension studies in CISGen but this is achievable for the investigators and their colleagues. Data collected in CISGen would be a valuable resource to the wider scientific community and could be applied to a large set of biological problems and these data can rapidly add to the knowledge base for any new genomewide association study (GWAS) finding. Delivery of sophisticated and user-friendly databases are a key component of CISGen.

Accomplishing this overarching goal requires an exceptional diversity of scientific expertise – psychiatry, human genetics, mouse behavior, mouse genetics, statistical genetics, computational biology, and systems biology. Experts in these disciplines are deeply involved in CISGen and are committed to the projects described herein. Successful integration of these diverse fields is non-trivial; however, all scientists on this application have had extensive interactions over the past five years, already know how to work together, and have a working knowledge of their colleagues’ expertise. UNC-Chapel Hill has an intense commitment to inter- disciplinary genomics research and provides a fertile backdrop for 21st century projects like CISGen.

Collaborating InstitutionsThe Jackson Laboratory, North Carolina State University, University of Texas at Arlington

Center Web Site: Center for Integrated Systems Genomics at UNC (CISGen)

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Center for Cell Circuits

P50 HG006193
Aviv Regev
The Broad Institute, Inc., Cambridge, Mass.

Systematic reconstruction of genetic and molecular circuits in mammalian cells remains a significant, largescale and unsolved challenge in genomics. The urgency to address it is underscored by the sizeable number of GWAS-derived disease genes whose functions remain largely obscure, limiting our progress towards biological understanding and therapeutic intervention. Recent advances in probing and manipulating cellular circuits on a genomic scale open the way for the development of a systematic method for circuit reconstruction. Here, we propose a Center for Cell Circuits to develop the reagents, technologies, algorithms, protocols and strategies needed to reconstruct molecular circuits. Our preliminary studies chart an initial path towards a universal strategy, which we will fully implement by developing a broad and integrated experimental and computational toolkit. We will develop methods for comprehensive profiling, genetic perturbations and mesoscale monitoring of diverse circuit layers (Aim 1). In parallel, we will develop a computational framework to analyze profiles, derive provisional models, use them to determine targets for perturbation and monitoring, and evaluate, refine and validate circuits based on those experiments (Aim 2). We will develop, test and refine this strategy in the context of two distinct and complementary mammalian circuits. First, we will produce an integrated, multi-layer circuit of the transcriptional response to pathogens in dendritic cells (Aim 3) as an example of an acute environmental response. Second, we will reconstruct the circuit of chromatin factors and non-coding RNAs that control chromatin organization and gene expression in mouse embryonic stem cells (Aim 4) as an example of the circuitry underlying stable cell states. These detailed datasets and models will reveal general principles of circuit organization, provide a resource for scientists in these two important fields, and allow computational biologists to test and develop algorithms. We will broadly disseminate our tools and methods to the community, enabling researchers to dissect any cell circuit of interest at unprecedented detail. Our work will open the way for reconstructing cellular circuits in human disease and individuals, to improve the accuracy of both diagnosis and treatment.

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Analysis of Human Genome Using Integrated Technologies

P50 HG002357
Michael P. Snyder
Yale University, New Haven, Conn.

We propose to establish a center to build genomic DNA arrays and develop novel technologies that will use these arrays for the large-scale functional analysis of the human genome. 0.3-1.4 kb fragments of nonrepetitive DNA from each of chromosomes 22, 21, 20, 19,7, 17, and perhaps the X chromosome will be prepared by PCR and attached to microscope slides. The arrays will be used to develop technologies for the large-scale mapping of 1) Transcribed sequences. 2) Binding sites of chromosomal proteins. 3) Origins of replication. 4) Genetic mutation and variation. A web-accessible database will be constructed to house the information generated in this study; data from other studies will also be integrated into the database. The arrays and technologies will be made available throughout both the Yale University and the larger scientific community. They will be integrated into our training programs for postdoctoral fellows, graduate students and undergraduates at Yale. We expect these procedures to be applicable to the analysis of the entire human genome and the genomes of many other organisms.

Center Web Site: Yale University Center for Excellence in Genomic Science

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Genomic Analysis of the Genotype-Phenotype Map

P50 HG002790
Simon Tavaré
University of Southern California, Los Angeles

Our Center, which started in 2003, focused on implications of haplotype structure in the human genome. Since that time, there have been extraordinary advances in genomics: Genome-wide association studies using single nucleotide polymorphisms and copy number variants are now commonplace, and we are rapidly moving towards whole-genome sequence data for large samples of individuals. Our Center has undergone similar dramatic changes. While the underlying theme remains the same — making sense of genetic variation — our focus is now explicitly on how we can use the heterogeneous data produced by modern genomics technologies to achieve such an understanding. The overall goal of our proposal is to develop an intellectual framework, together with computational and statistical analysis tools, for illuminating the path from genotype to phenotype, and for predicting the latter from the former. We will address three broad questions related to this problem: 1) How do we infer mechanisms by which genetic variation leads to changes in phenotype? 2) How do we improve the design, understanding and interpretation of association studies by exploiting prior information? 3) How do we identify general principles about the genotype-phenotype map? We will approach these questions through a series of interrelated projects that combine computational and experimental methods, explored in Arabidopsis, Drosophila and human, and involve a wide range of researchers including molecular biologists, population geneticists, genetic epidemiologists, statisticians, computer scientists, and mathematicians.

Collaborating InstitutionsUniversity of Utah

Center Web Site: The USC Center of Excellence in Genomic Science

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Genomic Analysis of Network Perturbations in Human Disease

P50 HG004233
Marc Vidal
Dana-Farber Cancer Institute, Boston

Genetic differences between individuals can greatly influence their susceptibility to disease. The information originating from the Human Genome Project (HGP), including the genome sequence and its annotation, together with projects such as the HapMap and the Human Cancer Genome Project (HCGP) have greatly accelerated our ability to find genetic variants and associate genes with a wide range of human diseases. Despite these advances, linking individual genes and their variations to disease remains a daunting challenge. Even where a causal variant has been identified, the biological insight that must precede a strategy for therapeutic intervention has generally been slow in coming. The primary reason for this is that the phenotypic effects of functional sequence variants are mediated by a dynamic network of gene products and metabolites, which exhibit emergent properties that cannot be understood one gene at a time. Our central hypothesis is that both human genetic variations and pathogens such as viruses influence local and global properties of networks to induce “disease states.” Therefore, we propose a general approach to understanding cellular networks based on environmental and genetic perturbations of network structure and readout of the effects using interactome mapping, proteomic analysis, and transcriptional profiling. We have chosen a defined model system with a variety of disease outcomes: viral infection. We will explore the concept that one must understand changes in complex cellular networks to fully understand the link between genotype, environment, and phenotype. We will integrate observations from network-level perturbations caused by particular viruses together with genome-wide human variation datasets for related human diseases with the goal of developing general principles for data integration and network prediction, instantiation of these in open-source software tools, and development of testable hypotheses that can be used to assess the value of our methods. Our plans to achieve these goals are summarized in the following specific aims: 1. Profile all viral-host protein-protein interactions for a group of viruses with related biological properties. 2. Profile the perturbations that viral proteins induce on the transcriptome of their host cells. 3. Combine the resulting interaction and perturbation data to derive cellular network-based models. 4. Use the developed models to interpret genome-wide genetic variations observed in human disease, 5. Integrate the bioinformatics resources developed by the various CCSG members within a Bioinformatics Core for data management and dissemination. 6. Building on existing education and outreach programs, we plan to develop a genomic and network centered educational program, with particular emphasis on providing access for underrepresented minorities to internships, workshop and scientific meetings.

Center Web SiteCenter for Cancer Systems Biology (CCSB) Center of Excellence in Genomic Science

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Reporter: Aviva Lev-Ari, PhD, RN

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Reporter: Aviva Lev-Ari, PhD, RN

Systems Pharmacology – Pathways to Patient Response @ BioIT World, April 9-11, 2013, World Trade Center, Boston, MA

Jake Y. Chen’s presentation at the conference is to be viewed at the link, below

http://www.chiresource.com/BIT-05-23/Presentations/NPC/Chen_Jake.pdf

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Reporter and Curator: Dr. Sudipta Saha, Ph.D.

 

Abbreviations:

CVD: Cardiovascular Disease

HHcy: Hyperhomocysteinemia

Hcy: Homocysteine

SAAs: Sulfur Amino Acids

Cys: Cysteine

GSH: Glutathione

S8: Elemental Sulfur

LBM: Lean Body Mass

 

According to World Health Organization estimates, 16.7 million deaths are attributable to cardiovascular disease (CVD) each year, accounting for 30% of all deaths worldwide and constituting an international pandemic. More than half of these deaths occur in developing countries where vegetarian diets consisting of several varieties of legumes and starchy foods have prevailed for millennia. The beneficial health effects of such regimens in the prevention of chronic disorders such as CVD, diabetes, and cancer have been documented by many investigators and, explaining their growing popularity in Westernized countries during the past several decades. It is estimated that about 2% to 5% of individuals living in developed countries have adopted vegetarianism as a lifestyle choice.

Plant-based regimens, however, do not optimally fulfill the nutritional requirements of population groups living in developing countries, as illustrated by the increasing incidence of hyperhomocysteinemia (HHcy) states, now recognized as a critical factor in occurrence of CVD and stroke. HHcy was originally associated with the pathogenesis of atherosclerosis by the study of the vascular pathology of children with inherited disorders of methionine (Met) metabolism. Dietary insufficiency or malabsorption of any of three water-soluble B vitamins (B6, pyridoxal-5′-phosphate; B9, folates; or B12, cobalamins) regulating the Met–homocysteine (Hcy) cycle are regarded as key determinants of acquired HHcy. In particular, cobalamin deficiency constitutes a worldwide problem and is currently regarded as the principal causal factor of HHcy in vegetarian populations and because vitamin B12 is almost totally absent from plant foods. In contrast, folates are abundant in plant foods, and pyridoxal-5′-phosphate is ubiquitous in unprocessed foods from plant and animal sources. Nevertheless, some studies undertaken in developing areas have shown that HHcy status may develop despite normal B12 status, prompting the search for alternative explanations.

A possible causal factor for HHcy in vegetarian populations is related to the observation that most plant foods contain lower concentrations of protein and essential amino acids, especially lysine and Met, than animal foods. White beans, for example, contain about half the sulfur amino acids (SAAs; 422 mg/100 g of edible portion) contained in bovine meat (930 mg/100 g). As a result, the Met provided by vegetarian diets does not meet the tissue requirements of mammalian species. Clinical investigations conducted in subclinically malnourished patients and recent experimental studies of the mouse and rat models have revealed that restriction of dietary Met intake inhibits the trans-sulfuration cascade and leads to HHcy, irrespective of cobalamin status. The present field study was undertaken to investigate the importance of dietary vitamin B12 and Met deficiency in the development of HHcy. The results explain how the altered body composition of vegetarian subjects affects SAA metabolism and produces HHcy, a risk factor for CVD in vegetarian populations.

The discovery that Cys (Cysteine)and GSH (Glutathione) participate in the non-enzymatic conversion of elemental sulfur (S8) into H2S is also important. This converting process may be impeded in the case of insufficient dietary S8 intake and underlying malnutrition, causing decreased Cys and GSH bioavailability. Pedologists and agronomists have demonstrated for many decades that S8 is an essential element in plant nutrition, because deficiency of S8 produces growth retardation, decreased chlorophyll synthesis, and decreases in fertility and crop yields. Because plant foods supply inadequate SAAs for mammalian tissue requirements, consumption of foods with imbalanced nitrogen:sulfur ratios grown in S8-deficient agricultural soils will exacerbate protein malnutrition. S8 deficiency is a worldwide soil problem affecting more than half the countries producing mainly foodstuffs of plant origin, including rice, soybeans, wheat, maize, and oilseeds.

The status of plant agronomy, the mammalian requirements for elemental S8 are presently unknown. Only very recently has the essentiality of sulfur has been recognized in human nutrition, causing Hcy elevation in deficient subjects. The Indian subcontinent, notably the northern region extending from Pakistan to Bangladesh, is one of the areas with soil that is most severely deficient in S8, contributing to the public health problem of CVD. More than 40% of Indian patients with HHcy-induced CVD are refractory to combined administration of folates and cobalamins, supporting the concept of S8 deficiency as the key etiologic factor. The concept of sulfur deficiency may explain why many clinical trials using B vitamin interventions have proved ineffective in the prevention of recurrent vascular disease in patients with advanced CVD, cerebrovascular disease, renal failure, and inflammatory disorders. Many other countries in southeastern Asia with vegetarian lifestyles, such as China, Taiwan, Indonesia, Philippines, Pakistan, and Sri Lanka, are also affected by increasing CVD morbidity and mortality. These developments call attention to the need to redefine CVD risk factors in South Asia and explain why cardiologists from five of these countries, Bangladesh, India, Pakistan, Nepal, and Sri Lanka, have exhorted their governments to focus more attention on CVD epidemiology.

In conclusion, the investigation shows that a vegetarian population consuming a diet deficient in SAAs is characterized by normal B vitamin status, normal serum lipids, subclinical protein malnutrition, and decreased LBM (Lean Body Mass), leading to an adaptive downregulation of the trans-sulfuration pathway, HHcy, and oxidative stress, thereby increasing the vulnerability to CVD.

 

Source References:

http://www.nutritionandmetabolism.com/content/9/1/80

http://www.ncbi.nlm.nih.gov/pubmed/9155227

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=814540

http://ajcn.nutrition.org/content/59/5/1203S.abstract

http://www.eurekaselect.com/59886/article

 

Other related articles were published in this Open Access Online Scientific Journal:

Coming Soon (section under preparation)

 

Clinical Trials:

Study 1:

Title: Examining B12 Deficiency Associated With C677T Mutation on MTHFR Gene in Terms of Commonness and Endothelial Function

Recruitment:  Active, not recruiting

Study Results: No Results Available

Conditions: B12 Deficiency Combined With C677T Mutation on MTHFR Gene

Interventions: Dietary Supplement: B12 Vitamin|Dietary Supplement: Vitamin B12 + Folic Acid

URL: http://ClinicalTrials.gov/show/NCT00730574

Study 2:

Title: Long-term Use of Proton Pump Inhibitors May Cause Vitamin B12 Deficiency in the Institutionalized Elderly

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Other: blood collection|Drug: treatment (cyanocobalamin nasal spray)

URL: http://ClinicalTrials.gov/show/NCT00843453

Study 3:

Title: Oral Vitamin B12 Administration for Vitamin B12 Deficiency After Total Gastrectomy

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Drug: mecobalamin

URL: http://ClinicalTrials.gov/show/NCT00699478

Study 4:

Title: Metformin Use and Vitamin B12 Deficiency

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency|Type 2 Diabetes Mellitus

Interventions:

URL: http://ClinicalTrials.gov/show/NCT01136512

Study 5:

Title: Vitamin B12 Supplementation Study

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Dietary Supplement: Vitamin B12

URL: http://ClinicalTrials.gov/show/NCT00826657

Study 6:

Title: Can Recombinant Human Intrinsic Factor Be Used for Evaluation of the Vitamin B12 Absorption?

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Drug: Recombinant human intrinsic factor

URL: http://ClinicalTrials.gov/show/NCT00279552

Study 7:

Title: How Many Patients Are in Need of Vitamin B12 Injections?

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Drug: vitamin B12

URL: http://ClinicalTrials.gov/show/NCT00326833

Study 8:

Title: The Association Between Religious Origin and Age, and Vitamin B12 and Folic Acid Plasma Levels in Non Jewish Population in Western Galilee

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency|Folic Acid Deficiency

Interventions: Other: Blood Sample

URL: http://ClinicalTrials.gov/show/NCT01297361

Study 9:

Title: The Role of Methycobalamin in Early Dementia Patients With Vitamin B12 Deficiency and Hyperhomocysteinaemia.

Recruitment: Completed

Study Results: No Results Available

Conditions: Dementia With Vitamin B12 Deficiency

Interventions: Drug: Mecobalamin

URL: http://ClinicalTrials.gov/show/NCT00165711

Study 10:

Title: The Role of Methylcobalamin in Early Dementia Patients With Vitamin B12 Deficiency and Hyperhomocysteinaemia ?

Recruitment: Completed

Study Results: No Results Available

Conditions: Dementia

Interventions: Drug: methylcobal

URL: http://ClinicalTrials.gov/show/NCT00164983

Study 11:

Title: Oral/Intramuscular B12 to Treat Cobalamin Deficiency

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Drug: oral Cobalamin (vitamin B12)|Drug: intramuscular Cobalamin (vitamin B12)

URL: http://ClinicalTrials.gov/show/NCT01476007

Study 12:

Title: Impact of Vitamin b12 Replacement on Epogen Requirements in Hemodialysis Patients and Impact on Quality of Life

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency|End Stage Renal Disease

Interventions: Drug: Vitamin B12 injections monthly

URL: http://ClinicalTrials.gov/show/NCT01360983

Study 13:

Title: Cobalamin Status in Young Children With Developmental Delay

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Dietary Supplement: Hydroxycobalamin (Vitamin B12 Depot, Nycomed Pharma)

URL: http://ClinicalTrials.gov/show/NCT00710138

Study 14:

Title: Cobalamin Status in Young Children With Gastrointestinal Symptoms or Feeding Problems

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Dietary Supplement: Hydroxycobalamin (Vitamin B12 Depot, Nycomed Pharma)

URL: http://ClinicalTrials.gov/show/NCT00710359

Study 15:

Title: Cobalamin Supplementation During Infancy; Effect on B-Vitamin Status, Growth and Psychomotor Development

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Drug: Hydroxycobalamin (Vitamin B12 Depot, Nycomed Pharma)

URL: http://ClinicalTrials.gov/show/NCT00479479

Study 16:

Title: Supplementary Vitamin B12 Affects on Elevated Homocysteine Levels of Vegetarians – Clinical Trial

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Dietary Supplement: Inactive lozenge|Dietary Supplement: Methylcobalamin

URL: http://ClinicalTrials.gov/show/NCT01661309

Study 17:

Title: Vitamin B12 Acceptance and Biomarker Response Study

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Drug: Oral administration of vitamin B12|Drug: i.m. injection of vitamin B12

URL: http://ClinicalTrials.gov/show/NCT01832129

Study 18:

Title: Efficacy and Safety Study of Oral Eligen® B12 in Subjects With Low Serum Cobalamin

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B 12 Deficiency

Interventions: Other: Vitamin B12 (cyanocobalamin)

URL: http://ClinicalTrials.gov/show/NCT01312831

Study 19:

Title: Holotranscobalamin Remains Unchanged During Pregnancy

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions:

URL: http://ClinicalTrials.gov/show/NCT00467623

Study 20:

Title: Relative Bioavailability of Folic Acid and L-5-Methlytetrahydrofolate

Recruitment: Completed

Study Results: No Results Available

Conditions: Vitamin B12 Deficiency

Interventions: Dietary Supplement: L-5-methyltetrahydrofolate (Metafolin ®)|Dietary Supplement: folic acid|Dietary Supplement: Placebo

URL: http://ClinicalTrials.gov/show/NCT01584050

Study 21:

Title: Cobalamin Absorption From Fortified Food

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Vitamin B-12 Deficiency|Achlorhydria

Interventions:  Other: 14C-B12 fortified bread

URL: http://ClinicalTrials.gov/show/NCT01399164

Study 22:

Title: Vitamin B12 Supplementation During Pregnancy

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Nutritional Anemia in Mothers.|Nutritional Anemia in Infants.

Interventions: Dietary Supplement: Vitamin B12|Dietary Supplement: Placebo

URL: http://ClinicalTrials.gov/show/NCT01795131

Study 23:

Title: Oral Vitamin B12 Supplementation and Cognitive Performance in Elderly People

Recruitment: Completed

Study Results: No Results Available

Conditions: Cognitive Decline|Cognitive Symptoms

Interventions: Behavioral: vitamin B12 supplementation|Behavioral: vitamin B12 + folic acid combined supplementation

URL: http://ClinicalTrials.gov/show/NCT00111267

Study 24:

Title: Postoperative Vitamin Supplementation in Morbidly Obese Patient (VITAAL Study)

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Obesity|Vitamin Deficiency

Interventions: Dietary Supplement: Fit For me|Dietary Supplement: Davitamon

URL: http://ClinicalTrials.gov/show/NCT01609387

Study 25:

Title: The Bread Trial: Effects of Bread Fortified With Folic Acid and Vitamin B12

Recruitment: Completed

Study Results: No Results Available

Conditions: Healthy

Interventions: Procedure: consumption of fortified bread

URL: http://ClinicalTrials.gov/show/NCT00353353

Study 26:

Title: Comparison of Vitamin B12 Supplementation to Selective Serotonin Reuptake Inhibitor (SSRI) Versus SSRI Antidepressant Treatment Alone

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Major Depressive Disorder

Interventions: Dietary Supplement: Vitamin B12

URL: http://ClinicalTrials.gov/show/NCT00939718

Study 27:

Title: NAC-003 P.L.U.S. Program (Progress Through Learning Understanding & Support)

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Early Memory Loss|Mild Cognitive Impairment|Alzheimer’s Disease|Vascular Dementia

Interventions: Other: CerefolinNAC®

URL: http://ClinicalTrials.gov/show/NCT01370954

Study 28:

Title: Evaluation of Holotranscobalamin as an Indicator of Vitamin B12 Absorption

Recruitment: Completed

Study Results: Has Results

Conditions: Disorder of Vitamin B12

Interventions: Dietary Supplement: Vitamin B12

URL: http://ClinicalTrials.gov/show/NCT00235573

Study 29:

Title: Evaluation of the Efficacy in Decreasing Iron Absorption in Patients With Congenital Dyserythropoietic Anemia Type I by Treatment With LOSEC

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: CDA Type I

Interventions: Drug: omeprazole

URL: http://ClinicalTrials.gov/show/NCT01795794

Study 30:

Title: WENBIT – Western Norway B Vitamin Intervention Trial

Recruitment: Completed

Study Results: No Results Available

Conditions: Coronary Artery Disease|Myocardial Infarction|Cerebrovascular Stroke

Interventions: Drug: folic acid, vitamin B12 (cyanocobalamin), vitamin B6 (pyridoxine)|Drug: folic acid, vitamin B12 (cyanocobalamin)|Drug: vitamin B6 (pyridoxine)|Drug: placebo

URL: http://ClinicalTrials.gov/show/NCT00354081

Study 31:

Title: The Norwegian Vitamin Trial (NORVIT)

Recruitment: Completed

Study Results: No Results Available

Conditions: Acute Myocardial Infarction

Interventions: Drug: Folic acid|Drug: Vitamin B12|Drug: Vitamin B6

URL: http://ClinicalTrials.gov/show/NCT00266487

Study 32:

Title: Efficacy of a Novel Multivitamin-Mineral Supplement in Preventing Vitamin Deficiency in Postoperative Bariatric Patients

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Bariatric Surgery Candidate

Interventions: Dietary Supplement: AquaVanta Chewable Tablet|Dietary Supplement: Flinstones Complete|Dietary Supplement: Nature Made Calcium Softgels|Dietary Supplement: Nature Made Calcium Softgels|Dietary Supplement: Twin Labs Iron Caps|Dietary Supplement: Rexall Vitamin B12 Tablet

URL: http://ClinicalTrials.gov/show/NCT01475617

Study 33:

Title: Multiple Nutritional Deficiencies Causing Dementia of the Alzheimer Type

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Mild Cognitive Impairment|Alzheimers Disease

Interventions:

URL: http://ClinicalTrials.gov/show/NCT01479855

Study 34:

Title: Effect of Prenatal Nutritional Supplementation on Birth Outcome in Hounde District, Burkina Faso

Recruitment: Completed

Study Results: No Results Available

Conditions: Intrauterine Growth Retardation|Low Birth Weight

Interventions: Dietary Supplement: UNIMMAP – multiple micronutrients|Dietary Supplement: Food supplement enriched with multiple micronutrients

URL: http://ClinicalTrials.gov/show/NCT00909974

Study 35:

Title: Assessment of Nutritional Consequences of Sleeve Gastrectomy

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Obesity

Interventions: Procedure: Longitudinal sleeve gastrectomy

URL: http://ClinicalTrials.gov/show/NCT01475903

Study 36:

Title: A Retrospective Analysis of Neevo®/Neevo®DHA Compared to a Standard Prenatal Vitamin in Anemia During Pregnancy

Recruitment: Completed

Study Results: No Results Available

Conditions: Anemia in Pregnancy|Preeclampsia

Interventions: Other: Neevo® (a medical food)|Other: Prenatal vitamins (≤1mg folic acid, 27 – 35mg iron, and ≤12mcg vitamin B12)

URL: http://ClinicalTrials.gov/show/NCT01062958

Study 37:

Title: Interaction of Cobalamin Status With Nitrous Oxide in Relation to Postoperative Cognitive Changes in the Elderly

Recruitment: Completed

Study Results: No Results Available

Conditions: Avitaminosis|Delirium, Dementia, Amnestic, Cognitive Disorders

Interventions: Drug: general anesthesia

URL: http://ClinicalTrials.gov/show/NCT00212147

Study 38:

Title: A Retrospective Analysis of Neevo® and NeevoDHA® Compared to a Standard Prenatal Vitamin in Anemia During Pregnancy

Recruitment: Terminated

Study Results: No Results Available

Conditions: Anemia in Pregnancy|Pre-eclampsia

Interventions: Other: Neevo®|Other: Prenatal vitamins

URL: http://ClinicalTrials.gov/show/NCT01193192

Study 39:

Title: Efficacy Trial to Examine Efficacy of Multimicronutrient Home Supplementation in Infants

Recruitment: Completed

Study Results: No Results Available

Conditions: Iron Deficiency Anemia|Infectious Diseases|Undernutrition

Interventions: Dietary Supplement: Sprinkles|Dietary Supplement: Ferripel-3, Vitamins A&D drops

URL: http://ClinicalTrials.gov/show/NCT00276198

Study 40:

Title: B Vitamin Status in Premature and Small for Gestational Age(SGA) Infants

Recruitment: Completed

Study Results: No Results Available

Conditions: Biochemical Cobalamin Status|Motor Neurodevelopment

Interventions: Dietary Supplement: Hydroxycobalamin|Dietary Supplement: Sham injection

URL: http://ClinicalTrials.gov/show/NCT01201005

Study 41:

Title: Effect of Zinc and Vitamin A Supplementation on Diarrhea, Physical Growth and Immune Response in Malnourished Children

Recruitment: Completed

Study Results: No Results Available

Conditions: Diarrhea|Pneumonia|Acute Respiratory Tract Infection

Interventions: Drug: Zinc and vitamin A single dose at enrollment|Drug: Placebo and vitamin A single dose at enrollment

URL: http://ClinicalTrials.gov/show/NCT00272116

Study 42:

Title: The Contribution of Health in Utero to Capacity Formation, Education and Economic Outcomes: Experimental Evidence From Tanzania

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: We Focus on the Effect of Folic Acid on Cognitive Development, Educational Outcomes and Parental Behavior.

Interventions: Drug: Folic Acid

URL: http://ClinicalTrials.gov/show/NCT01412580

Study 43:

Title: Absorption of Heme and Non-Heme Iron in Pregnant and Non-pregnant Women and Mechanisms of Fetal Iron Transfer

Recruitment: Completed

Study Results: No Results Available

Conditions: Iron Deficiency

Interventions:

URL: http://ClinicalTrials.gov/show/NCT01019096

Study 44:

Title: Project Grow Smart: Intervention Trial of Multiple Micronutrients and Early Learning Among Infants in India

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Nutritional Deficiencies|Developmental Delay

Interventions: Dietary Supplement: Micronutrient Intervention|Behavioral: Early Learning

URL: http://ClinicalTrials.gov/show/NCT01660958

Study 45:

Title: Role of Vitamin D in the Prevention and Treatment of Deseases Associated With Insulin Resistance

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Vitamin D-deficient|Insulin-resistant

Interventions: Dietary Supplement: Vitamin D|Other: Placebo

URL: http://ClinicalTrials.gov/show/NCT01779908

Study 46:

Title: Effectiveness of Selling Micronutrient Sprinkles in Rural Kenya

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Anemia, Iron-deficiency

Interventions: Dietary Supplement: Micronutrient powders (Sprinkles)

URL: http://ClinicalTrials.gov/show/NCT01088958

Study 47:

Title: Prevention of Intrauterine Growth Retardation in Hounde District, Burkina Faso

Recruitment: Completed

Study Results: No Results Available

Conditions: Multiple Micronutrient Deficiencies During Pregnancy

Interventions: Dietary Supplement: Multiple micronutrient supplements (MMN)|Dietary Supplement: IFA

URL: http://ClinicalTrials.gov/show/NCT00642408

Study 48:

Title: Néevo®/NéevoDHA® P.L.U.S. Program (Progress Through Learning, Understand & Support)

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Pregnancy

Interventions: Other: Néevo®/ NéevoDHA®

URL: http://ClinicalTrials.gov/show/NCT01358552

Study 49:

Title: The Effects of 8-week Choline, Betaine, and Folic Acid Supplementation on Plasma Homocysteine Concentration During Guanidinoacetic Acid Loading in Young Healthy Volunteers

Recruitment: Completed

Study Results: No Results Available

Conditions: Hyperhomocysteinemia

Interventions: Drug: TEST 1|Drug: TEST 2|Drug: TEST 3|Drug: TEST 4

URL: http://ClinicalTrials.gov/show/NCT01371357

Study 50:

Title: Prevention of Recurrent Aphthous Stomatitis Using Vitamins

Recruitment: Completed

Study Results: No Results Available

Conditions: Aphthous Stomatitis

Interventions: Dietary Supplement: multivitamin

URL: http://ClinicalTrials.gov/show/NCT00527306

Study 51:

Title: 5-Methyltetrahydrofolate Survival and Inflammation in ESRD Patients

Recruitment: Completed

Study Results: No Results Available

Conditions: Mortality|Hyperhomocysteinemia|Inflammation

Interventions: Drug: 5-MTHF (5-methyltetrahydrofolate)|Drug: folic acid

URL: http://ClinicalTrials.gov/show/NCT00626223

Study 52:

Title: Effects of Low-dose Complex B-vitamins on Homocysteine and Framingham Risk Score Among Chinese Elderly

Recruitment: Completed

Study Results: No Results Available

Conditions: Hyperhomocysteinemia

Interventions: Dietary Supplement: Low-dose complex B-vitamins

URL: http://ClinicalTrials.gov/show/NCT00755664

Study 53:

Title: Nutrition Intervention in Drug Naive HIV-infected Kenyan Women and Their Children

Recruitment: Completed

Study Results: No Results Available

Conditions:  HIV Infections

Interventions: Dietary Supplement: Meat Biscuit|Dietary Supplement: Soy Biscuit|Dietary Supplement: Wheat Biscuit

URL: http://ClinicalTrials.gov/show/NCT00562874

Study 54:

Title: Nutrition and Cognition in Indian Children

Recruitment: Completed

Study Results: No Results Available

Conditions: Healthy

Interventions: Behavioral: micronutrients

URL: http://ClinicalTrials.gov/show/NCT00467909

Study 55:

Title: Randomized Study of Folic Acid Therapy for Hyperhomocysteinemia in Patients With End Stage Renal Disease Receiving Hemodialysis

Recruitment: Recruiting

Study Results: No Results Available

Conditions: End Stage Renal Disease|Hyperhomocysteinemia

Interventions: Drug: cyanocobalamin|Drug: folic acid|Drug: pyridoxine

URL: http://ClinicalTrials.gov/show/NCT00004495

Study 56:

Title: LEARN-6™: A Prospective, Observational Nursing Home Study

Recruitment: Completed

Study Results: No Results Available

Conditions: Anemia|Chronic Kidney Disease

Interventions: Other: Observations

URL: http://ClinicalTrials.gov/show/NCT00727571

Study 57:

Title: A Retrospective Analysis of Cerefolin NAC® in Cognitively Impaired Patients

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Mild Cognitive Impairment

Interventions:

URL: http://ClinicalTrials.gov/show/NCT01594541

Study 58:

Title: Antenatal Micronutrient Supplementation and Infant Survival

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Infant Mortality|Preterm Birth|Low Birth Weight|Neonatal Mortality|Perinatal Mortality

Interventions: Dietary Supplement: Iron (27 mg) – folic acid (600 ug)|Dietary Supplement: Multiple micronutrient

URL:                      http://ClinicalTrials.gov/show/NCT00860470

Study 59:

Title: Changes in Microbiota and Iron Status After Iron Fortification of Complementary Foods

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Bacterial Infections

Interventions: Dietary Supplement: fortification with iron and micronutrients|Dietary Supplement: Sprinkles

URL: http://ClinicalTrials.gov/show/NCT01111864

Study 60:

Title: Homocyst(e)Ine, Vitamin Status, and CVD Risk

Recruitment: Completed

Study Results: No Results Available

Conditions: Cardiovascular Diseases|Cerebrovascular Accident|Coronary Disease|Myocardial Infarction|Heart Diseases|Hyperhomocysteinemia

Interventions:

URL: http://ClinicalTrials.gov/show/NCT00005482

Study 61:

Title: Screening for the Transthyretin-Related Familial Amyloidotic Polyneuropathy

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Polyneuropathies|Amyloidosis|Amyloid Neuropathies|Amyloidosis, Familial|Metabolic Diseases

Interventions:

URL: http://ClinicalTrials.gov/show/NCT01705626

Study 62:

Title: Effect of Folic Acid Supplementation on Plasma Homocysteine Level in Obese Children

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Hyperhomocysteinemia|Obesity

Interventions: Drug: Folic Acid|Drug: placebo

URL: http://ClinicalTrials.gov/show/NCT01766310

Study 63:

Title: Plasma Homocysteine Distribution in the United States

Recruitment: Completed

Study Results: No Results Available

Conditions: Cardiovascular Diseases|Heart Diseases|Hyperhomocysteinemia

Interventions:

URL: http://ClinicalTrials.gov/show/NCT00005483

Study 64:

Title: Effect of S-adenosylmethionine (SAMe) on Blood Levels of Homocysteine

Recruitment: Recruiting

Study Results: No Results Available

Conditions: Hyperhomocysteinemia

Interventions: Dietary Supplement: S-adenosylmethionine

URL: http://ClinicalTrials.gov/show/NCT00473200

Study 65:

Title: Iron and Vitamin Adminstration Prior to Joint Replacement to Prevent Transfusion

Recruitment: Not yet recruiting

Study Results: No Results Available

Conditions: Excessive Amount of Blood / Fluid Transfusion

Interventions: Drug: Iron Supplement,|Drug: Placebo

URL: http://ClinicalTrials.gov/show/NCT01676740

Study 66:

Title: Micronutrients and Antioxidants in HIV Infection

Recruitment: Recruiting

Study Results: No Results Available

Conditions: HIV Infection

Interventions: Dietary Supplement: Micronutrients and antioxidants|Dietary Supplement: Multivitamins and minerals

URL: http://ClinicalTrials.gov/show/NCT00798772

Study 67:

Title: Multivitamin Dosage Regimens in the Prevention of Adverse Pregnancy Outcomes Among HIV-Positive Women

Recruitment: Completed

Study Results: No Results Available

Conditions: HIV Infections

Interventions: Dietary Supplement: Multivitamins-Multiples of RDA|Dietary Supplement: Multivitamins-Single RDA

URL: http://ClinicalTrials.gov/show/NCT00197678

Study 68:

Title: A Trial of Vitamins and HAART in HIV Disease Progression

Recruitment: Completed

Study Results: No Results Available

Conditions: HIV Infections

Interventions: Dietary Supplement: Multivitamins (including B, C and E)|Dietary Supplement: Multivitamins B, C and E

URL: http://ClinicalTrials.gov/show/NCT00383669

Study 69:

Title: Trial of Vitamins Among Children of HIV-infected Women

Recruitment: Completed

Study Results: No Results Available

Conditions: HIV Infections|Pregnancy Complications

Interventions: Drug: Multivitamins – vitamins B complex, C and E|Drug: Placebo

URL: http://ClinicalTrials.gov/show/NCT00197730

Study 70:

Title: Trial of Vitamins in HIV Progression and Transmission

Recruitment: Completed

Study Results: No Results Available

Conditions: HIV Infections|Disease Transmission, Vertical

Interventions: Dietary Supplement: Vitamin A + Beta Carotene|Dietary Supplement: Multivitamins|Other: Placebo

URL: http://ClinicalTrials.gov/show/NCT00197743

Study 71:

Title: A Study in Patients With Amyotrophic Lateral Sclerosis (ALS)

Recruitment: Active, not recruiting

Study Results: No Results Available

Conditions: Amyotrophic Lateral Sclerosis (ALS)

Interventions: Drug: E0302 (mecobalamin)|Drug: E0302 (mecobalamin)|Drug: Placebo

URL: http://ClinicalTrials.gov/show/NCT00444613

Read Full Post »

Reporter: Aviva Lev-Ari, PhD, RN

Systems Pharmacology – Pathways to Patient Response @ BioIT World, April 9-11, 2013, World Trade Center, Boston, MA

Eric Sobie’s presentation at the conference is to be viewed at the link, below

http://www.chiresource.com/BIT-05-23/Presentations/NPC/Sobie_Eric.pdf

http://www.mountsinai.org/profiles/eric-a-sobie

Read Full Post »

Mesothelin: An early detection biomarker for cancer (By Jack Andraka)

Author/ Curator:  Tilda Barliya PhD

I was recently amazed to read about a young teen who scooped the headlines with his story: Jack Andraka created an early detection test for pancreatic cancer (PC) (1). While we extensively discussed pancreatic cancer in previous posts (1b), this one deserve it’s on attention.

Andraka tells the audience about his journey from learning about a the  family member  diagnosed with PC, to a flash insight while learning about carbon nanotubes during a biology class, through the screening and finding one protein out of thousands and all the way up his final discovery. His journey wasn’t easy to say the least, he story though deserve all the applause.

Starting with his journey, Andraka began by “looking for a protein in the bloodstream that would be a biomarker for pancreatic cancer, one that would be found in all cases, even in the earliest stages”. He finally narrowed it down to the one that could work – Mesothelin.

So what is mesothelin?

Model for peritoneal metastasis of ovarian tumors. A model showing the importance of MUC16-mesothelin interaction in the peritoneal metastasis of ovarian tumors is shown.

Gubbels JA, et al. Mol. Cancer (2006). Model for peritoneal metastasis of ovarian tumors.

Mesothelin is a 4o kDa secreted protein expressed in normal mesothelial cells and over-expressed in several human tumors including mesothelioma, ovarian and pancreatic adenocarcinoma (2,3). Although the full mechanism by which mesothelin work is still unsolved, it is postulated thought, that mesothelin growth and apoptosis of pancreatic cancer cells by a p53 -dependent and independent pathways (7).

Andraka’s method:

human mesothelin-specific antibodies  were mixed with single walled carbon nanotubes and used to coat strips of ordinary filter paper. This made the paper conductive. The optimal layering was determined using a scanning electron microscope.  Cell media spiked with varying amounts of mesothelin was then tested against the paper biosensor and any change in the electrical potential of the sensor strip (due to the changing conductivity of the nanotubes) was measured, before and after each application.

The antibodies would bind to the mesothelin and enlarge. These beefed-up molecules would spread the nanotubes farther apart, changing the electrical properties of the network: The more mesothelin present, the more antibodies would bind and grow big, and the weaker the electrical signal would become.

A dose-response curve was constructed with an R2 value of .9992. Tests on human blood serum obtained from both healthy people and patients with chronic pancreatities, pancreatic intraepithelial neoplasia (a precursor to pancreatic carcinoma), or pancreatic cancer showed a similar response. The sensor’s limit of detection sensitivity was found to be 0.156 ng/mL; 10 ng/mL is considered the level of overexpression of mesothelin consistent with pancreatic cancer. Andraka’s sensor costs $0.03 (to compare to a $800 cost of a standard test) and 10 tests can be performed per strip, taking 5 minutes each. The method is 168 times faster, 26,667 times less expensive, and 400 times more sensitive than ELISA, and 25% to 50% more accurate than the CA19-9 test (5).

More so, Wang K and colleagues showed that inhibition of mesothelin may be used as novel strategy for targeting cancer cells (6). The authors showed that silencing the MSLN gene, encoding for mesothelin, inhibits cell proliferation and invasion. While this work is very impressive, the authors haven’t evaluated the potential use these siRNA in animal studies.

In summary:

It is very exiting to know that we may now have a simple and cheap blood test that has the huge potential to save many lives. All we need to do now is to conduct a multinational large scale screening for potential patients.

Andraka on his part is very hopeful, he believes  “it could potentially be used to test for ovarian and lung cancer too. And by switching out the protein the test reacts to, it could — down the road — be used for diseases as varied as heart disease and HIV/AIDS”.

Ref:

1. By: Kate Torgovnich . An early detection test for pancreatic cancer: Jack Andraka at TED2013.http://blog.ted.com/2013/02/27/an-early-detection-test-for-pancreatic-cancer-jack-andraka-at-ted2013/

1b. By; Tilda Barliya PhD. Pancreatic Cancer: Genetics, Genomics and Immunotherapy. http://pharmaceuticalintelligence.com/2013/04/11/update-on-pancreatic-cancer/

2. Mesothelin. http://en.wikipedia.org/wiki/Mesothelin

3. Nathalie Scholler. Mesothelin. http://www.med.upenn.edu/schollerlab/user_documents/Scholler%20Encyclopedia%20of%20Cancer%202008.pdf

4. Argani P, Iacobuzio-Donahue C, Ryu B, Rosty C, Goggins M, Wilentz RE, Murugesan SR, Leach SD, Jaffee E, Yeo CJ, Cameron JL, Kern SE and Hruban RH. Mesothelin is overexpressed in the vast majority of ductal adenocarcinomas of the pancreas: identification of a new pancreatic cancer marker by serial analysis of gene expression (SAGE). Clin Cancer Res. 2001 Dec;7(12):3862-3868. http://clincancerres.aacrjournals.org/content/7/12/3862.long

5. Jack Andraka and Glen Burnie, MD. A Novel Paper Sensor for the Detection of Pancreatic Cancer. http://apps.societyforscience.org/intelisef2012/project.cfm?PID=ME028&CFID=28485&CFTOKEN=10931553

6. Wang K, Bodempudi V, Liu Z, Borrego-Diaz E, Yamoutpoor F, et al. (2012) Inhibition of Mesothelin as a Novel Strategy for Targeting Cancer Cells. PLoS ONE 7(4): e33214. doi:10.1371/journal.pone.0033214. http://www.plosone.org/article/info:doi/10.1371/journal.pone.0033214

7.  Zheng C, Jia W, Tang Y, Zhao HL, Jiang Y and Sun S.  Mesothelin regulates growth and apoptosis in pancreatic cancer cells through p53-dependent and -independent signal pathway. Journal of Experimental & Clinical Cancer Research 2012, 31:84.  http://www.jeccr.com/content/pdf/1756-9966-31-84.pdf

Other related articles on this open Access Online Scientific Journal, include the following:

I. Pancreatic cancer genomes: Axon guidance pathway genes – aberrations revealed.

Aviva Lev-Ari, PhD, RN, 10/24/2012

http://pharmaceuticalintelligence.com/2012/10/24/pancreatic-cancer-genomes-axon-guidance-pathway-genes-aberrations-revealed/

II. Biomarker tool development for Early Diagnosis of Pancreatic Cancer: Van Andel Institute and Emory University.

Aviva Lev-Ari PhD,RN, 10/24/2012

http://pharmaceuticalintelligence.com/2012/10/24/biomarker-tool-development-for-early-diagnosis-of-pancreatic-cancer-van-andel-institute-and-emory-university/

III. Personalized Pancreatic Cancer Treatment Option.

Aviva Lev-Ari PhD, RN, 10/16/2012

http://pharmaceuticalintelligence.com/2012/10/16/personalized-pancreatic-cancer-treatment-option/

IV. Battle of Steve Jobs and Ralph Steinman with Pancreatic cancer: How we lost.

Ritu Saxena PhD, 5/21/2012

http://pharmaceuticalintelligence.com/2012/05/21/battle-of-steve-jobs-and-ralph-steinman-with-pancreatic-cancer-how-we-lost/

V.  Early Biomarker for Pancreatic Cancer Identified.

Prabodh Kandala, PhD, 5/17/2012

http://pharmaceuticalintelligence.com/2012/05/17/early-biomarker-for-pancreatic-cancer-identified/

VI. Usp9x: Promising therapeutic target for pancreatic cancer.

Ritu Saxen PhD, 5/14/2012

http://pharmaceuticalintelligence.com/2012/05/14/promising-therapeutic-target-discovered-for-pancreatic-cancer/

VII. Issues in Personalized Medicine in Cancer: Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing.

Stephen J. Williams, PhD, 10/4/2013

http://pharmaceuticalintelligence.com/2013/04/10/issues-in-personalized-medicine-in-cancer-intratumor-heterogeneity-and-branched-evolution-revealed-by-multiregion-sequencing/

VIII. In Focus: Targeting of Cancer Stem Cells.

Ritu Saxena, PhD, 3/27/2013

http://pharmaceuticalintelligence.com/2013/03/27/in-focus-targeting-of-cancer-stem-cells/

IIX. New Ecosystem of Cancer Research: Cross Institutional Team Science.

Aviva Lev-Ari. PhD, RN, 3/24/2013

http://pharmaceuticalintelligence.com/2013/03/24/new-ecosystem-of-cancer-research-cross-institutional-team-science/

IX. In Focus: Identity of Cancer Stem Cells.

Ritu Saxena, PhD, 3/22/2013

http://pharmaceuticalintelligence.com/2013/03/22/in-focus-identity-of-cancer-stem-cells/

 

Read Full Post »

Cancer Genomic Precision Therapy: Digitized Tumor’s Genome (WGSA) Compared with Genome-native Germ Line: Flash-frozen specimen and Formalin-fixed paraffin-embedded Specimen Needed

Curator: Aviva Lev-Ari, PhD, RN

Dr. Charles Swanton, Cancer Research, UK’s London Research Institute explained in his March 29, 2013 interview for Science, that the cancer treatments often fail as a result of the increasing evidence that tumors contain a heterogeneous mix of cells – tissue tagged with colored fluorescent markers for specific molecular changes sh0ws that not all cells in a tumor are the same.

http://www.sciencemag.org SCIENCE vol 339, 3/29/2013, 1543-1545

His team sequenced DNA taken from different parts of a patient’s kidney tumor, the sequence of each part was different. Severaal genetic changes were shared throughout the original tumor mass and iother tumors, or metastases, most were present in only some parts, suggesting that tumors host diverse populations of cells. some of these cells may be resistant to a treatment and continue to grow.

The findings presented below from Swanton’s Lab and from Polyak’s Lab demonstrate that intra-tumor heterogeneity as revealed by genome sequencing applied as Multiregion Sequencing might suggest that the current best practice in Oncology, of a single biopsy, must be abandoned for the sake of a new and more promising practice of multiple biopsies of the same tumor.

Kornelia Polyak’s Lab at Dana-Farber Cancer Institute, dedicated to the molecular analysis of human breast cancer

http://polyaklab.dfci.harvard.edu/

Our goals are to:

  • Better understand the molecular evolution of human breast tumors
  • Use this knowledge to improve the clinical management of breast cancer patients

Project 1: Breast tumor evolution

Modeling clonal evolution in mouse xenograft models

Cancers develop as a result of somatic evolution. Deciphering the evolutionary dynamics behind this should provide a more accurate understanding of how cancers arise and enable more intelligent approaches toward anti-cancer therapies. However, this area receives almost no experimental attention, and our understanding of clonal evolution in cancers is very rudimentary. To address this deficiency, we have developed a mouse xenograft model of human breast cancers that allows us to follow dynamics of clonal competition in genetically heterogeneous tumors.

Intratumor heterogeneity and metastasis

Metastatic dissemination of cancer cells is the most prominent cause of death due to breast cancer. Recent work in this field has established that the progression of metastatic invasion from the primary tumor to distant locations (such as bone, lungs, and brain) depends on heterogeneous interactions of cancer cells with each other and with cells composing the microenvironment. We aim to elucidate some of the factors and mechanisms that influence metastatic co-operation between cancer cells and their environment in order to fully understand the metastatic cascade and aid in the development of therapies that address this phenomenon.

Diversity in human breast tumors

Intra-tumor genetic and phenotypic diversity may predict the risk of breast cancer progression and response to treatment. To deepen our understanding of these factors, we have been defining intra-tumor diversity using immuno-FISH and ecological models in breast tumors at different progression stages (i.e., in situ, invasive, metastatic), and before and after chemotherapy or targeted (e.g., antu-Her2) treatment.

Project 2: The role of the tumor microenvironment in breast cancer

Interrogating consequences of interactions between breast carcinoma cells and tumor fibroblasts

While it is becoming increasingly apparent that interactions between carcinoma cells and tumor stroma are an essential part of tumor biology, our understanding of this crosstalk is far from complete. Using organotypic 3D culture models, we are interrogating mutual changes in transcriptome, metabolome, and phospho-proteome that result from the interaction between breast carcinoma cells and primary breast tumor-associated fibroblasts.

Myoepithelial cells and leukocytes in DCIS

The progression from in situ to invasive carcinoma is a key but poorly understood step of breast tumorigenesis, characterized by loss of the myepithelial cell layer and basement membrane. We hypothesize that the differentiation of bipotential mammary epithelial progenitors to myoepithelial cells is progressively inhibited by signals coming from tumor epithelial cells and stromal cells, such as leukocytes, leading to their eventual disappearance. Project objectives include:

  • Defining normal myoepithelial cell differentiation and its abnormalities in DCIS
  • Characterizing the role of immune cells in myoepithelial cell differentiation during breast carcinoma progression using in vivo and in vitro model systems and human breast tissue

The completion of this project will increase our understanding of the role of myoepithelial and immune cells in breast cancer, and may also provide new targets for breast cancer treatment via abnormally expressed paracrine signaling in the tumor microenvironment.

Project 3: Epigenetics in breast cancer risk and tumor development

Pregnancy study

Human epidemiological and experimental data in rodent models suggest that full-term pregnancy in early adulthood decreases the risk of estrogen receptor positive (ER+) breast cancer in post-menopausal women; however, the underlying mechanism is largely unknown. We hypothesized that the cancer-preventive effects of parity may be due to alterations in the number or properties of mammary epithelial progenitor/stem cells that are thought to be the cell-of-origin of breast cancer, rendering them less susceptible to oncogenesis. To test this hypothesis, we analyzed the relative frequency and comprehensive molecular profiles of four distinct cell types (CD24+ luminal, CD10+ myoepithelial, lin-/CD24-/CD44+ progenitor-enriched, and stromal fibroblasts) isolated from normal breast tissue of premenopausal nulliparous and parous women. Based on the comprehensive analysis of gene expression, DNA, and histone H3 K27 trimethylation profiles of these cell types, we determined that the most significant changes occurred in lin-/CD24-/CD44+ progenitor-enriched cells. The activity of many genes and pathways involved in development, differentiation, and cell cycle regulation are decreased in parous women that may contribute to their decreased breast cancer risk. We also identified a parity-associated gene signature that predicted clinical outcome in breast cancer patients diagnosed with ER+ tumors.

The role of DNA methylation in mouse mammary gland development

The mouse mammary gland is a useful model system for understanding factors that regulate mammary development. We are pursuing molecular characterization of the different cell types that comprise the mammary epithelium of the mouse. Based on the varying proportional distributions we observe in the mature, progenitor, and stem cell populations of the mammary gland during different life stages, we seek to understand the underlying molecular cues that maintain cell type identities and direct cellular distribution changes by studying the gene expression and epigenetic properties of distinct cell populations during puberty and pregnancy, stages during which there is dramatic tissue remodeling in the mammary gland. Furthermore, with the use of in vitro and in vivo mouse models for the functional characterization of maintenance DNA methylation, we are characterizing potential active roles of this important epigenetic mark in directing cell fate in the mammary gland.

Histone modifying enzymes as new therapeutic targets

The differentiation of normal stem cells and the development of normal tissue are controlled by epigenetic mechanisms. Abnormalities in these processes play a role in the initiation and progression of tumors and intra-tumor diversification of cancer cells. A number of histone-modifying genes were found to be mutated in breast and other cancers, implying that these genes may represent novel therapeutic targets and biomarkers. We have recently reported the characterization of cell-type specific patterning of histone and DNA methylation in normal breast tissues. We developed modified chromatin immunoprecipitation combined with high-throughput sequencing (ChIP-Seq) protocol which enables us to investigate the epigenetic status genome-wide, using limited numbers of cells purified from human breast tissue samples. Currently, we are using various genomic profiling and functional studies to validate several histone demethylases as potential therapeutic targets in breast cancer.

Determinants of basal-like and luminal breast cancer cell phenotypes

Basal-like and luminal breast tumors have distinct molecular profiles and clinical behavior, yet the mechanisms underlying these differences are poorly defined. We investigated the potential role of genetic factors in determining these distinct phenotypes and their inheritance pattern by generating somatic cell fusions between basal-like and luminal breast cancer cells and analyzing their molecular profiles and functional characteristics. Based on the molecular profiles, we identified candidate key transcriptional and epigenetic determinants of basal-like and luminal cell phenotypes. We are further characterizing these genes using functional genomics approaches.

Project 4: Emerging therapeutic targets in breast cancer

Amplified kinases and novel targets in breast cancer

Kinase inhibitors have been one of the most successful drugs for cancer treatments, but their efficacies in patients are still not satisfactory. We have identified novel kinases amplified in breast cancer, and are using functional genomic approaches to validate them as therapeutic targets.

Novel therapeutic targets in triple negative breast cancer

We have conducted an shRNA cell viability screen of 1,576 candidate genes differentially expressed between CD44+CD24- stem cell-like and CD44-CD24+ more differentiated luminal breast cancer cells. These shRNA were further tested across 14 breast cancer cell lines, thereby generating a list of 15 genes of high interest as candidate therapeutic targets against CD44+CD24- cells, including IL6, CXCL3, PTGIS, IGFBP7, PFKFB3 and HAS1. We have followed up and validated the Il6/Jak2/Stat3 signaling pathway in further detail and demonstrated that JAK2 inhibitors may effectively inhibit the growth of breast tumors that have activation of this pathway as determined based on expression of phospho-Stat3 (pStat3). Based on our preclinical data, a clinical trial testing the efficacy of Jak2 inhibitors in pStat3+ breast tumors (enriched in BLBC) is being initiated at DFCI. More recently we also found that a high fraction of inflammatory breast cancer (IBC) are also positive for pStat3, and thus, may respond to JAK kinase inhibition. Besides the JAK/Stat3 pathway, other potentially promising targets include CXCR2, PTGIS, and HAS1. We are conducting preclinical studies validating these genes and their combination as potential new therapeutic strategies in breast cancer.

 

Swanton’s results was published in NEJM on March 8, 2012. 143 citations followed by year end.

http://www.med.upenn.edu/timm/documents/Minn_NEJMTimmMainarticle.pdf

Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing

Marco Gerlinger, M.D., Andrew J. Rowan, B.Sc., Stuart Horswell, M.Math., James Larkin, M.D., Ph.D.,

David Endesfelder, Dip.Math., Eva Gronroos, Ph.D., Pierre Martinez, Ph.D., Nicholas Matthews, B.Sc.,

Aengus Stewart, M.Sc., Patrick Tarpey, Ph.D., Ignacio Varela, Ph.D., Benjamin Phillimore, B.Sc., Sharmin Begum, M.Sc.,

Neil Q. McDonald, Ph.D., Adam Butler, B.Sc., David Jones, M.Sc., Keiran Raine, M.Sc., Calli Latimer, B.Sc.,

Claudio R. Santos, Ph.D., Mahrokh Nohadani, H.N.C., Aron C. Eklund, Ph.D., Bradley Spencer-Dene, Ph.D.,

Graham Clark, B.Sc., Lisa Pickering, M.D., Ph.D., Gordon Stamp, M.D., Martin Gore, M.D., Ph.D., Zoltan Szallasi, M.D.,

Julian Downward, Ph.D., P. Andrew Futreal, Ph.D., and Charles Swanton, M.D., Ph.D.

Abstr act

From the Cancer Research UK London

Research Institute (M. Gerlinger, A.J.R.,

S.H., D.E., E.G., P.M., N.M., A.S., B.P.,

S.B., N.Q.M., C.R.S., B.S.-D., G.C., G.S.,

J.D., C.S.), Royal Marsden Hospital Department

of Medicine ( J.L., M.N., L.P.,

G.S., M. Gore), Wellcome Trust Sanger

Institute (P.T., I.V., A.B., D.J., K.R., C.L.,

P.A.F.), Barts Cancer Institute at the

Barts and the London School of Medicine

and Dentistry (M. Gerlinger), and the University

College London Cancer Institute

(C.S.) — all in London; the Technical University

of Denmark, Lyngby (A.C.E., Z.S.);

and Harvard Medical School, Boston (Z.S.).

Address reprint requests to Dr. Swanton at

the Cancer Research UK London Research

Institute, Translational Cancer Therapeutics

Laboratory, 44 Lincoln’s Inn Fields,

London WC2A 3LY, United Kingdom, or

at charles.swanton@cancer.org.uk.

Drs. Gerlinger, Larkin, Gronroos, Martinez,

and Swanton and Mr. Rowan, Mr. Horswell,

Mr. Endesfelder, Mr. Matthews, and

Mr. Stewart contributed equally to this

article.

N Engl J Med 2012;366:883-92.

Copyright © 2012 Massachusetts Medical Society.

Background

Intratumor heterogeneity may foster tumor evolution and adaptation and hinder

personalized-medicine strategies that depend on results from single tumor-biopsy

samples.

Methods

To examine intratumor heterogeneity, we performed exome sequencing, chromosome

aberration analysis, and ploidy profiling on multiple spatially separated samples obtained

from primary renal carcinomas and associated metastatic sites. We characterized

the consequences of intratumor heterogeneity using immunohistochemical analysis,

mutation functional analysis, and profiling of messenger RNA expression.

Results

Phylogenetic reconstruction revealed branched evolutionary tumor growth, with 63 to

69% of all somatic mutations not detectable across every tumor region. Intratumor

heterogeneity was observed for a mutation within an autoinhibitory domain of the

mammalian target of rapamycin (mTOR) kinase, correlating with S6 and 4EBP

phosphorylation in vivo and constitutive activation of mTOR kinase activity in vitro.

Mutational intratumor heterogeneity was seen for multiple tumor-suppressor genes

converging on loss of function; SETD2, PTEN, and KDM5C underwent multiple distinct

and spatially separated inactivating mutations within a single tumor, suggesting

convergent phenotypic evolution. Gene-expression signatures of good and poor prognosis

were detected in different regions of the same tumor. Allelic composition and

ploidy profiling analysis revealed extensive intratumor heterogeneity, with 26 of 30 tumor

samples from four tumors harboring divergent allelic-imbalance profiles and with

ploidy heterogeneity in two of four tumors.

Conclusions

Intratumor heterogeneity can lead to underestimation of the tumor genomics landscape

portrayed from single tumor-biopsy samples and may present major challenges to

personalized-medicine and biomarker development. Intratumor heterogeneity, associated

with heterogeneous protein function, may foster tumor adaptation and therapeutic

failure through Darwinian selection. (Funded by the Medical Research Council

and others.)

n engl j med 366;10 nejm.org march 8, 2012

Sci Transl Med 28 March 2012:
Vol. 4, Issue 127, p. 127ps10
Sci. Transl. Med. DOI: 10.1126/scitranslmed.3003854
  • PERSPECTIVE

TUMOR HETEROGENEITY

Intratumor Heterogeneity: Seeing the Wood for the Trees

  1. Timothy A. Yap1*,
  2. Marco Gerlinger2,3*,
  3. P. Andrew Futreal4,
  4. Lajos Pusztai5 and
  5. Charles Swanton2,6†

+Author Affiliations


  1. 1Department of Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK.

  2. 2Translational Cancer Therapeutics Laboratory, Cancer Research UK London Research Institute, 44 Lincoln’s Inn Fields, London WC2A 3LY, UK.

  3. 3Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Charterhouse Square, London EC1M 6BQ, UK.

  4. 4Wellcome Trust Sanger Institute, Hinxton, Cambridge CB10 1SA, UK.

  5. 5Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.

  6. 6University College London Cancer Institute, Huntley Street, London WC1E 6BT, UK.

  7. *These authors contributed equally to this work.
  1. Corresponding author. E-mail: charles.swanton@cancer.org.uk

ABSTRACT

Most advanced solid tumors remain incurable, with resistance to chemotherapeutics and targeted therapies a common cause of poor clinical outcome. Intratumor heterogeneity may contribute to this failure by initiating phenotypic diversity enabling drug resistance to emerge and by introducing tumor sampling bias. Envisaging tumor growth as a Darwinian tree with the trunk representing ubiquitous mutations and the branches representing heterogeneous mutations may help in drug discovery and the development of predictive biomarkers of drug response.

Citation: T. A. Yap, M. Gerlinger, P. A. Futreal, L. Pusztai, C. Swanton, Intratumor Heterogeneity: Seeing the Wood for the Trees. Sci. Transl. Med. 4, 127ps10 (2012).

THE EDITORS SUGGEST THE FOLLOWING RELATED RESOURCES ON SCIENCE SITE

In Science Translational Medicine

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    • Bert Vogelstein and
    • Kenneth W. Kinzler

    Sci Transl Med 28 March 2012 4:127ed2

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES:

  • Development of Therapeutic Combinations Targeting Major Cancer Signaling PathwaysJCO 20 April 2013 31:1592-1605
  • A tale of two approaches: complementary mechanisms of cytotoxic and targeted therapy resistance may inform next-generation cancer treatmentsCarcinogenesis 1 April 2013 34:725-738
  • Intratumor heterogeneity in human glioblastoma reflects cancer evolutionary dynamicsProc. Natl. Acad. Sci. USA 5 March 2013 110:4009-4014
  • Accelerating Cancer Therapy Development: The Importance of Combination Strategies and Collaboration. Summary of an Institute of Medicine WorkshopClin. Cancer Res. 15 November 2012 18:6101-6109
  • Pluripotent Stem Cell-Based Cancer Therapy: Promise and ChallengesSci Transl Med 28 March 2012 4:127ps9

VIEW VIDEO

Topol on the Cancer Clinic of the Future

Hello. I’m Dr. Eric Topol, director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape. In this series, The Creative Destruction of Medicine, named for the book I wrote, I am trying to zoom in on critical aspects of how the digital world can create better healthcare.

Cancer care is rapidly changing, if we think about where it was some years ago as it was really beautifully archived in a book by Sid Mukherjee, MD, The Emperor of All Maladies,[1] and to where we can go in the future. Just launched recently, for example, was MD Anderson Cancer Center’s Moon Shots program in cancer care.[2] The Moon Shots program is perhaps, because of genomics, digitizing the genome of the tumor, comparing it with the genome-native germ line. This gives us an opportunity we never had before.

So what is the cancer clinic of the future going to look like, because it’s just starting to get developed today? For example, when we have an individual presenting for a new diagnosis of cancer, we have to move away from fine-needle aspiration and minimal tissue; we need real tissue to be able to process it properly. Not only do we need the formalin-fixed paraffin-embedded (FFPE) specimen, but we also need another type of FF — that is, flash-frozen specimens so that we can then whole-genome sequence this tissue.

Now, when that is done at the primary diagnosis and done within hours and analyzed with the appropriate software algorithms, we could get the driver mutations nailed within 24 hours from the diagnosis. This can set up remarkably precise therapy that can be given to the patient on the basis of that individual’s tumor. There are no 2 different cancers that are the same anywhere. Just like there are no 2 individuals who have the same DNA, that’s the same for a tumor.

One of the issues that we have to confront is that there’s a lot of intratumor heterogeneity. We need multiple samples to sequence from the tumor, and if there’s already a metastatic lesion, we need a sample of that as well. Multiple sequencing, frozen tissue, genome-driven guided therapy — right from the get-go — is what we need. That’s not what we have today, but that’s where we can go in the future of cancer genomic medicine. It’s really an exciting opportunity. It has to be validated.

The cancer drugs that are used today are remarkably expensive, and what’s fascinating is to see — and this is a recurrent theme — is that a drug being used, for example, for renal carcinoma can also be used for leukemia. There was a classic 3-part article on the front page of the New York Times [3] that exemplified some of the stories along those lines.

It’s a story about mutations — a war on mutations, not a war on cancer — and this type of cancer clinic in the future can take us there but there’s going to have to be a whole different look with respect to the way that we take samples of the tumor. We need much more tissue, and to use frozen tissue so that we don’t have to bootstrap the FFPE (that paraffin-embedded specimen) and only get a couple of hundred genes or coding elements, but in fact get a whole genome from the flash-frozen specimen. That’s really important, and we have to move in that direction — get more tissue in order to account for the heterogeneity that we know exists. And we have to do deep sequencing of that frozen tissue in order to get the driver mutations identified, and also be able to anticipate where relapses can occur downstream.

That is precision therapy. This exemplifies the future of cancer genomic medicine, and it will be really interesting to see how that plays out in these cancer clinics of the future.

Thanks so much for joining us for this segment, and stay tuned for more from The Creative Destruction of Medicine series.

References

  1. Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. New York: Scribner; 2010. The 2011 Pulitzer Prize Winners: General Nonfiction. http://www.pulitzer.org/works/2011-General-Nonfiction. Accessed March 5, 2013.
  2. University of Texas MD Anderson Center. Moon Shots program. http://cancermoonshots.org/. Accessed March 5, 2013.
  3. Kolata G. In treatment for leukemia, glimpses of the future. New York Times. July 7, 2012.http://www.nytimes.com/2012/07/08/health/in-gene-sequencing-treatment-for-leukemia-glimpses-of-the-future.html?
  4. pagewanted=all&_r=0. Accessed March 5, 2013.

SOURCE:

http://www.medscape.com/viewarticle/780424?src=emailthis

Charles Swanton Publications

London Research Institute

44 Lincoln’s Inn Fields
London
WC2A 3LY
United Kingdom

Emailcharles.swanton@cancer.org.uk
WebLab website

Primary research papers

The following publications have been supported by Cancer Research UK funding for this researcher.

2010

From genomic landscapes to personalized cancer management-is there a roadmap?
Swanton C;Caldas C
Ann N Y Acad Sci 2010; 1210 ( ):34-44.
PubMed;  DOI: 10.1111/j.1749-6632.2010.05776.x.

Minimising Immunohistochemical False Negative ER Classification Using a Complementary 23 Gene Expression Signature of ER Status
Li QY;Eklund AC;Juul N;Haibe-Kains B;Workman CT;Richardson AL;Szallasi Z;Swanton C
PLoS ONE 2010; (11):e15031.
DOI: 10.1371/journal.pone.0015031.

How Darwinian models inform therapeutic failure initiated by clonal heterogeneity in cancer medicine
Gerlinger M;Swanton C
Br J Cancer 2010; 103 (8):1139-1143.
UKPubMed (open access);  PubMed;  DOI: 10.1038/sj.bjc.6605912.

Anti-cancer drug resistance: Understanding the mechanisms through the use of integrative genomics and functional RNA interference
Tan DSW;Gerlinger M;Teh BT;Swanton C
Eur J Cancer 2010; 46 (12):2166-2177.
PubMed;  DOI: 10.1016/j.ejca.2010.03.019.

A retrospective analysis of clinical outcome of patients with chemo-refractory metastatic breast cancer treated in a single institution phase I unit
Brunetto AT;Sarker D;Papadatos-Pastos D;Fehrmann R;Kaye SB;Johnston S;Allen M;De Bono JS;Swanton C
Br J Cancer 2010; 103 (5):607-612.
PubMed;  DOI: 10.1038/sj.bjc.6605812.

FKBPL Regulates Estrogen Receptor Signaling and Determines Response to Endocrine Therapy
McKeen HD;Byrne C;Jithesh PV;Donley C;Valentine A;Yakkundi A;O’Rourke M;Swanton C;McCarthy HO;Hirst DG;Robson T
Cancer Res 2010; 70 (3):1090-1100.
DOI: 10.1158/0008-5472.CAN-09-2515.

Prognostic and Predictive Biomarkers in Resected Colon Cancer: Current Status and Future Perspectives for Integrating Genomics into Biomarker Discovery
Tejpar S;Bertagnolli M;Bosman F;Lenz HJ;Garraway L;Waldman F;Warren R;Bild A;Collins-Brennan D;Hahn H;Harkin DP;Kennedy R;Ilyas M;Morreau H;Proutski V;Swanton C;Tomlinson I;Delorenzi M;Fiocca R;Van Cutsem E;Roth A
Oncologist 2010; 15 (4):390-404.
DOI: 10.1634/theoncologist.2009-0233.

Assessment of an RNA interference screen-derived mitotic and ceramide pathway metagene as a predictor of response to neoadjuvant paclitaxel for primary triple-negative breast cancer: a retrospective analysis of five clinical trials
Juul N;Szallasi Z;Eklund AC;Li QY;Burrell RA;Gerlinger M;Valero V;Andreopoulou E;Esteva FJ;Symmans WF;Desmedt C;Haibe-Kains B;Sotiriou C;Pusztai L;Swanton C
Lancet Oncol 2010; 11 (4):358-365.
PubMed;  DOI: 10.1016/S1470-2045(10)70018-8.

2009

RNAi-mediated functional analysis of pathways influencing cancer cell drug resistance
Lee AJX;Kolesnick R;Swanton C
Expert Rev Mol Med 2009; 11 ():e15.
PubMed;  DOI: 10.1017/S1462399409001070.

Advances in personalized therapeutics in non-small cell lung cancer: 4q12 amplification, PDGFRA oncogene addiction and sunitinib sensitivity
Swanton C;Burrell RA
Cancer Biol Ther 2009; (21):2051-2053.
PubMed;

Chromosomal instability A composite phenotype that influences sensitivity to chemotherapy
McClelland SE;Burrell RA;Swanton C
Cell Cycle 2009; (20):3262-3266.
PubMed;

Genetic prognostic and predictive markers in colorectal cancer
Walther A;Johnstone E;Swanton C;Midgley R;Tomlinson I;Kerr D
Nat Rev Cancer 2009; (7):489-499.
PubMed;

Chromosomal instability determines taxane response
Swanton C;Nicke B;Schuett M;Eklund AC;Ng C;Li QY;Hardcastle T;Lee A;Roy R;East P;Kschischo M;Endesfelder D;Wylie P;Kim SN;Chen JG;Howell M;Ried T;Habermann JK;Auer G;Brenton JD;Szallasi Z;Downward J
Proc Natl Acad Sci U S A 2009; 106 (21):8671-8676.
UKPubMed (open access);  PubMed;  DOI: 10.1073/pnas.0811835106.

Molecular classification of solid tumours: towards pathway-driven therapeutics
Swanton C;Caldas C
Br J Cancer 2009; 100 (10):1517-1522.
PubMed;

2008

Epothilones and new analogues of the microtubule modulators in taxane-resistant disease
Harrison M;Swanton C
Expert Opin Invest Drugs 2008; 17 (4):523-546.
PubMed;

Targeting Polo-Like Kinase: Learning Too Little Too Late?
Olmos D;Swanton C;de Bono J
J Clin Oncol 2008; 26 (34):5497-5499.
PubMed;

Concordance of exon array and real-time PCR assessment of gene expression following cancer cell cytotoxic drug exposure
Lee AJX;East P;Pepper S;Nicke B;Szallasi Z;Eklund AC;Downward J;Swanton C
Cell Cycle 2008; (24):3947-3948.
PubMed;

Functional genomic analysis of drug sensitivity pathways to guide adjuvant strategies in breast cancer
Swanton C;Szallasi Z;Brenton JD;Downward J
Breast Cancer Res 2008; 10 (5):214.
UKPubMed (open access);  PubMed;  DOI: 10.1186/bcr2159.

Unraveling the complexity of endocrine resistance in breast cancer by functional genomics
Swanton C;Downward J
Cancer Cell 2008; 13 (2):83-85.
PubMed;

 

146 Publications on PubMed by Polyak’s Lab

 

Other related articles on this Open Access Online Scientific Journal include the following:

Issues in Personalized Medicine in Cancer: Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing

Stephen J. Williams, Ph.D. 4/10/2013

http://pharmaceuticalintelligence.com/2013/04/10/issues-in-personalized-medicine-in-cancer-intratumor-heterogeneity-and-branched-evolution-revealed-by-multiregion-sequencing/

Pfizer’s Kidney Cancer Drug Sutent Effectively caused REMISSION to Adult Acute Lymphoblastic Leukemia (ALL)

Aviva Lev-Ari, PhD, RN, 7/10/2012

http://pharmaceuticalintelligence.com/2012/07/10/pfizers-kidney-cancer-drug-sutent-effectively-caused-remission-to-adult-acute-lymphoblastic-leukemia-all/

On Tumor and mutations

http://pharmaceuticalintelligence.com/?s=tumor+mutations

On ‘genomics mutations’

http://pharmaceuticalintelligence.com/?s=genomics+mutations

On ‘cancer sequencing’

http://pharmaceuticalintelligence.com/?s=cancer+sequencing

 On Metastasis

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Under Nutrition Early in Life may lead to Obesity

Reporter and Curator: Dr. Sudipta Saha, Ph.D.

With the growing worldwide obesity epidemic, including huge populations in developing countries, such as China, India, Mexico and Brazil, the causes of this health and economic catastrophe have been increasingly studied. It is well known that metabolic syndrome and obesity exhibit a high correlation with low or absent physical exercise practices and the consumption of calorie-rich diets in developing countries; however, although the inhabitants may actually experience a nutrition transition, high levels of overweight and obese individuals could not be justified solely by diet and physical inactivity, other hallmarks, such as metabolic programming by the under nutrition early in life and epigenetic modification could also be underlining the obesity onset.

In addition to the pathophysiological aspects that have emerged from studies on metabolic programming caused by environmental insults during fetal life, another interesting point that is relevant to this issue is the role of epigenetic changes in the increased risk of developing metabolic diseases, such as type 2 diabetes and obesity, later in life. Epigenetic mechanisms, such as DNA methylation and/or nucleoprotein acetylation/methylation, are crucial to the normal/physiological development of several tissues in mammals, and they involve several mechanisms to guarantee fluctuations of enzymes and other proteins that regulate the metabolism. As previously reviewed, the intrauterine phase of development is particularly important for the genomic processes related to genes associated with metabolic pathways. Therefore, this phase of life may be particularly important for nutritional disturbance. In humans who experienced the Dutch famine Winter in 1944–1945 and in rats that were deprived of food in utero, epigenetic modifications were detected in the insulin-like growth factor 2 (IGF2) and pancreatic and duodenal home box 1 (Pdx1), which are the major factors involved in pancreas development and pancreatic β-cell maturation. Although it is known that the pancreas and the pancreatic β-cells develop/maturate during the embryonic phase, the postnatal life is also crucial for the maintenance processes that control the β-cell mass, such as proliferation, neogenesis and apoptosis. Nevertheless, no data on metabolic programming as the result of protein-restricted diet during lactation only have yet been reported, and no direct association with epigenetic modifications has been observed; on the other hand, because stressor insults during the milk suckling phase can lead to disturbances in glucose metabolism, hypothalamic neurons, ANS activity and β-cell mass/function of the pancreatic β-cells in rodents, further studies are needed on this topic.

Two decades ago, it was observed that low birth weight was related to adult chronic, non-transmissible diseases, such as type 2 diabetes, cardiovascular disease and obesity. It has been speculated that a nutritional injury during perinatal growth, including uterine and early postnatal life, may contribute to adapting the adult metabolism toward nutritional restriction. However, if an abundant diet is offered to people who have been undernourished during the perinatal life, this opportunity induces a metabolic shift toward the storage of energy and high fat tissue accumulation, thus leading to high risks of the onset of metabolic/coronary diseases onset. These observations led to the introduction of the term DOHaD (Developmental Origins of Health and Disease) previously known as the Barker thrifty phenotype hypothesis. Currently, the concept of DOHaD is extended to any other insults during perinatal life, pregnancy and/or lactation, such as underweight, overweight, diabetic or hyperplasic mothers. This concept also includes any type of stressful situations that may predispose babies or pups to develop metabolic disorders when they reach adulthood.

Source References:

 

http://www.nutritionandmetabolism.com/content/9/1/80

 

http://www.ncbi.nlm.nih.gov/pubmed/19955786?dopt=Abstract&holding=f1000,f1000m,isrctn

 

http://www.ncbi.nlm.nih.gov/pubmed/12886432?dopt=Abstract&holding=f1000,f1000m,isrctn

 

http://www.ncbi.nlm.nih.gov/pubmed/8733829?dopt=Abstract&holding=f1000,f1000m,isrctn

 

http://www.ncbi.nlm.nih.gov/pubmed/9478036?dopt=Abstract&holding=f1000,f1000m,isrctn

 

 

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Reporter: Aviva Lev-Ari, PhD, RN

 

Personalized Medicine Takes A Giant Step Forward At The Mount Sinai Medical Center

New ‘CLIPMERGE’ program helps physicians identify gene-drug interactions to improve treatment decisions.

NEW YORK

 – April 5, 2013 /Press Release/  –– 

Physicians and researchers at The Mount Sinai Medical Center will soon be utilizing a potentially revolutionary new data management and analysis platform that is external to, but communicates with, Mount Sinai’s Epic Electronic Health Record (EHR). The platform, developed at Mount Sinai, gives doctors real-time therapeutic and diagnostic guidance based on their patient’s genetic profile. Mount Sinai is pilot-testing the platform through a new research program called CLIPMERGE, which stands for CLinical Implementation of Personalized Medicine through Electronic health Records and Genomics, and is currently enrolling patients.

CLIPMERGE is described in an article to be published in the August issue of Clinical Pharmacology and Therapeutics. The article has been published online as an advance article preview, available at http://www.nature.com/clpt/journal/vaop/naam/pdf/clpt201372a.pdf.

The program is initially inviting 1,500 Mount Sinai patients, who are already enrolled in the BioMe™ “bio bank’ to take part. Once a patient has consented to take part in CLIPMERGE, their DNA, derived from saliva, is analyzed for genetic variations that may affect how a drug works in that individual.

These variations are stored by the CLIPMERGE platform, and remain there silently, until that patient is prescribed a medication by their physician for whom CLIPMERGE has genomically-relevant information – such as it having a lower likelihood of being effective or there being a higher chance of side-effects due to that patient’s particular type of genetic variation. When this happens, CLIPMERGE generates and sends a message, in real time, to the physician to let them know.

This process of providing relevant information to physicians at the point of care when they are treating patients is called “clinical decision support,” and just as it sounds, is intended to support physicians in their clinical decision making. For example, CLIPMERGE will advise physicians if a patient’s genetic profile indicates that he or she would be a “poor metabolizer” of a particular drug that they are prescribing.  In that scenario, CLIPMERGE would display an alert on the physician’s EHR screen, consisting of text describing the reason for the alert, some suggestions of alternative medications or doses that could be used, and a link to reference material so that physicians can read more about the science and evidence for pharmacogenomics.

The article gives an example of a patient whose genomic testing indicates he or she is a “poor metabolizer” of a prescribed drug, clopidogrel (Plavix ©).  The CLIPMERGE alert that is displayed on the physician’s screen states: “Poor metabolizer status is associated with significantly diminished antiplatelet response to clopidogrel and increased risk for adverse cardiovascular events following percutaneous coronary intervention.”  It then suggests the physician consider alternative medication.

“Our knowledge of pharmacogenomics, or genome-drug interactions, and how genetics can influence why some patients react better to some drugs than others, is growing rapidly and will likely transform how drugs are prescribed in the future,” said lead author and the principal investigator of CLIPMERGE Omri Gottesman, MD, a physician- scientist at The Charles Bronfman Institute for Personalized Medicine at the Icahn School of Medicine at Mount Sinai. “What has been lacking to date is technology that can enable us to effectively implement pharmacogenomic information at the point of care and sufficient knowledge about how this information should be communicated to doctors. We hope that through CLIPMERGE, we can establish best practices both technological and human; and a robust process for clinical-decision support to deliver relevant genomic information to physicians at the moment they are caring for patients.”

“Combining BioMe (the bio bank program at Mount Sinai) with CLIPMERGE has allowed us to attain real-time feedback on optimal therapeutics, based on a patient’s DNA, for multiple conditions related to cardiovascular disease, blood clots, high cholesterol, depression and pain” said Erwin Bottinger, MD, the Irene and Dr. Arthur Fishberg Professor of Medicine, and Director of The Charles Bronfman Institute for Personalized Medicine at the Icahn School of Medicine at Mount Sinai.  “This is an important step forward on the road to Personalized Medicine.”

Beyond the 1,500 patients enrolled in the pilot project, Mount Sinai has enrolled a total of 25,000 patients in BioMe™. “Enrolling this number of patients is a significant achievement for Mount Sinai and combined with programs such as CLIPMERGE, is propelling us to the forefront of precision medicine and its application in the clinical setting,” said Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean of Mount Sinai School of Medicine and Executive Vice President for Academic Affairs of The Mount Sinai Medical Center.  “The future of medicine lies in genomics research and translating it to the bedside – and Mount Sinai’s commitment to translational research makes us uniquely poised to lead that revolution.”

The Mount Sinai BioMe™ Biobank, established in 2007 with a donation from the Andrea and Charles Bronfman Philanthropies, is now one of the largest repositories of its kind in the U.S.  For more information, go to:http://icahn.mssm.edu/research/institutes/institute-for-personalized-medicine/innovation-and-technology/biome-platform.

About The Mount Sinai Medical Center

The Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai. Established in 1968, the Icahn School of Medicine is one of the leading medical schools in the United States, and is noted for innovation in education, biomedical research, clinical care delivery, and local and global community service. It has more than 3,400 faculty in 32 departments and 14 research institutes, and ranks among the top 20 medical schools both in National Institutes of Health (NIH) funding and by U.S. News & World Report.

The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary- and quaternary-care teaching facility and one of the nation’s oldest, largest and most-respected voluntary hospitals. In 2012, U.S. News & World Report ranked The Mount Sinai Hospital 14th on its elite Honor Roll of the nation’s top hospitals based on reputation, safety, and other patient-care factors.  Mount Sinai is one of 12 integrated academic medical centers whose medical school ranks among the top 20 in NIH funding and by  U.S. News & World Report and whose hospital is on the U.S. News & World Report Honor Roll.  Nearly 60,000 people were treated at Mount Sinai as inpatients last year, and approximately 560,000 outpatient visits took place.

For more information, visit http://www.mountsinai.org.
Find Mount Sinai on:
Facebook: http://www.facebook.com/mountsinainyc
Twitter @mountsinainyc
YouTube: http://www.youtube.com/mountsinainy

 

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Reversal of Cardiac mitochondrial dysfunction

Curator: Larry H Bernstein, MD, FACP

This article is the FOURTH in a four-article Series covering the topic of the Roles of the Mitochondria in Cardiovascular Diseases. They include the following;

  • Mitochondria and Cardiovascular Disease: A Tribute to Richard Bing, Larry H Bernstein, MD, FACP

http://pharmaceuticalintelligence.com/2013/04/14/chapter-5-mitochondria-and-cardiovascular-disease/

  • Mitochondrial Metabolism and Cardiac Function, Larry H Bernstein, MD, FACP

http://pharmaceuticalintelligence.com/2013/04/14/mitochondrial-metabolism-and-cardiac-function/

  • Mitochondrial Dysfunction and Cardiac Disorders, Larry H Bernstein, MD, FACP

http://pharmaceuticalintelligence.com/2013/04/14/mitochondrial-dysfunction-and-cardiac-disorders/

http://pharmaceuticalintelligence.com/2013/04/14/reversal-of-cardiac-mitochondrial-dysfunction/

 

Mitochondrial metabolism and cardiac function

There is sufficient evidence to suggest that, even with optimal therapy, there is an

  • attenuation or loss of effectiveness of neurohormonal antagonism as heart failure worsens.

The production of oxygen radicals is increased in the failing heart, whereas

  • normal antioxidant enzyme activities are preserved.

Mitochondrial electron transport is an enzymatic source of oxygen radical generation and

  • can be a therapeutic target against oxidant-induced damage in the failing myocardium.

Therefore, future therapeutic targets

  • must address the cellular and molecular mechanisms that contribute to heart failure.

Furthermore, since  fundamental characteristics of the failing heart are 

  • defective mitochondrial energetics and
  • abnormal substrate metabolism

we might expect that substantial benefit may be derived from the development of therapies aimed at

  • preserving cardiac mitochondrial function and
  • optimizing substrate metabolism.

Nutrition and physiological function

Blockade of electron transport in isolated, perfused guinea pig hearts –
before ischaemia with the reversible complex I inhibitor amobarbital
  • decreased superoxide production and
  • preserved oxidative phosphorylation in cardiac mitochondria,
  • decreased myocardial damage.
But when ascorbic acid was administered orally to chronic heart failure patients, there were improvements
  • in endothelial function but
  • no improvement in skeletal muscle energy metabolism.
Angiotensin I-converting enzyme (ACE) inhibitors with trandolapril treatment  in models of heart failure
  • appear to preserve mitochondrial function
  • improving cardiac energy metabolism and
  • function in rats with chronic heart failure.
Similarly perindopril treatment   – in rat skeletal muscle after myocardial infarction -restored :
  • levels of the mitochondrial biogenesis transcription factors PPARg coactivator-1a and
  • nuclear respiratory factor-2a, and
  • prevented mitochondrial dysfunction
Tissue effects of ACE inhibition, such as
might activate intracellular signalling cascades that
  • stimulate mitochondrial biogenesis and
  • improve energy metabolism.
Clearly, the mechanisms of metabolic regulation by
  • existing cardioprotective agents require further investigation.

Substrate metabolism in the failing heart

Increased sympathetic drive in heart failure patients causes adipose tissue lipolysis, thus
  • elevating plasma FFA concentrations.
Myocardial FFA uptake rates are largely determined by circulating FFA concentrations.
In addition to being a major fuel in heart,
  • fatty acids are ligands for the peroxisome proliferator-activated receptors (PPARs),
    •  members of the nuclear hormone receptor (NHR) family.
One PPAR subtype, PPARa, is highly expressed in heart and skeletal muscle. PPARs regulate gene expression by
binding to response elements in the promoter region of target genes that control fatty acid metabolism, including
It has been known for many years that high plasma FFA concentrations are detrimental to the heart,
  • increasing oxygen consumption for any given workload.
Decreased myocardial oxygen efficiency could result, in part,
  • from the inherent stoichiometric inefficiency of fatty acid oxidation,
  • which accounts for the consumption of 12% more oxygen per ATP synthesized than glucose oxidation.

High levels of plasma FFAs have been associated with increased cardiac UCP3 levels in patients undergoing CABG(Fig) and

  • are believed to activate the uncoupling action of UCP3.

http://htmlimg1.scribdassets.com/8o5pfgywg0lyerj/images/4-244729cb6a.jpg

Fig .  Metabolic modulation of the failing heart can be achieved by inhibiting mitochondrial beta-oxidation with trimetazidine, or
  • free fatty acid (FFA) uptake via the carnitine palmitoyltransferase (CPT) system with perhexiline,
    • giving rise to more oxygen-efficient glucose oxidation.
Alternatively, CPT is inhibited by malonyl-coenzyme A (CoA),
  • synthesized from cytosolic acetyl-CoA by acetyl-CoA  carboxylase.
Pharmacological inhibition, or mutation, of
  • malonyl-CoA decarboxylase, which normally converts malonyl-CoA back to acetyl-CoA,
  • elevates malonyl-CoA levels, inhibiting mitochondrial FFA uptake and thus protects the failing heart.

Nutritional Support for the Mitochondria

Human Studies                                       Animal or In Vitro Studies

Alpha lipoic acid                                                    Resveratrol
Co-Enzyme Q10                                                      EgCG
Acetyl-L-Carnitine                                                Curcumin

Lipoic Acid & Acetyl-L-Carnitine

Alpha lipoic acid is known to be a mitochondrial antioxidant that preserves or improves mitochondrial function.

  •  lipoic acid can prevent arterial calcification, and
  • arterial calcification may be related to mitochondrial dysfunction
  • methods are under study to increase lipoic acid synthase production, the enzyme responsible for making lipoic acid in the body.

Co-Enzyme Q10

It is well known that statin drugs taken for high cholesterol severely reduce CoQ10 levels, and causes other negative cardiovascular side effects.
A  study on CAD patients has shown that over 8 weeks of supplementing with 300mg of CoQ10 reversed

  • mitochondrial dysfunction (as measured by a reduced lactate:pyruvate ratio) and
  • improved endothelial function (as measured by increased flow-mediated dilation)

Other Mitochondrial Antioxidants

Other natural compounds that have been shown to have antioxidant effects in the mitochondria include

  • resveratrol, found in wine and grapes,
  • curcumin from turmeric and
  • EGCG, found abundantly in green tea extract.

But no studies have been conducted for these compounds in CVD.

Metabolic syndrome and serum carotenoids: findings of a cross-sectional study
in Queensland, Australia

Metabolic syndrome and serum carotenoids.

T Coyne, TI Ibiebele, PD Baade, CS McClintock and JE Shaw.
Viertel Center for Research in Cancer Control, Cancer Council Queensland, and School of Public Health,
Queensland University of Technology and University of Queensland, Brisbane, Australia
Several components of the metabolic syndrome are known to be oxidative stress-related conditions
  1. diabetes and
  2. cardiovascular disease,
Carotenoids are compounds derived primarily from plants and several have been shown to be potent antioxidant nutrients.
Both diabetes and cardiovascular disease are known to be oxidative stress-related conditions such that
  • antioxidant nutrients may play a protective role in these conditions.
Several cross–sectional surveys have found lower levels of serum carotenoids among those with impaired glucose metabolism or type 2 diabetes.
Carotenoids are compounds derived primarily from plants, several of which are known to be potent antioxidants.
Epidemiological evidence indicates that some serum carotenoids may play a protective role against the development of chronic diseases such as
  1. atherosclerosis,
  2. stroke,
  3. hypertension,
  4. certain cancers,
  5. inflammatory diseases and
  6. diabetic retinopathy.

The primary carotenoids found in human serum are

  1. α-carotene
  2. β-carotene
  3. β-cryptoxanthin
  4. lutein/zeaxanthin
  5. lycopene.
The aim of this study was to examine the associations between metabolic syndrome status and major serum carotenoids in adult Australians.
Data on the presence of the metabolic syndrome, based on International Diabetes Federation 2005 criteria, were collected from 1523 adults
aged 25 years and over in six randomly selected urban centers in Queensland, Australia, using a cross sectional study design.
The following were determined:
  1. Weight
  2. height
  3. BMI
  4. waist circumference
  5. blood pressure
  6. fasting and 2-34 hour blood glucose
  7. lipids
  8. five serum carotenoids.
Criteria used to assess the number of metabolic syndrome components present in a 171 participant using the
2005 International Diabetes Federation definition are as follows:
Components = 0 -none of the metabolic syndrome components (i.e. abdominal obesity, raised triglyceride,
reduced HDL-cholesterol, raised blood pressure, and impaired fasting plasma glucose) are present;
  1. Components = any 1 one of the five metabolic syndrome components is present ;
  2. Components = 2 – any two of the five components are present;
  3. Components = 3 any three of the components are present;
  4. Components = 4 – any four of the components are present;
  5. Components = 5 = all five metabolic syndrome components are present.
This study investigated the relationships between these five primary serum carotenoids and the metabolic syndrome
in a cross-sectional population-based study in Queensland, Australia.  Distributions of serum carotenoids were skewed
and therefore natural logarithmically transformed to better approximate the normal distribution for regression analyses.
Association between log transformed serum carotenoids as dependent variables and metabolic syndrome status were
assessed using multiple linear regression analysis. Results are reported as back transformed geometric means.
Analysis was performed for each serum carotenoid separately, and the sum of the five carotenoids,
adjusting for the following potential confounders:
  1. age
  2. sex
  3. education
  4. BMI
  5. smoking
  6. alcohol intake
  7. physical activity
  8. vitamin use.
Mean serum alpha-carotene, beta-carotene and the sum of the five carotenoid concentrations were significantly lower (p<0.05)
in persons with the metabolic syndrome (after adjusting for age,sex, education, BMI status, alcohol intake, smoking, physical activity
status and vitamin/mineral use) than persons without the syndrome. Alpha, beta and total carotenoids also decreased significantly
(p<0.05) with increased number of components of the metabolic syndrome, after adjusting for these confounders. These differences
were significant among former smokers and non-smokers, but not in current smokers. Low concentrations of serum
  • alpha-carotene,
  • beta carotene and
  • the sum of five carotenoids
appear to be associated with metabolic syndrome status.
The overall prevalence of the syndrome was 24% and was significantly higher among males than females. As would be expected, significant
differences in prevalence of the syndrome were seen with
  • body mass index
  • waist circumference
  • systolic and diastolic blood pressure
  • blood lipids.
Significant differences were also evident by
  • age group, smoking status, educational status and income.
Income was marginally inversely associated. The prevalence increased with age, and was lower in those with post graduate education.
No significant differences were seen by alcohol intake, physical activity levels,  vitamin usage, or fruit intake. There was actually an
  • inverse relationship between vegetable intake (not fruit) and serum carotenoids.
Those who consumed 4 serves or more of vegetable were less likely to have the metabolic syndrome
  • compared to those who consumed 1 serve or less of vegetables.
The mean concentrations of serum alpha-carotene, beta-carotene and the sum of the five carotenoids were significantly lower for participants
  • with the metabolic syndrome present compared with those without the syndrome, after adjusting for potential confounding variables.
Concentrations of alpha-carotene, beta-carotene and the sum of the five carotenoids decreased significantly as
  • the number of components of the metabolic syndrome increased after adjusting for potential confounding variables.
Similarly there was an inverse association between quartiles of
  • individual and total serum carotenoids and metabolic syndrome status and each of its components.
This study was designed to investigate the association between several serum carotenoids and the metabolic syndrome.
The data from the present population study suggest that several serum carotenoids are inversely related to the metabolic syndrome.
The study showed significantly lower concentrations present among those with the metabolic syndrome of
  1. α-carotene,
  2. β-carotene and
  3. the sum of the five carotenoids
 compared to those without.We also found decreasing concentrations of all the carotenoids tested as

  • the number of the metabolic syndrome components increased.
This was significant for
  1. α-carotene,
  2. β-carotene,
  3. β-cryptoxanthin
  4. total carotenoids.
    (not lycopenes)
These findings are consistent with data reported from the third National Health and Nutrition Examination Survey (NHANES III).
In the NHANES III study, significantly lower concentrations of all the carotenoids, except lycopene, were found among persons
with the metabolic syndrome compared with those without, after adjusting for confounding factors similar to those in our study.

Carnitine: A novel health factor-An overview. 

CD Dayanand, N Krishnamurthy, S Ashakiran, KN Shashidhar
Int J Pharm Biomed Res 2011; 2(2): 79-89.  ISSN No: 0976-0350
Carnitine comprises L-carnitine, acetyl –L-carnitine and Propionyl –L-carnitine. Carnitine is
  • obtained in greater amount from animal dietary sources than from plant sources.
The endogenous synthesis of carnitine takes place in animal tissues like
  • liver
  • kidney
  • brain
using precursor amino acids lysine and methionine by a pathway
  • dependent on iron, vitamin C, niacin, pyridoxine .
This is the basis of vegans generally depending on carnitine in larger proportion
  • through in vivo synthesis than omnivorous subjects.
The concentration of tri-methyl lysine residues and the tissue specificity of  butyro-betaine dehydrogenase
  • plays a significant role in regulating the carnitine biosynthesis.
Carnitine transport from the site of synthesis to target tissue occurs via blood.
The measurement of plasma carnitine concentration represents –
  • the balance between the rate of synthesis and rate of excretion
    • through specific transporter proteins.
The cellular functional role of carnitine depends on the uptake into cells through
  1. carnitine transport proteins and
  2. transport into mitochondrial matrix.
The function of carnitine is to traverse Long-chain Fatty Acids across inner mitochondrial membrane
  • for β-oxidation, thereby, generating ATP.
Carnitine deficiency results in muscle disorders.  The deficiency states are primary and secondar.
The primary is of systemic or myopathic, characterized by a defect of high affinity organic cation transporter protein (CTP)
  • present on the plasma membrane of liver and kidney and
  • also due to dysfunction of carnitine reabsorbtion through
    • similar transport proteins in renal tubules.
Secondary carnitine deficiency is associated with
  1. mitochondrial disorders and also
  2. defective β-oxidation such as CPT-II and acyl CoA dehydrogenase.
In recent times, carnitine has been extensively studied in various research activities to explore the therapeutic benefit.
Thus, carnitine justifies as a novel health factor.

Propionyl-L-carnitine Corrects Metabolic and Cardiovascular Alterations in
Diet-Induced Obese Mice and Improves Liver Respiratory Chain Activity

C Mingorance,  L Duluc, M Chalopin, G Simard, et al.
PLC improved the insulin-resistant state and reversed the increased total cholesterol
but not the increase in free fatty acid, triglyceride and HDL/LDL ratio induced by high-fat diet.
Vehicle-HF exhibited a reduced

  • cardiac output/body weight ratio,
  • endothelial dysfunction and
  • tissue decrease of NO production,

all of them being improved by PLC treatment.
The decrease of hepatic mitochondrial activity by high-fat diet was reversed by PLC.

Oral administration of PLC improves the insulin-resistant state developed by obese animals and
decreases the cardiovascular risk associated with the metabolically impaired mitochondrial function.

Omega-3 Fatty Acid and cardioprotection

The Benefits of Flaxseed    

By Elaine Magee, MPH, RD    WebMD Expert Column
Some call it one of the most powerful plant foods on the planet. There’s some evidence it may help reduce your risk of

  • heart disease, cancer, stroke, and diabetes.

That’s quite a tall order for a tiny seed that’s been around for centuries.

Flaxseed was cultivated in Babylon as early as 3000 BC. In the 8th century, King Charlemagne believed so strongly in the
health benefits of flaxseed that he passed laws requiring his subjects to consume it. Now, thirteen centuries later, some
experts say we have preliminary research to back up what Charlemagne suspected.

http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/article_
thumbnails/features/benefits_of_flaxseed_features/375x321_benefits_of_flaxseed_features.jpg

Not only has consumer demand for flaxseed grown, agricultural use has also increased.
Flaxseed is what’s used to feed all those chickens that are laying eggs with higher levels of omega-3 fatty acids.
Although flaxseed contains all sorts of healthy components, it owes its primary healthy reputation to three of them:

  1. Omega-3 essential fatty acids, have been shown to have heart-healthy effects.  1.8 grams of plant omega-3s/tablespoon ground.
  2. Lignans, which have both plant estrogen and antioxidant qualities.  75 to 800 times more lignans than other plant foods.
  3. Fiber. Flaxseed contains both the soluble and insoluble types.

Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Diseases

CJ Lavie, RV Milani, MR Mehra, and HO Ventura.
J. Am. Coll. Cardiol. 2009;54;585-594.   http://dx.doi.org/10.1016/j.jacc.2009.02.084
Fish oil is obtained in the human diet by eating oily fish, such as
  • herring, mackerel, salmon, albacore tuna, and sardines, or
  • by consuming fish oil supplements or cod liver oil.
Fish do not naturally produce these oils, but obtain them through the ocean food chain from the marine microorganisms
  • that are the original source of the omega-3 polyunsaturated fatty acids (ω-3 PUFA) found in fish oils.
Numerous prospective and retrospective trials from many countries, including the U.S., have shown that moderate
  • fish oil consumption decreases the risk of major cardiovascular (CV) events, such as
  1. myocardial infarction (MI),
  2. sudden cardiac death (SCD),
  3. coronary heart disease (CHD),
  4. atrial fibrillation (AF), and most recently,
  5. death in patients with heart failure (HF).
Most of the evidence for benefits of the ω-3 PUFA has been obtained for
  • eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), the long-chain fatty acids in this family.
There is support for a benefit from alpha-linolenic acid (ALA),
  • the plant-based precursor of EPA.
The American Heart Association (AHA) has currently endorsed the use of ω-3 PUFA in patients with documented CHD

  • at a dose of approximately 1 g/day of combined DHA and EPA, either in the form of fatty fish or fish oil supplements
The health benefits of these long chain fatty acids are numerous and remain an active area of research.
Omega-3 polyunsaturated fatty acid (ω-3 PUFA) therapy continues to show great promise in primary and,
  • particularly in secondary prevention of cardiovascular (CV) diseases.
This portion of discussion summarizes the current scientific data on the effects of the long chain ω-3 PUFA
  • in the primary and secondary prevention of various CV disorders.
The most compelling evidence for CV benefits of ω-3 PUFA comes from 4 controlled trials
  • of nearly 40,000 participants randomized to receive eicosapentaenoic acid (EPA)
  • with or without docosahexaenoic acid (DHA) in studies of patients
    • in primary prevention,
    • after myocardial infarction, and
    • with heart failure (HF).
The evidence from retrospective epidemiologic studies and from large randomized controlled trials
show the benefits of ω-3 PUFA, specifically EPA and DHA, in primary and secondary CV prevention
and provide insight into potential mechanisms of these observed benefits.

Background Epidemiologic Evidence

During the past 3 decades, numerous epidemiologic and observational studies have been published on the CV benefits of ω-3 PUFA.
As early as 1944, Sinclair described the rarity of CHD in Greenland Eskimos, who consumed a diet high in whale, seal, and fish.
More than 30 years ago, Bang and Dyberg reported that despite a diet low in fruit, vegetables, and complex carbohydrates but
high in saturated fat and cholesterol, serum cholesterol and triglycerides were lower in Greenland Inuit than in age-matched residents
of Denmark, and the risk of MI was markedly lower in the Greenland population compared with the Danes. These initial observations raised
speculation on the potential benefits of ω-3 PUFA (particularly EPA and DHA) as the protective “Eskimo factor”.
Potential EPA and DHA Effects   
  1. Antiarrhythmic effects
  2. Improvements in autonomic function
  3. Decreased platelet aggregation
  4. Vasodilation
  5. Decreased blood pressure
  6. Anti-inflammatory effects
  7. Improvements in endothelial function
  8. Plaque stabilization
  9. Reduced atherosclerosis
  10. Reduced free fatty acids and triglycerides
  11. Up-regulated adiponectin synthesis
  12. Reduced collagen deposition
The target EPA + DHA consumption should be at least 500 mg/day for individuals without underlying overt CV disease
  • and at least 800 to 1,000 mg/day for individuals with known coronary heart disease and HF.
Further studies are needed to determine optimal dosing and the relative ratio of DHA and EPA ω-3 PUFA that
  • provides maximal cardioprotection in those at risk of CV disease
  • as well in the treatment of atherosclerotic, arrhythmic, and primary myocardial disorders.
Lavie et al.  Omega-3 PUFA and CV Diseases  J Am Coll Cardiol 2009; 54(7): 585–94

Assessing Appropriateness of Lipid Management Among Patients With Diabetes Mellitus

Moving From Target to Treatment.   AJ Beard, TP Hofer, JR Downs, et al. and Diabetes Clinical Action Measures Workgroup
Performance measures that emphasize only a treat-to-target approach may motivate ove-rtreatment with high-dose statins,
  • potentially leading to adverse events and unnecessary costs.
We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed
  • to encourage appropriate treatment with moderate-dose statins while minimizing over-treatment.
We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients ≥18 years of age with diabetes mellitus.
We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old:
  1.  having a low-density lipoprotein (LDL) <100 mg/dL,
  2. taking a moderate-dose statin regardless of LDL level or measurement, or
  3. receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is ≥100 mg/dL.
We examined possible over-treatment for patients ≥18 years of age by examining the proportion of patients
  • without ischemic heart disease who were on a high-dose statin.
We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models.
Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure:
  1. 67.2% with LDL <100 mg/dL,
  2. 13.0% with LDL ≥100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and
  3. 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort ≥18 years of age, 13.7% were potentially over-treated.
Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age
  • are receiving appropriate dyslipidemia management.

Exercise training and mitochondria in heart failure

The beneficial effects of exercise in the rehabilitation of patients with heart failure are well established,
with improvements observed in
  • exercise capacity,
  • quality of life,
  • hospitalization rates and
  • morbidity/mortality.
There is no evidence of training-induced
improvements in cardiac energy metabolism or
  • mitochondrial function, and
  • no modification of myocardial oxidative capacity,
  • oxidative enzymes, or
  • energy transfer enzymes
in exercising rats with experimental heart failure, but there is  evidence of
There are also improvements in
  • skeletal muscle oxidative capacity with
  • increased mitochondrial density
following endurance training in heart failure patients associated with alleviation of symptoms such as
  • exercise intolerance and
  • chronic fatigue.
The mechanism underlying improvements in mitochondrial function may perhaps be a result of
  • more effective peripheral oxygen delivery following training,
  • alleviating tissue hypoxia and oxidative stress.

Treating Type 2 diabetes, and lowering cardiovascular disease risk

Treating Diabetes and Obesity with an FGF21-Mimetic Antibody
Activating the βKlotho/FGFR1c Receptor Complex

IN Foltz, S Hu, C King, Xinle Wu, et al.  Amgen and Texas A&M HSC, Houston, TX.
Sci Transl Med  Nov 2012; 4(162), p. 162ra153
http://dx.doi.org/10.1126/scitranslmed.3004690

Fibroblast growth factor 21 (FGF21) is a distinctive member of the FGF family with potent beneficial effects on

  1. lipid
  2. body weight
  3. glucose metabolism

A monoclonal antibody, mimAb1, binds to βKlotho with high affinity and specifically

  • activates signaling from the βKlotho/FGFR1c (FGF receptor 1c) receptor complex.

Injection of mimAb1 into obese cynomolgus monkeys led to FGF21-like metabolic effects:

  1. decreases in body weight,
  2. plasma insulin,
  3. triglycerides, and
  4. glucose during tolerance testing.

Mice with adipose-selective FGFR1 knockout were refractory to FGF21-induced improvements

  • in glucose metabolism and body weight.

mimAb1 depends on βKlotho to activate FGFR1c, but

  • it is not expected to induce side effects caused by activating FGFR1c alone.

The results in obese monkeys (with mimAb1) and in FGFR1 knockout mice (with FGF21) demonstrated

  • the essential role of FGFR1c in FGF21 function and
  • suggest fat as a critical target tissue for the cytokine and antibody.

This antibody activates FGF21-like signaling through cell surface receptors, and  provided

  • preclinical validation for an innovative therapeutic approach to diabetes and obesity.

Influencing Factors on Cardiac Structure and Function Beyond Glycemic Control
in Patients With Type 2 Diabetes Mellitus (T2DM)

R Ichikawa, M Daimon, T Miyazaki, T Kawata, et al.     Cardiovasc Diabetol. 2013;12(38)

We studied 148 asymptomatic patients with T2DM without overt heart disease.
Early (E) and late (A) diastolic mitral flow velocity and early diastolic mitral annular velocity (e’)

  • were measured for assessing left ventricular (LV) diastolic function.

In addition

  • insulin resistance,
  • non-esterified fatty acid,
  • high-sensitive CRP,
  • estimated glomerular filtration rate,
  • waist/hip ratio,
  • abdominal visceral adipose tissue (VAT),
  • subcutaneous adipose tissue (SAT)

In T2DM (compared to controls),

  • E/A and e’ were significantly lower, and
  • E/e’, left atrial volume and LV mass were significantly greater

VAT  and age were independent determinants of

  • left atrial volume (β =0.203, p=0.011),
  • E/A (β =−0.208, p=0.002), e’ (β =−0.354, p<0.001) and
  • E/e’ (β=0.220, p=0.003).

Independent determinants of LV mass were

  • systolic blood pressure,
  • waist-hip ratio (β=0.173, p=0.024)
  • VAT/SAT ratio (β=0.162, p=0.049)

Excessive visceral fat accompanied by adipocyte dysfunction may play a greater role than

  • glycemic control in the development of diastolic dysfunction and LV hypertrophy in T2DM

Inhibition of oxidative stress and mtDNA damage

Novel pharmacological agents are needed that

  • optimize substrate metabolism and
  • maintain mitochondrial integrity,
  • improve oxidative capacity in heart and skeletal muscle, and
  • alleviate many of the clinical symptoms associated with heart failure.

The evidence for the attenuation or loss of effectiveness of neurohormonal antagonism as heart failure worsens

  • indicates future therapeutic targets must address the cellular and molecular mechanisms that contribute to heart failure.

Pharmacological Targets of oxidative stress and mitochondrial damage

Defective mitochondrial energetics and abnormal substrate metabolism are fundamental characteristics of CHF.

A significant benefit may be derived from developing therapies aimed at

  • preserving cardiac mitochondrial function and
  • optimizing substrate metabolism.
Oxidative stress is enhanced in myocardial remodelling and failure. The increased production of oxygen radicals in the failing heart
  • with preserved antioxidant enzyme activities suggests
  • mitochondrial electron transport as a source of oxygen radical generation
  • can be a therapeutic target against oxidant-induced damage in the failing myocardium.
Chronic increases in oxygen radical production in the mitochondria
  • leads to mitochondrial DNA (mtDNA) damage,
  • functional decline,
  • further oxygen radical generation, and
  • cellular injury.
MtDNA defects may thus play an important role in the
  • development and progression of myocardial remodelling and failure.
Reactive oxygen species induce
  1. myocyte hypertrophy,
  2. apoptosis, and
  3. interstitial fibrosis
  4. by activating matrix metallo-proteinases,
  5. promoting the development and
  6. progression of maladaptive myocardial remodelling and failure.
Oxidative stress has direct effects on cellular structure and function and
  • may activate integral signalling molecules in myocardial remodelling and failure (Figure).
ROS result in a phenotype characterized by
  • hypertrophy and apoptosis in isolated cardiac myocytes.
Therefore, oxidative stress and mtDNA damage are good therapeutic targets.
Overexpression of the genes for
  • peroxiredoxin-3 (Prx-3), a mitochondrial antioxidant, or
  • mitochondrial transcription factor A (TFAM),
    • could ameliorate the decline in mtDNA copy number in failing hearts.
Consistent with alterations in mtDNA, the
  • decrease in mitochondrial function was prevented,
  • proving that the activation of Prx-3 or TFAM gene expression
  • could ameliorate the pathophysiological processes seen
  1. in mitochondrial dysfunction and
  2. myocardial remodelling.
Inhibition of oxidative stress and mtDNA damage
  • could be novel and effective treatment strategies for heart failure.
Proposed mechanisms through which overexpression of the
  • mitochondrial transcription factor A (TFAM) gene prevents
  • mitochondrial DNA (mtDNA) damage,
  • oxidative stress, and
  • myocardial remodelling and failure.
In wild-type mice, mitochondrial transcription factor A
  • directly interacts with mitochondrial DNA to form nucleoids.
Stress such as ischaemia causes mitochondrial DNA damage, which
  1. increases the production of reactive oxygen species (ROS)
  2. leading to a catastrophic cycle of mitochondrial electron transport impairment,
  3. further reactive oxygen species generation, and mitochondrial dysfunction.
TFAM overexpression may protect mitochondrial DNA from damage by
  1. directly binding and stabilizing mitochondrial DNA and
  2. increasing the steady-state levels of mitochondrial DNA
ameliorating mitochondrial dysfunction and thus the development and progression of heart failure.

Conclusion

Heart failure is a multifactorial syndrome that is characterized by
  • abnormal energetics and substrate metabolism in heart and skeletal muscle.
Although existing therapies have been beneficial, there is a clear need for new approaches to treatment.
Pharmacological targeting of the cellular stresses underlying mitochondrial dysfunction, such as
  • elevated fatty acid levels,
  • tissue hypoxia and oxidative stress and
  • metabolic modulation of heart and skeletal muscle mitochondria,
    • appears to offer a promising therapeutic strategy for tackling heart failure.
Murray AJ, Anderson RE, Watson GC, et al. Uncoupling proteins in human heart. Lancet 2004; 364:1786.
Delarue J, Magnan C. Free fatty acids and insulin resistance. Curr Opin ClinNutr Metab Care 2007; 10:142
Lee L, Campbell R, Scheuermann-Freestone M, et al. Metabolic modulation with perhexiline in chronic heart failure: a randomized, controlled trialof short-term use of a novel treatment. Circulation 2005; 112:3280
Tsutsui H, Kinugawa S, Matsushima S. Mitochondrial oxidative stress and dysfunction in myocardial remodelling. Cardiovasc Res. 2009;81(3):449-56. http://dxdoi.org/10.1093/cvr/cvn280.
C Maack, M Böhm. Targeting Mitochondrial Oxidative Stress in Heart Failure. J Am Coll Cardiol. 2011;58(1):83-86. http://dx.doi.org/10.1016/j.jacc.2011.01.032

 References

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http://pharmaceuticalintelligence.com/2012/11/14/mitochondrial-dynamics-and-cardiovascular-diseases/

Mitochondrial Damage and Repair under Oxidative Stress   larryhbern
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Mitochondria: Origin from oxygen free environment, role in aerobic glycolysis, metabolic adaptation   larryhbern
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Ca2+ signaling: transcriptional control     larryhbern
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MIT Scientists on Proteomics: All the Proteins in the Mitochondrial Matrix identified  Aviva Lev-Ari
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Nitric Oxide has a ubiquitous role in the regulation of glycolysis -with a concomitant influence on mitochondrial function    larryhbern
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Ubiquinin-Proteosome pathway, autophagy, the mitochondrion, proteolysis and cell apoptosis  larryhbern
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Low Bioavailability of Nitric Oxide due to Misbalance in Cell Free Hemoglobin in Sickle Cell Disease – A Computational Model   Anamika Sarkar
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The rationale and use of inhaled NO in Pulmonary Artery Hypertension and Right Sided Heart Failure    larryhbern
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Mitochondria and Cardiovascular Disease: A Tribute to Richard Bing, Larry H Bernstein, MD, FACP
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Clinical Trials Results for Endothelin System: Pathophysiological role in Chronic Heart Failure, Acute Coronary Syndromes and MI – Marker of Disease Severity or Genetic Determination? Aviva Lev-Ari, PhD, RN 10/19/2012
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Inhibition of ET-1, ETA and ETA-ETB, Induction of NO production, stimulation of eNOS and Treatment Regime with PPAR-gamma agonists (TZD): cEPCs Endogenous Augmentation for Cardiovascular Risk Reduction – A Bibliography, Aviva Lev-Ari, PhD, RN 10/4/2012
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Cardiovascular Risk Inflammatory Marker: Risk Assessment for Coronary Heart Disease and Ischemic Stroke – Atherosclerosis. Aviva Lev-Ari, PhD, RN 10/30/2012
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Cholesteryl Ester Transfer Protein (CETP) Inhibitor: Potential of Anacetrapib to treat Atherosclerosis and CAD.     Aviva Lev-Ari, PhD, RN 4/7/2013
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Hypertriglyceridemia concurrent Hyperlipidemia: Vertical Density Gradient Ultracentrifugation a Better Test to Prevent Undertreatment of High-Risk Cardiac Patients, Aviva Lev-Ari, PhD, RN  4/4/2013  http://pharmaceuticalintelligence.com/2013/04/04/hypertriglyceridemia-concurrent-hyperlipidemia-vertical-density-gradient-ultracentrifugation-a-better-test-to-prevent-undertreatment-of-high-risk-cardiac-patients/

Fight against Atherosclerotic Cardiovascular Disease: A Biologics not a Small Molecule – Recombinant Human lecithin-cholesterol acyltransferase (rhLCAT) attracted AstraZeneca to acquire AlphaCore.
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High-Density Lipoprotein (HDL): An Independent Predictor of Endothelial Function & Atherosclerosis, A Modulator, An Agonist, A Biomarker for Cardiovascular Risk.   Aviva Lev-Ari, PhD, RN 3/31/2013
http://pharmaceuticalintelligence.com/2013/03/31/high-density-lipoprotein-hdl-an-independent-predictor-of-endothelial-function-artherosclerosis-a-modulator-an-agonist-a-biomarker-for-cardiovascular-risk/

Peroxisome proliferator-activated receptor (PPAR-gamma) Receptors Activation: PPARγ transrepression for Angiogenesis in Cardiovascular Disease and PPARγ transactivation for Treatment of Diabetes.
Aviva Lev-Ari, PhD, RN 11/13/2012
http://pharmaceuticalintelligence.com/2012/11/13/peroxisome-proliferator-activated-receptor-ppar-gamma-receptors-activation-pparγ-transrepression-for-angiogenesis-in-cardiovascular-disease-and-pparγ-transactivation-for-treatment-of-dia/

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Structure of the human mitochondrial genome.

Structure of the human mitochondrial genome. (Photo credit: Wikipedia)

English: Treatment Guidelines for Chronic Hear...

English: Treatment Guidelines for Chronic Heart Failure (Photo credit: Wikipedia)

English: Oxidative stress process Italiano: Pr...

English: Oxidative stress process Italiano: Processo dello stress ossidativo (Photo credit: Wikipedia)

Diagram taken from the paper "Dissection ...

Diagram taken from the paper “Dissection of mitochondrial superhaplogroup H using coding region SNPs” (Photo credit: Asparagirl)

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