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

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

Genetics and Male Endocrinology

Image Source: Created by Noam Steiner Tomer 8/10/2020

Male sexual differentiation and development proceed under direct control of androgens.  Androgen action is mediated by the intracellular androgen receptor, which belongs to the superfamily of ligand-dependent transcription factors. Mutations in the androgen receptor gene cause phenotypic abnormalities of male sexual development that range from a:

  • female phenotype (complete testicular feminization), to that of
  • under-virilized or infertile men.

Using the tools of molecular biology, it was analyzed androgen receptor gene mutations in 31 unrelated subjects with androgen resistance syndromes. Most of the defects are due to nucleotide changes that cause premature termination codons or single amino acid substitutions within the open reading frame encoding the androgen receptor, and the majority of these substitutions are localized in three regions of the androgen receptor:

Less frequently, partial or complete gene deletions have been identified. Functional studies and immunoblot assays of the androgen receptors in patients with androgen resistance indicate that in most cases the phenotypic abnormalities are the result of impairment of receptor function or decreases in receptor abundance or both.

In the X-linked androgen insensitivity syndrome, defects in the androgen receptor gene have prevented the normal development of both internal and external male structures in 46, XY individuals.

The complete form of androgen insensitivity syndrome is characterized by

  • 46, XY karyotype,
  • external female phenotype,
  • intra-abdominal testes,
  • absence of uterus and ovaries,
  • blindly ending vagina, and
  • gynecomastia.

There is also a group of disorders of androgen action that result from partial impairment of androgen receptor function. Clinical indications can be abnormal sexual development of individuals with a

  • predominant male phenotype with
  • severe hypospadias and micropenis or of individuals with a
  • predominantly female phenotype with cliteromegaly,
  • ambiguous genitalia, and
  • gynecomastia.

Complete or gross deletions of the androgen receptor gene have not been frequently found in persons with the complete androgen insensitivity syndrome, whereas point mutations at several different sites in exons 2-8 encoding the DNA- and androgen-binding domain have been reported in both partial and complete forms of androgen insensitivity, with a relatively high number of mutations in two clusters in exons 5 and 7.

The number of mutations in exon 1 is extremely low, and no mutations have been reported in the hinge region, located between the DNA-binding domain and the ligand-binding domain.

The X-linked condition of spinal and bulbar muscle atrophy (Kennedy’s disease) is characterized by a progressive motor neuron degeneration associated with signs of androgen insensitivity and infertility. The molecular cause of spinal and bulbar muscle atrophy is an expanded length (> 40 residues) of one of the polyglutamine stretches in the N-terminal domain of the androgen receptor.

Source References:

http://www.ncbi.nlm.nih.gov/pubmed/8421085

http://www.ncbi.nlm.nih.gov/pubmed/8732995

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Reporter: Aviva Lev-Ari, PhD, RN

Genomics: The single life

Sequencing DNA from individual cells is changing the way that researchers think of humans as a whole.

31 October 2012

The tendency of sperm to swim alone makes the cells ideal for single-cell genomics. Adam Auton, a statistical geneticist at Albert Einstein College of Medicine in New York is using sperm to study recombination, the process that shuffles genes during the formation of germ cells and therefore influences which genes are inherited. Recombination is one of the fundamental forces that shapes genetic diversity,” he says. “In recent years we’ve learned that there is considerable variation in the recombination rate between different populations, between the sexes and even between individuals.” But pinning down the rate in people once seemed impossible because it would have required finding individuals with hundreds of children and sequencing their genomes.

The ability to sequence single cells meant that researchers could take another approach. Working with a team at the Chinese sequencing powerhouse BGI, Auton sequenced nearly 200 sperm cells and was able to estimate the recombination rate for the man who had donated them. The work is not yet published, but Auton says that the group found an average of 24.5 recombination events per sperm cell, which is in line with estimates from indirect experiments2. Stephen Quake, a bioengineer at Stanford University in California, has performed similar experiments in 100 sperm cells and identified several places in the genome in which recombination is more likely to occur. The location of these recombination ‘hotspots’ could help population biologists to map the position of genetic variants associated with disease.

Quake also sequenced half a dozen of those 100 sperm in greater depth, and was able to determine the rate at which new mutations arise: about 30 mutations per billion bases per generation3, which is slightly higher than what others have found. “It’s basically the population biology of a sperm sample,” Quake says, and it will allow researchers to study meiosis and recombination in greater detail.

SOURCE:  

VIEW ARTICLE IN NATURE

http://www.nature.com/news/genomics-the-single-life-1.11710#/genome

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

It is well established that food restriction delays pubertal onset, whereas refeeding abolishes this delay. In addition, murine and human genetic models of leptin deficiency fail to enter puberty, and treatment with leptin can establish a pulsatile secretory pattern of gonadotropins that is characteristic of early puberty. The female transgenic skinny mouse, which is an in vivo model of chronic hyperleptinemia in the absence of adipose tissue, enters puberty precociously. Data regarding the effects of leptin administration on pubertal onset are controversial. It has been shown that intracerebroventricular leptin administration prevents the delay in vaginal opening induced by chronic food restriction in the rat. By contrast, it has been found that artificially raised leptin levels are not sufficient to abolish the delay of pubertal onset caused by food deprivation. Thus, the question arises whether leptin might be a ‘permissive factor’ (tonic mediator), whose concentration above a certain threshold is required for pubertal onset, or a ‘trigger’ (phasic mediator) that determines the pubertal spurt through a rise in serum concentration at an appropriate time of development.

The temporal correlation between increases in leptin concentration and the initiation of LH pulsatility over the peripubertal period has been studied in several species. In men it has been shown that leptin levels rise by 50% before the onset of puberty, and decrease to baseline after the initiation of puberty. Other cross-sectional studies showed that age has a significant effect on serum leptin concentrations through prepuberty into early puberty. It has been reported repeatedly that there are no significant changes in leptin levels over the peripubertal period in male rhesus macaques; however, more recent studies performed in castrated male monkeys showed that nocturnal levels of leptin increase just before the nocturnal prepubertal increase in pulsatile LH release.

A possible explanation for such contrasting reports in monkeys could be the sampling of nocturnal rather than diurnal blood. Indeed, in primates, prepubertal changes in nocturnal LH release occur approximately five months before diurnal variations. Another reason might be the use of different models: agonadal monkeys were treated with intermittent exogenous GnRH to sensitize the pituitary to endogenous GnRH, thus magnifying the LH release independently from gonadal influences. In the same study, the leptin rise was accompanied by a sustained increase in nocturnal GH and IGF-I concentrations before the onset of puberty, which is defined as the increase in nocturnal pulsatile LH secretion. It is not clear whether one of the two metabolic signals has a predominant role or whether both act in concert. Indeed, it has been reported that the maximum increase in GH and leptin occurs simultaneously, about 10–30 days before the onset of puberty. However, these conclusions were based on results from a study that used castrated animals, which in the strictest sense do not undergo puberty. Thus, it remains to be clarified whether the same mechanisms that result in the onset of the pubertal rise in LH secretion in castrated animals are also responsible for the reactivation of the HPG axis in intact animals.

The sexual dimorphism in leptin concentrations becomes evident after puberty. In males, leptin levels rise throughout childhood, reach a peak in the early stages of puberty and then decline, whereas they increase steadily during pubertal development in females. Consequently, leptin levels are three to four times higher in females than in males. The reason for this postpubertal sexual dimorphism in leptin levels is not clear. After puberty, serum testosterone and testicular volume are inversely related to leptin levels in males, whereas in females, when adjusted for adiposity indexes, estradiol is directly correlated with leptin levels. These observations indicate that androgens and estradiol might account, at least in part, for the gender differences in circulating leptin levels. This is also supported by in vitro studies which show that androgens and estrogens inhibit and stimulate leptin expression and release from human adipocytes in culture, respectively.

Thus, puberty represents a turning point in the sexual dimorphic relationships between the HPG axis and leptin by determining the steroid milieu that leads to a different regulation of leptin secretion in the sexes.

Source References:

http://www.sciencedirect.com/science/article/pii/S1043276000003520#

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Xarelto (Rivaroxaban): Anticoagulant Therapy gains FDA New Indications and Risk Reduction for: (DVT) and (PE), while in use for Atrial fibrillation increase in Gastrointestinal (GI) Bleeding Reported

Reporter: Aviva Lev-Ari, PhD, RN

 

UPDATED on 8/17/2018

NOAC’s Brain Bleed Risk Outside Afib May Be Dose-Dependent

Higher risk seen only with higher rivaroxaban doses in meta-analysis

by Ashley Lyles, MedPage Today Intern 

The findings indicate the following risk of intracranial hemorrhage versus aspirin:

  • 10 mg of rivaroxaban taken once per day or 5 mg taken two times a day (three trials, OR 1.43, 95% CI 0.93-2.21)
  • 5 mg of apixaban twice daily (one trial, OR 0.84, 95% CI 0.38-1.88)

The study also showed that 15 mg to 20 mg of rivaroxaban each day was linked with an increased risk of fatal bleeding (two trials, OR 2.37, 95% CI 1.30-4.29). On the other hand, 10 mg of rivaroxaban each day or 5 mg taken twice a day (three trials, OR 1.47, 95% CI 0.72-2.97) and 5 mg of apixaban taken twice per day (one trial, OR 0.66, 95 % CI 0.19-2.35) were not linked with an increased risk.

Increased risk of major bleeding compared with aspirin was seen with 15 mg to 20 mg dose of rivaroxaban each day (two trials, OR 2.64, 95% CI 1.68-4.16) and a 10 mg dose of rivaroxaban once a day or 5 mg twice per day (three trials, OR 1.56, 95% CI 1.31-1.85).

Primary Source

JAMA Neurology

Source Reference: Huang W, et al “Association of intracranial hemorrhage risk with non–vitamin k antagonist oral anticoagulant use vs aspirin use a systematic review and meta-analysis” JAMA Neurology 2018; DOI: 10.1001.

SOURCE

https://www.medpagetoday.com/cardiology/strokes/74552?xid=nl_mpt_cardiodaily_2018-08-17&eun=g99985d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=AHAWeekly_081718&utm_term=AHA%20Cardiovascular%20Daily%20-%20Active%20Users%20180%20days

 

UPDATED on 10/9/2017

Xarelto Flop in Stroke Prevention Trial; Syncope Device; Workout by Watching Hockey, Theater?

Recent developments of interest in cardiovascular medicine

  • by Crystal Phend,Senior Associate Editor, MedPage TodayOctober 09, 2017

https://www.medpagetoday.com/Cardiology/Prevention/68421

Rivaroxaban (Xarelto) flopped for preventing recurrent strokes and increased bleeding compared with aspirin in top-line results from the phase III NAVIGATE ESUS trial, Bayer and Janssen announced. (Genetic Engineering and Biotechnology News)

Xarelto (Rivaroxaban): Anticoagulant Therapy gains FDA New Indications and Risk Reduction for: (DVT) and (PE), while in use for Atrial fibrillation, increase in Gastrointestinal (GI) Bleeding Reported compared with Coumadin

Rivaroxaban Gains FDA Indications For The Treatment And Prevention Of DVT And PE

The FDA today expanded the indication for rivaroxaban (Xarelto, Johnson & Johnson) to include the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and to reduce the risk of recurrent DVT and PE.

The oral anticoagulant is already approved to reduce the post-surgical risk of DVT and PE  after hip and knee replacement surgery and to reduce the risk of stroke in people with atrial fibrillation. The new indication was granted under the FDA’s priority review program.

“Xarelto is the first oral anti-clotting drug approved to treat and reduce the recurrence of blood clots since the approval of warfarin nearly 60 years ago,” said Richard Pazdur,  director of the FDA’s Office of Hematology and Oncology Products, in an FDA press release.

Here is the FDA press release:

FDA expands use of Xarelto to treat, reduce recurrence of blood clots
The U.S. Food and Drug Administrationtoday expanded the approved use of Xarelto (rivaroxaban) to include treating deep vein thrombosis (DVT) or pulmonary embolism (PE), and to reduce the risk of recurrent DVT and PE following initial treatment.Blood clots occur when blood thickens and clumps together. DVT is a blood clot that forms in a vein deep in the body. Most deep vein blood clots occur in the lower leg or thigh. When a blood clot in a deep vein breaks off and travels to an artery in the lungs and blocks blood flow, it results in a potentially deadly condition called PE.Xarelto is already FDA-approved to reduce the risk of DVTs and PEs from occurring after knee or hip replacement surgery (July 2011), and to reduce the risk of stroke in people who have a type of abnormal heart rhythm called non-valvular atrial fibrillation (November 2011).

The FDA reviewed Xarelto’s new indication under the agency’s priority review program, which provides an expedited six-month review for drugs that offer major advances in treatment or that provide treatment when no adequate therapy exists.

“Xarelto is the first oral anti-clotting drug approved to treat and reduce the recurrence of blood clots since the approval of warfarin nearly 60 years ago,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research.

Other drugs approved by FDA to treat or reduce the risk of blood clots include Lovenox (enoxaparin), generic versions of enoxaparin, Arixtra (fondaparinux), Fragmin (dalteparin), Coumadin (warfarin), and heparin.

The safety and effectiveness of Xarelto for the new indications were evaluated in three clinical studies. A total of 9,478 patients with DVT or PE were randomly assigned to receive Xarelto, a combination of enoxaparin and a vitamin K antagonist (VKA), or a placebo. The studies were designed to measure the number of patients who experienced recurrent symptoms of DVT, PE or death after receiving treatment.

Results showed Xarelto was as effective as the enoxaparin and VKA combination for treating DVT and PE. About 2.1 percent of patients treated with Xarelto compared with 1.8 percent to 3 percent of patients treated with the enoxaparin and VKA combination experienced a recurrent DVT or PE. Additionally, results from a third study showed extended Xarelto treatment reduced the risk of recurrent DVT and PE in patients. About 1.3 percent of patients treated with Xarelto compared with 7.1 percent of patients receiving placebo experienced a recurrent DVT or PE.

The major side effect observed with Xarelto is bleeding, similar to other anti-clotting drugs.

Xarelto is marketed by Raritan, N.J.-based Janssen Pharmaceuticals Inc.

For more information:

FDA: Office of Hematology and Oncology Products

FDA: Approved Drugs: Questions and Answers

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

 

SOURCE:

http://www.forbes.com/sites/larryhusten/2012/11/02/rivaroxaban-gains-fda-indications-for-the-treatment-and-prevention-of-dvt-and-pe/?goback=%2Egde_2069447_member_181862591

Cardiac Atrial Fibrillation

ATLANTA, Georgia — Patients with atrial fibrillation receiving anticoagulant therapy are more likely to experience gastrointestinal (GI) bleeding when treated with rivaroxaban than when treated with warfarin, according to a new analysis of data from ROCKET AF.

Christopher Nessel, MD, from research and development at Johnson & Johnson in Raritan, New Jersey, reported the findings here at CHEST 2012: American College of Chest Physicians Annual Meeting.

“Compared with warfarin, the risk of GI bleeding is increased with rivaroxaban, but the incidence of life-threatening or fatal GI bleeding is lower,” Dr. Nessel told Medscape Medical News. “A careful benefit/risk assessment is needed prior to prescribing rivaroxaban for high-risk patients,” he added.

The analysis examined the incidence and outcomes of GI hemorrhage in 14,264 patients with nonvalvular atrial fibrillation enrolled in ROCKET AF.

The patients were randomized to either rivaroxaban or dose-adjusted warfarin. All GI bleeding events were recorded during treatment and for 2 days after the last dose was administered. Severity of bleeding was defined by a corresponding drop in hemoglobin or transfusion of more than 2 units of red cells.

The composite principal safety end point for GI bleeding events (upper GI, lower GI, and rectal bleeding) occurred more frequently in the 394 patients receiving rivaroxaban than in the 290 receiving warfarin (3.61% vs 2.60% per year; hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.19 to 1.61). Major bleeding was more frequent with rivaroxaban than with warfarin (2.00% vs 1.24% per year; HR, 1.61; 95% CI, 1.30 to 1.99), as was clinically relevant nonmajor bleeding (1.75% vs 1.39% per year; HR, 1.26; 95% CI, 1.20 to 1.55).

Patients who experienced major GI bleeding were more likely to have experienced GI bleeding in the past, to have mild anemia, to have a lower creatinine clearance, to be previous or current smokers, and to be older than patients who did not experience a GI bleeding during the trial (n = 13,552). They were also less likely to be female and to have previously experienced a stroke or transient ischemic attack.

The incidence of severe bleeding (transfusion of at least 4 units) was similar in the rivaroxaban and warfarin groups (49 vs 47). Six patients developed fatal bleeding: 1 in the rivaroxaban group and 5 in the warfarin group.

Data May Give Clinicians Pause When Considering Rivaroxaban

“The data presented extend the observations from the ROCKET AF clinical study,” Dr. Nessel said. “Specifically, the analyses identified characteristics of nonvalvular atrial fibrillation patients that may predispose them to the occurrence of GI hemorrhage. The data also indicated that the overall fatality rates for bleeds of this nature are very low.”

Independent commentator James Wisler, MD, from the division of cardiovascular disease at Duke University Medical Center in Durham, North Carolina, pointed out that this study underscores the importance of critically evaluating these newer anticoagulants when considering their use in a given patient.

“The decision regarding which anticoagulant to use for a given patient is complex, and risks and benefits need to be considered thoughtfully,” he told Medscape Medical News. He added that the results of this study might give some physicians pause about initiating a newer anticoagulant, such as rivaroxaban, in a given patient with atrial fibrillation and an unfavorable risk profile, such as those with a previous GI bleed.

“While the previously published results from ROCKET AF suggested that the risk profiles were similar between rivaroxaban and warfarin, these results demonstrate that there is indeed a subpopulation of patients who may be better served with warfarin than rivaroxaban,” he explained.

According to Dr. Wisler, both this analysis and the initial ROCKET AF study demonstrate that rivaroxaban is associated with fewer episodes of severe or fatal bleeding events, despite the increase in major and clinically relevant nonmajor bleeding observed in the specific subgroup of this study. “Currently, it is unclear why this discrepancy exists,” he added.

He recommends that clinicians take a careful patient history to assess bleeding risk factors when considering the initiation of a newer anticoagulant such as rivaroxaban.

“While perhaps more convenient and efficacious, certain patient populations, such as that evaluated in this study, may receive net harm from these newer agents,” he said.

SOURCE:

CHEST 2012: American College of Chest Physicians Annual Meeting. Presented October 22, 2012.

http://journal.publications.chestnet.org/issue.aspx?journalid=99&issueid=25283

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Reporter: Aviva Lev-Ari, PhD, RN

arrayMap: A Reference Resource for Genomic Copy Number Imbalances in Human Malignancies

Haoyang Cai#, Nitin Kumar#, Michael Baudis*Institute of Molecular Life Sciences, University of Zurich, Zurich, Switzerland

Abstract Top

Background

The delineation of genomic copy number abnormalities (CNAs) from cancer samples has been instrumental for identification of tumor suppressor genes and oncogenes and proven useful for clinical marker detection. An increasing number of projects have mapped CNAs using high-resolution microarray based techniques. So far, no single resource does provide a global collection of readily accessible oncogenomic array data.

Methodology/Principal Findings

We here present arrayMap, a curated reference database and bioinformatics resource targeting copy number profiling data in human cancer. The arrayMap database provides a platform for meta-analysis and systems level data integration of high-resolution oncogenomic CNA data. To date, the resource incorporates more than 40,000 arrays in 224 cancer types extracted from several resources, including the NCBI’s Gene Expression Omnibus (GEO), EBI’s ArrayExpress (AE), The Cancer Genome Atlas (TCGA), publication supplements and direct submissions. For the majority of the included datasets, probe level and integrated visualization facilitate gene level and genome wide data review. Results from multi-case selections can be connected to downstream data analysis and visualization tools.

Conclusions/Significance

To our knowledge, currently no data source provides an extensive collection of high resolution oncogenomic CNA data which readily could be used for genomic feature mining, across a representative range of cancer entities. arrayMap represents our effort for providing a long term platform for oncogenomic CNA data independent of specific platform considerations or specific project dependence. The online database can be accessed at http//www.arraymap.org.

Citation: Cai H, Kumar N, Baudis M (2012) arrayMap: A Reference Resource for Genomic Copy Number Imbalances in Human Malignancies. PLoS ONE 7(5): e36944. doi:10.1371/journal.pone.0036944

Editor: Ying Xu, University of Georgia, United States of America

Received: January 10, 2012; Accepted: April 16, 2012; Published: May 18, 2012

Copyright: © 2012 Cai et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: HC is supported through a personal grant from the China Scholarship Council. NK and MB had received support through the Krebsliga Schweiz and the University of Zurich’s Research Priority Program Systems Biology. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

* E-mail: michael.baudis@imls.uzh.ch

# These authors contributed equally to this work.

Introduction Top

Genomic copy number abnormalities (CNAs) are a relevant feature in the development of basically all forms of human malignancies [1]. Many genomic imbalances are recurrent and display tumor-specific patterns [2],[3]. It is believed that these genomic instabilities reveal mutations in tumor suppressor genes and oncogenes which eventually result in a clone of fully malignant cells. Investigation of CNA hot spots (chromosomal loci frequently involved in CNA) has proven to be an effective methodology to identify novel cancer-causing genes [4][5]. On a systems level, CNA data along with expression or somatic mutation data is used to detect pathways altered in cancers and to deduce functional relevance of pathway members[6][7]. Since many CNAs have been attributed to specific tumor types or clinical risk profiles, in some entities copy number profiling is employed to characterize different biological as well as clinical subtypes with implications for treatment and individual prognosis. Subtype-associated CNA regions are used to predict causative genes, furthering understanding of biological differences and leading to discovery of new therapeutic targets [8][9].

Throughout the last two decades, molecular-cytogenetic techniques have been applied to scan genomic copy number profiles in virtually all types of human neoplasias. For whole genome analysis, these techniques predominantly consist of chromosomal and array comparative genomic hybridization (CGH), including CNA detection by cDNA and single nucleotide polymorphism (SNP) arrays [10][12]. While chromosomal CGH has a limited spatial resolution of several megabases, the resolution of recent array based technologies (aCGH) is mainly limited due to cost/benefit evaluations instead of technical obstacles. In this article, we use the terms “array CGH” and “aCGH” for all technical variants of whole genome copy number arrays. This includes e.g. single color arrays for which regional copy number normalization is performed through bioinformatics procedures applied to external references and internal data distribution.

The flood of new insights into structural genomic changes in health and disease has led to an increased interest in genomic data sets in genetic and cancer research. Several systematic studies of CNAs across many cancer types have been performed [13][14]. These efforts attempt a more complete understanding of functional effect of CNAs in the context of cancer.

The exponential increase of high resolution CNA datasets offers new challenges and opportunities for large-scale genomic data mining, data modeling and functional data integration. Several online resources have been developed, focusing on different aspects of data content as well as representation [6][15][19]. An overview of some of the prominent examples is given in Table 1. In principle, these databases facilitate access and utilization of CNA data. However, they are limited to specific aCGH platforms and/or single institutions as well as limited disease categories, or, as in the cases of GEO [15] and Ensembl ArrayExpress[16], mainly serve as raw data repositories. To the best of our knowledge, no single data source does yet provide an extensive collection of high resolution oncogenomic CNA data which readily could be used for genomic feature mining, across a representative range of cancer entities.

Table 1. Prominent online resources of genomic data.

doi:10.1371/journal.pone.0036944.t001

Here we present “arrayMap”, a web-based reference database for genomic copy number data sets in cancer. We have generated a pipeline to accumulate and process oncogenomic array data into a unified and structured format. The resource incorporates associated histopathological and clinical information where accessible.

So far, arrayMap contains more than 40,000 arrays on 224 cancer types from five main data sources: NCBI GEO, EBI ArrayExpress, The Cancer Genome Atlas, publication supplements and user submitted data. Samples of interest can be browsed, visualized and analyzed via an intuitive interface. Computational tools are provided for biostatistical data analysis such as CNA clustering for case specific or for subset data and basic clinical correlations. arrayMap is publicly available at www.arraymap.org.

Results Top

Data Content

Our combination of both “top-down” (publication driven) as well as “bottom-up” (array data driven) approaches allowed us to identify a comprehensive set of accessible aCGH based cancer CNA data sets and to estimate the ratio of accessible data of the overall published/deposited data.

As main result of the array data driven approach, we extracted 495 series comprising of 32002 arrays, generated on 237 platforms from NCBI’s GEO. Among those, raw data files of approximately 29000 whole genome arrays were suitable for inclusion into our data processing pipeline. When reviewing the content of AE, we found that the majority of AE cancer genome data sets were also submitted to GEO. At the time of writing, 11 datasets including 712 arrays not present in GEO had been processed based on AE specific series. Detailed information on the GEO/AE data sets is provided in Table S1.

The top-down procedure was based on our group’s continuous monitoring of cancer related articles utilizing genome copy number screening approaches, as established for our “Progenetix” project (www.progenetix.org[19]). The census date for the literature based data collection was August 15 2011. At this point, we had identified 931 articles discussing a total of 53213 genomic cancer CNA profiles based on aCGH techniques. Of these, 8728 cases out of 199 articles so far had been extracted from publication related sources (e.g. supplementary data tables) and annotated and made been accessible through Progenetix. This data included cases for which only supervised information but no probe data was available (e.g. author annotated Golden Path or cytogenetic CNA regions). Literature based data sets containing probe specific data or with the respective data presented to us by the authors (640 samples) were included into our arrayMap data processing pipeline.

The data content of arrayMap is summarized in Table 2. Current numbers on the website will include changes based on ongoing annotation efforts (i.e. addition of data sets, removal of low quality arrays).

Table 2. aCGH data integrated in arrayMap.

doi:10.1371/journal.pone.0036944.t002

As a by-product of our data collection and annotation efforts, we are able to provide estimates of content and trends for the platform usage and cancer entity coverage for the majority of published data. According to the assigned ICD-O 3 (International Classification of Diseases for Oncology, 3rd Edition) code and descriptive diagnostic text, breast carcinoma predominates as single largest clinical entity with 6459 arrays.Table S2 presents sample sets in arrayMap classified by ICD-O code.

The most widely available array CGH platforms are either based on large insert clones (BAC/P1 arrays) or based on shorter single-stranded DNA molecules (oligonucleotide arrays), which may or may not include single-nucleotide polymorphism specific probe sequences (SNP arrays). Also, although designed for gene expression profiling, cDNA arrays were used by several laboratories for measuring genomic copy number changes. Although all these platforms are considered suitable for whole genome CNA analysis, their probe densities and other parameters can affect specific features of the analysis results [20][23]Table S3 lists the general platform types and corresponding overall numbers of the data registered in arrayMap.

In reviewing the technical platform composition, two related trends become apparent (Figure 1). Originally developed in groups with expertise in molecular cytogenetics and cancer genome analysis, printed large insert clone arrays (BAC/P1) were the first whole genome CNA screening tools with a spatial resolution surpassing that of chromosomal CGH. Other groups re-employed cDNA arrays, developed for expression screening, for genomic hybridizations. However, over the last years one can observe the overwhelming use of various industrially produced oligonucleotide array platforms, which compensate their low single probe fidelity through a probe density at 1–3 orders of magnitude higher than common for BAC/P1 arrays. Another reason for the success of oligonucleotide arrays is the integration of SNP specific probes, which in principle allows to use of the same experiments for genetic association studies and the evaluation of copy number neutral loss of heterozygosity regions [12][24][25].

Figure 1. Distribution of resolutions and techniques of GEO platforms.

Each point represents a genomic array. The Y axis is labeled with probe number in log scale. The X axis denotes the time sequence of array data generation. From left to right are years from 2001 to 2011.

doi:10.1371/journal.pone.0036944.g001

thumbnail

Data Access and Usage Scenarios

Based on our experience from the Progenetix project, a strong emphasis was put on a user friendly data interface. Here, we followed a “dual user type” scenario: Users without bioinformatics background should be able to intuitively visualize core data features as well as to perform standard analysis procedures, while for bioinformaticians the formatted database content should be accessible to use with their analysis tools of choice.

Query interface.

Data browsing in arrayMap is based on two types of query methods: search by experimental series metadata and search by sample features.

In the series query form, users can perform various search options by specifying (i) descriptive diagnosis text; (ii) disease classification (ICD-O 3 code(s)); (iii) disease locus (ICD topography code(s)); (iv) PubMed ID; (v) technique(s); (vi) series ID. For sample specific queries, additional features are available: sample ID; platform ID or description; and single or combined regional CNAs. Users can input gene name(s) in “regional CAN” search field. When at least two characters are entered into the field, suggestions based on a HUGO gene list are displayed for selection. Gene selections will be converted to genomic locations.

In the results table, associated array information is displayed. A number of links to additional and/or outside data is provided, according to the information available: the corresponding PubMed entries; the original GEO/AE accession display page for more complete information; the case and publication entries on the Progenetix website for further analysis; and importantly the array specific data visualization page.

Data download options.

On pages resulting from sample queries or sample data processing, users are presented with options to download sample data based on the current queryÕs return. Currently, three different file types are offered: JSON files, tab separated feature files and segments list files. These files enable bioinformaticians to perform further analyses based on their tools of choice. Particularly, the JSON format can be used for direct database import (e.g. MongoDB) or can be deparsed by common libraries (e.g. JSON.pm), or being read into web applications.

Array probe data visualization.

In the array plot interface, original plots of genomic array data sets can be searched and visualized (Figure S1). Default threshold parameters which were either provided with the data or assigned during the initial visualization will be loaded. In single array visualization, the general view of probe distribution and post-thresholding segmentation results are displayed for the whole genome as well as for each individual chromosome. If multiple arrays are retrieved, users can select sample data for downstream analysis procedures. Figure S2 shows the screenshot of single array visualization.

Users can segment the raw data values and re-plot the results after revising the following parameters:

  • Golden path edition, default HG18/NCBI Build 36. This is still the commonly used version of the human reference genome assembly. At the moment, coordinates of probes from all platforms were remapped to HG18. For the near future, we intend to allow for a selection of updated genome editions.
  • Chromosomes to plot, default 1 to 22. Single or all chromosomes can be selected for re-plotting. To avoid gender bias, most platforms do not contain probes in chromosome X and Y during the design.
  • Loss/gain thresholds. Cut-offs from which a segment is considered a genomic loss or gain. The optimum thresholds may vary between platforms.
  • Region size in kb. Sets a filter to remove CNA below (e.g. probable noise) or above (e.g. exclude non-focal CNA) a certain size range.
  • Minimal probe numbers for segments. This parameter can be used to limit the minimal number of probes required for a segment to be considered (e.g. to remove aberrant segmentation due to probe level noise). Empirical examples would be values of 2–3 for high quality BAC arrays and 6–10 for Affymetrix SNP 6 arrays.
  • Plot region. Single genomic region to be plotted, overriding the chromosome selection above. When selected, plots with this region will be generated for all current arrays. This is valuable to e.g. display the CNA status and copy number transition points for specific genes of interest (Figure S3).
Zoom-in visualization of focal CNA.

Figure 2 shows the visualization of focal genomic imbalances, e.g. to identify genes of interest targeted by focal CNA. The whole genome view of GSM535547 (human high grade glioma sample analyzed by Agilent Human Genome CGH Microarray 244A) shows a small regional deletion in chromosome 9p21. When plotting the approximate locus of the deletion (specified as chr9:21600000-22400000), genes, probes and chromosome bands in this zoomed in region are shown. Two genes, MTAP and CDKN2A can be seen as being localized in a potential homozygously deleted region. The focal deletion of these known tumor suppressor genes [26][27] points to their specific involvement in the glioblastoma sample analyzed here.

Figure 2. Zoom-in visualization of focal CNA.

(A) GSM535547 (human high grade glioma, Agilent CGH 244A) shows high quality of probe hybridization signal. CNAs are easy to distinguish. (B) When zoom-in the whole chromosome 9, an approximately 80 MB deletion is displayed, with two breakpoints located in p and q arm respectively. In addition, a small regional deletion in 9p21 is quite clear. Color bars in lower region of the panel represent 848 genes located in chromosome 9. (C) Zoom in the potential homozygously deleted region in 9p21 by specifying the exact region: chr9:21600000-22400000. The zoomed-in plot shows probes, chromosome band and two tumor suppressor genes, MTAP and CDKN2A. Gene name and location will be given while mouse hover. They link to UCSC genome browser with additional information.

doi:10.1371/journal.pone.0036944.g002

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Querying compound CNA.

The concept of focal CNA detection can be integrated with a global search for arrays containing gene specific regional imbalances. As an example, we demonstrate the search for arrays displaying imbalances in 4 gene loci associated with glioblastoma: EGFR, a transmembrane receptor and proto-oncogene [28]; PTEN, a tumor suppressor gene [29]; ASPM, frequently overexpressed in glioblastoma relative to normal brain tissue [30]; and CDKN2A (see above). In the “Search Samples” form, the “Match (Multiptle) Regions & Types” can be used to specify the genomic regions of those four genes including the expected CNA type: for EGFR (chr7:55054219-55242524:1), PTEN (chr10:89613175-89718511:-1), ASPM (chr1:195319885-195382287:1) and CDKN2A (chr9:21957751-21984490:-1), respectively. When executing the query, these regions were matched with the whole database and returned cases which have imbalances overlapping all these regions. When excluding controls and “worst quality” datasets, 303 out of 42421 arrays could be identified matching all four CNA regions. In addition to glioblastoma, several other types of cancer cases were among the results, including e.g. neuroblastomas, breast carcinomas, melanomas and lung carcinomas, which is in accordance with some previous observations [31][34]. CNA and associated data of those cases can be processed by online tools for further analysis and visualization (Figure S4) or downloaded for offline processing.

Copy number profiling of selected cancer entities.

One aim of arrayMap is to allow researchers to conveniently perform aCGH meta-analysis across different platforms. By selecting a single or several cancer entities e.g. based on their ICD entity codes or diagnostic keywords, users are able to generate disease specific CNA frequency profiles or to compare profiles of different cancer types.

As an example, we used ICD-O code 9440/3 (glioblastoma, NOS) to query the database. 1478 arrays from 25 publications were returned and passed to our suite of online analysis tools. Chromosomal ideograms and histograms were generated representing the frequency of copy number aberrations identified over the whole dataset (Figure 3A). In the overall aberration profile, the most common genomic imbalances included whole chromosome 7 gain and chromosome 10 loss, as well as focal gains e.g. on bands 1q21 and 17q21. In our example dataset, a prominent focal deletion hot-spot was centered around 9p21.3 (921 of 1478 arrays, 62.31%) which had been discussed previously [35]. The distribution of CNAs over the individual arrays was visualized through a matrix plot (Figure 3B). As additional information to the frequency histograms, this form of visualization facilitates e.g. the detection of CNA patterns among individual arrays as well as the concordance of individual CNAs (e.g. here the arm-level changes in chromosome 7 and 10).

Figure 3. Copy number profiling of glioblastoma.

(A) Chromosomal ideogram and histogram showing frequency of copy number aberrations. Percentage values corresponding to gains (yellow) and losses (blue) identified over the whole dataset. The most frequent imbalances include gain of chromosome 7 and loss of chromosome 10, 9p21.3. (B) Matrix plot of 1478 glioblastoma cases. The Y axis represents individual samples. The distribution of genomic copy number imbalances reveals the individual aberration patterns of glioblastoma. (C) Heatmap of regional CNA frequencies for 1478 arrays. The intensity of green and red color components correlates to the relative gain and loss frequencies, respectively. If dataset contains cancer subtypes, cancers with similar CNA frequency profiles will be clustered together, such that differences between subtypes will be revealed (e.g. see Figure S4H).

doi:10.1371/journal.pone.0036944.g003

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In the matrix plot, clicking on a certain segment would open the related view in the UCSC genome browser[36], for detailed information related to this genomic region (SVG plot only). The plot order of arrays can be re-sorted according to ICD morphology, ICD topography, clinical group or PubMed ID, which can be helpful in associating CNA patterns to external classification categories. For the selected classification criterium (default: ICD morphology), regional CNA frequencies for cases matching the different values will be visualized through a heatmap (Figure 3C); this feature is especially useful when comparing a number of different primary classification criteria.

An Overall Genomic Copy Number Profile of Cancer

Our high quality core dataset in arrayMap was used to generate an overall cancer copy number aberration profile based on 29,137 arrays (Figure 4). This data represented 177 cancer types according to ICD-O 3 code, with 59 types among them contained more than 50 arrays. Overall, one of the most common genomic alteration is copy-number gain of chromosome band 8q24, which is found in 30% of total samples. According to the COSMIC [37] database, the most significant cancer gene in this region is MYC. It is a well-documented oncogene codes for a transcription factor that is believed to regulate the expression of 15% of all genes, including genes involved in cell division, growth, and apoptosis [38][39]. Other common imbalances observed in at least 25% of oncogenomic arrays included gains of regions on e.g. 17q21 (29%), 1q21 (33%) and loss of regions on e.g. 8p23 (32%) and 9p21 (25%), including focal deletions of the CDKN2A/B locus (Figure 2).

Figure 4. The overall cancer copy number aberration profile consisted of 29137 arrays.

This plot represents 177 cancer types according to ICD-O 3 code. Percentage values in Y axis corresponding to numbers of gains (green) and losses (red) account for the whole dataset.

doi:10.1371/journal.pone.0036944.g004

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While the overall CNA frequency distribution points towards DNA features targeted in multiple entities, this information is insufficient for deriving molecular mechanisms associated with specific cancer types. The genomic heterogeneity of different neoplasias is reflected in the varying patterns of regional CNA frequencies. Based on our core dataset, we have generated a heatmap-style visualization of frequency profiles for all ICD-O entities containing more than 50 arrays (Figure S5). The striking patterning of the CNA profiles indicates the non-random occurrence of CNAs, and should be seen as an invitation to explore e.g. CNA similarities shared by separate histopathological entities, as a way to transpose knowledge about pathophysiological mechanisms.

Discussion Top

arrayMap was developed to facilitate the progress of oncogenomic research. Our aim is to provide high-quality genomic copy number profiles of human tumors, along with a set of tools for accessing and analyzing CNA data. The service has been implemented with a straightforward web interface, including search options for CNA features and clinical annotation data. All assembled datasets are processed into platform independent segmentation and, for the vast majority of arrays, probe level data files, and are presented in consistent formats. Importantly, the direct access to precomputed probe level data plots supports a rapid evaluation of experiments for features of interest. As a curated database using standardized annotation schemes (e.g. ICD classification), arrayMap facilitates the exploration of cancer type specific CNA data, as well as the statistical association of genomic features to clinical parameters.

arrayMap is a dynamic database that is being continuously expanded and improved. We will review the existing and newly published articles to update the database periodically. Over the past decade, we have witnessed a rapidly increasing number of aCGH publications, which gives us sufficient evidences to anticipate that cases in our database will continue to be deposited at a high rate. Although arrayMap is not a user driven repository, we welcome and support users interested in using the site for yet undisclosed data, if they agree on data sharing upon publication.

Although, in contrast to the continuous data from expression analysis, copy number analysis explores discrete value spaces (countable number of DNA copies, for segments defined by genomic base positions), interpretation of the data can vary due to different low level (e.g. signal/background correction) and higher level (e.g. segmentation algorithms, regional or size based filtering) procedures. In that respect, we have to emphasize that the results of our data processing and annotation procedures are open to scrutiny. We encourage a critical review of individual results, and are open for suggestions regarding improved processing procedures for specific platforms.

In this paper, we have provided example scenarios of using arrayMap on different levels, i.e. locus centric and for entity profiling. We believe that systematic analyses will help researchers to discover features which are indiscernible in individual studies, and thus bring new insights for understanding of disease pathology and the development of new therapeutic approaches [40][43]. We expect that researchers will integrate arrayMap data with their own analysis efforts, e.g. to increase sample size or for result verification purposes. We hope that this database will promote further evolution of microarray data meta-analysis. ArrayMap provides access to more than 200 tumor types, which makes it suitable for research across cancer entities. Furthermore, normal sample controls are of vital importance for genomic imbalances studies. ArrayMap includes more than 3000 normal samples from healthy individuals or from normal tissues of cancer patients. These data could be integrated as reference dataset e.g. to account for copy number variation data superimposed on the tumor profiling results.

In the near future, with the continuous accumulation of very high resolution CNA data from genomic arrays and next-generation sequencing experiments, it will become possible to integrate these data into systems biology methods to elucidate effects of genomic instability, and describe the results from more perspectives. Envisioned examples would be e.g. the identification of genes that are involved in metastasis and treatment response; identification of chromosomal breakpoints distribution in cancer; and modeling functional networks in cancer by systems biology approaches.

Methods Top

Dataset Collection

Raw experimental data from a variety of platforms and repositories were extracted. They were converted to an uniform format which is suited to our reanalysis and visualization system. After a series of parsing procedures, the called copy number data is stored in arrayMap. The flowchart of arrayMap data collection and analysis is as shown in Figure 5. Five main data sources are integrated into arrayMap:

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Figure 5. The flowchart of arrayMap data collection and analysis procedures.

Publicly available raw data or segmented data was collected from the respective data sources. Files were re-processed by distinct procedures, according to the different data types. Probe coordinates were remapped to the most commonly encountered human reference genome assembly (NCBI Build 36/hg18). All probe specific ratios were converted to log2 values. Thresholds for genomic gain and loss were obtained from the original publications or series annotations; if not available, empirical thresholds were assigned. A minimum of 2 probes was required for calling a CNA segment, with higher values used on high-density arrays and/or in cases of excessive probe level noise. Processed probe and segment information was converted to uniform formats and stored in per-sample text files, which are accessed through the arrayMap web applications.

doi:10.1371/journal.pone.0036944.g005

GEO/AE.

For extracting appropriate data Series from GEO/AE, two basic criteria have to be fulfilled. First, the raw data has to be from human malignancies analyzed by BAC, cDNA, aCGH or oligonucleotide arrays. Second, the array platform must be genome wide, with the optional omission of the sex chromosomes. Chromosome or region specific arrays were excluded because they were not able to reveal the whole genomic profile of the respective cancer. Associated clinical data was extracted if available.

TCGA.

Segmentation data with available clinical information was extracted and incorporated into the database. Due to data sharing restrictions, TCGA data is an exception in that, so far no probe level data is incorporated into arrayMap. This exception was accepted since users will be able to access individual TCGA datasets through the projects web portal at http://tcga-data.nci.nih.gov/tcga/.

Publications.

Many aCGH datasets can be found in the text or supplementary files of publications. In order to collect data from publications, we relied on our Progenetix projectÕs setup. Data in Progenetix is manually curated. The collection strategies are:

  • literature mining using complex search parameters through PubMed
  • identification of called aCGH data, in GP annotation or tabular format (article, supplementary tables)
  • evaluation of supplementary files for probe specific data tables
  • follow-up on article links outs, to repository entries or referenced datasets
User submission.

User submitted data was provided in a number of formats which were converted to the standard format as described. Although we accept and support private datasets, we insist on integration of at least the genomic and core clinical data (e.g. disease classifiers) upon publication of the datasets analysis results.

Dataset Analysis

Probe remapping.

A pipeline has been generated for determining the genomic positions for the tens to hundreds of thousands array probes with reference to a common genome Golden Path edition. For each array platform, the genome positions of probes were remapped to the current commonly used version of the human reference genome assembly (NCBI Build 36.1/hg18). Specific mapping procedures were employed for different types of probes. BAC clones were firstly remapped according to the clone sets information of Sanger/DECIPHER database [44]. If the probe position was not available, the UCSC Genome annotation database [36] (release hg18) was used for compensation. After these two steps, a mean of 98% of the BAC clones were remapped. For IMAGE clone sets, only the UCSC Genome annotation database was used. The average remapping rate of IMAGE clones was 91%. Affymetrix raw CEL data files were analyzed based on hg18 library files, namely the output segments have hg18 coordinates. The summary of the percentage of mapped probes is given in Table 3. The mapping details for each platform can be found in the (Table S4).

Table 3. Percentage of remapped probes according to platform types.

doi:10.1371/journal.pone.0036944.t003

Probe signal normalization.

The array data available was given in a variety of formats, most frequently as log2 ratio of probe hybridization intensity. In order to make data from different platforms directly comparable, all other types of normalized values were converted to log2. For dye swap experiments, reference/tumor intensity ratios data was “reversed” representing a tumor/reference value. For some two-color arrays for which only raw signal intensity were provided, the normalized log2 ratio for each probe was calculated by.

where T and T represent tumor sample intensity and tumor channel background intensity respectively, and R and R represent reference sample intensity and reference channel background intensity respectively. If multiple instances of the same clone exist, the average signal intensity of the certain clone was considered.

To call gains and losses according to normalized log2 ratio is an important step to identify copy number imbalances. For each re-analyzable dataset, related publications were explored to obtain original threshold descriptions. If this information was not available, empirical thresholds were assigned and resulting CNA calls were visually compared with probe value plots. Processing method and threshold information for each array are provided in the Table S5.

Affymetrix genotyping arrays.

For the widely used Affymetrix GenomeWide SNP arrays, raw CEL files were downloaded and underwent a massive re-analysis using the R package aroma.affymetrix [45] with the CRMAv.2 method [46]. During the processing step, approximately 50 normal sample arrays were employed as a reference set for each array type to reduce the noise level. Normal tissue arrays from different labs were extracted and used to build the reference dataset. In order to obtain high quality arrays, we excluded arrays which contain segments greater than 3 mega-bases, since copy number variations are always smaller than 3 mega-bases. The list of normal tissue reference arrays is giving in Table S6.

Quality control.

In our review of array data deposited in GEO or collected from publication supplements we encountered a large number of individual data sets with insufficient or limited probe quality. Also, for samples of unprocessed raw data (e.g. Affymetrix CEL files), we found that QC measures reported previously (e.g. call rate [47], NUSE [48], RLE [48]) only had a limited accuracy for detection of arrays with inadequate probe level data. Currently, the most viable strategy for quality assessment of processed, heterogeneous copy number arrays is the visual inspection of probe plotting and segmentation results through an experienced researcher. For the first arrayMap edition we generated a quality classification system, which contains a total of 4 categories based on inspections of genome-wide array plots:

  • Excellent. Probe signal distribution is significantly different between normal regions and imbalance regions. Signal baseline is distinct and unique, making segmentation threshold realistic appearing. Chromosomal changes are pretty clear.
  • Good. In general good quality. Probe signal may contain some noise, but tolerable. Chromosomal changes are distinguishable.
  • Hypersegmented. Serrated distribution of probe signal intensities, causing dozens of separate peaks and discontinuous segments. Chromosomal changes are always up to several hundreds and smaller than 5 mega-bases.
  • Noisy. Probe signal intensities are highly scattered, but well-distributed, with high standard deviation, resulting in the inability to differentiate copy number changes.

Depending on the intended research purpose this basic classification system can be used for a pre-analysis triage of copy number data. Applying stringent review criteria we identified a core dataset with “excellent” quality arrays accounting for approximately 60 percent of total arrays. We are currently working on a platform independent quality assessment system for genomic arrays, which will be implemented in future versions of the arrayMap resource.

Associated data.

For arrayMap, data is stored with separate datasets for each array. This is in contrast to the Progenetix database, for which technical replicates where available are combined into case specific CNA profiles. In arrayMap, technical replicates are assigned an identical case identifier to facilitate downstream statistical procedures including e.g. clinical data correlations. The assignment of the correct diagnostic entity to each sample is an essential step in generating a binding between genomic and associated data points. At the same time, to ensure annotation consistency and make the retrieval process more efficient, for all CNA profiles the following data points were manually collected from GEO/ArrayExpress and published papers if available.

  • Descriptive diagnostic text, as available through the original source
  • Diagnostic classification according to the International Classification of Diseases in Oncology (ICDO 3, morphology with code)
  • Tumor locus according to ICD (ICD topography with code)
  • Source of material (e.g. primary tumor, cell line, metastasis)
  • Clinical parameters where available, including age, gender, grade, clinical stage (TNM coded), recurrence/progression, time to recurrence/progression, death and followup
Web Server.

An online interface of arrayMap database was created using Perl common gateway interface (CGI) and R scripts running on Mac OS X Server. Sample and series data is stored using a MongoDB database eingine (http://www.mongodb.org). Precomputed array plots are stored as flat files, mostly in both SVG and PNG versions. The online release of the service has been optimized to be compatible with major browsers supporting current web standards (CSS2, HTML5, XML with inline SVG; e.g. Safari > = 3.0, Firefox > = 3.0, InternetExplorer > = 9, Google Chrome) with limited fallback support. Dynamic graphics provided in the array plot module were implemented as server side services by technologies including XML/XHTML, JavaScript, SVG and HTML5 Canvas.

For the future, we intend a quarterly database content revision to ensure inclusion of newly published articles and GEO/AE entries. Archived versions of the sample annotations will be made available upon special request. Additional feature and small data updates will be performed as seen necessary. The “News” page of Progenetix/arrayMap will be used for feature and content announcements.

Supporting Information Top

Figure S1.

Array data sets visualization. Original plots and optimized parameters for GSE21530 which contains 8 intimal sarcoma samples hybridized on Agilent CGH Microarray 244A platform. The normalized probe signal log2 ratios and post-thresholding segmentation results for each array are intuitively displayed. Genomic alterations are represented by horizontal green (gain) and red (loss) lines. Alterations defined here as regions with log2 ratio >0.15 or <−0.15. Simplified schemas of CNAs link to UCSC genome browser for further review.

(PDF)

Figure S2.

Screenshot of single array visualization. ArrayMap plots for GSM630977 (acute myelogenous leukemia). Besides the whole genome view, subviews of each chromosome are displayed as well. From these plots, different kinds of genetic variation events are clearly revealed, e.g. massive genomic rearrangement in chromosome 6; arm-level gain of chromosome 8q and 3MB focal change around 1p31.3. Through the “Plot Array Data” interface, users can segment the raw data values and re-plot the results with customized parameters.

(PDF)

Figure S3.

Plot single genomic region. In the “Plot Array Data” interface, input the precise location (chr5:1100000-1400000) in “Plot Region” field. Plots with this region were generated for all 8 arrays in the current series (GSE21530). In this region, there are 5 genes which are shown schematically as colored boxes. CNA status and copy number transition points for these genes are displayed.

(PDF)

Figure S4.

Compound CNA query. (A) Four gene loci associated with glioblastoma (EGFR, PTEN, ASPM and CDKN2A) were inserted into “Match (Multiple) Regions & Types” field. 303 out of 42421 arrays were returned. (B) Classification information of these 303 arrays were displayed and can be selected for the following analysis. (C) Statistical and plot parameters can be customized. Associated data was processed by online tools, and returned results included: (D) Chromosomal ideogram and (E) histogram, show frequency of copy number aberrations; (F) Matrix plot reveals the aberration pattern of selected arrays; (G) Array classification tree generated by hierarchical Ward clustering, arrays with similar frequency of CNA are part of the tree branch. (H) Heatmap of CNA frequencies clustered by clinical group.

(PDF)

Figure S5.

Heatmap of frequency profiles for 59 cancer types. Heatmap visualization of frequency profiles for all ICD-O entities containing more than 50 arrays in our core dataset. Region specific gain/loss frequencies were mapped to 1MB intervals. The intensity of colors (green: gains; losses: red) corresponds to the relative frequency of CNAs for each interval.

(PDF)

Table S1.

Entities extracted from NCBI GEO and EBI ArrayExpress.

(XLS)

Table S2.

Cancer entities grouped by ICD-O code.

(XLS)

Table S3.

Platform type distribution in arrayMap.

(XLS)

Table S4.

Probe remapping rate for platforms.

(XLS)

Table S5.

Processing method and threshold for calling genomic gains and losses.

(XLS)

Table S6.

Normal tissue reference arrays for Affymetrix platforms.

(XLS)

Acknowledgments Top

We want to thank Christian von Mering, Homayoun Bagheri, Henrik Bengtsson and Nuria Lopez-Bigas for helpful discussions.

Author Contributions Top

Conceived and designed the experiments: HC NK MB. Performed the experiments: HC MB. Analyzed the data: HC NK MB. Contributed reagents/materials/analysis tools: HC NK MB. Wrote the paper: HC MB.

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SOURCE:

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0036944

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Reporter: Aviva Lev-Ari, PhD, RN

 

According to The 2012 Johns Hopkins Heart Attack Prevention White Paper by Heart Experts

Roger S. Blumenthal, M.D. 

Director, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease

Professor of Medicine, Johns Hopkins University School of Medicine

and

Simeon Margolis, M.D., Ph.D.

Professor of Medicine and Biological Chemistry

Johns Hopkins University School of Medicine

 

The death rate from heart attacks has been declining steadily for many years, in large part because people are receiving better medical care. Yet too many men and women are not taking the steps that could help protect them.

It’s easier than you think. But you’d be amazed how many people ignore the #1 tool for preventing a heart attack:

What really triggers a heart attack?

What you need to know sooner rather than later.

See who’s most likely to have a heart attack. You’ll learn the most common risk factors and how to minimize them. You’ll also learn the importance of primary prevention if you haven’t been diagnosed with coronary heart disease (CHD) or suffered a heart attack.

Discover the changes that take place in the coronary arteries leading up to a heart attack.

Learn what happens during a heart attack, and how the steps you take during the first hour can affect survival.

Find out why a yearly flu shot can protect your heart. You’ll learn about the importance of taming inflammation.

Learn what your waist measurement can reveal about the health of your heart.

But this is only the beginning. Learn about the standard screening tests, and the newer, potentially better alternatives being developed.

The heart-mind connection: How cognitive behavior therapy (CBT) may help ward off a heart attack

Evidence linking the flu vaccine to lower heart attack risk.

Angina: A critical warning of heart disease that should never be ignored.

Latest thinking on how ministrokes (TIAs) lead to heart attack.

Explore new technologies that are now available to assess the health of your coronary arteries. See how the tests are done and how they compare to traditional methods of predicting future heart attacks.

You will feel far better prepared to have an intelligent conversation with your doctor about the issues that concern you most.

How great is your risk?

A close look at the factors that set the stage for heart attack.

Simply, clearly and accurately, the specialists at Johns Hopkins explain the major risk factors that lead to heart attack.

You will take a close look at the different types of lipids. Understand cholesterol’s role in your body… the difference between “good” HDL and “bad” LDL cholesterol… why reducing cholesterol levels can help prevent coronary heart disease and heart attacks… how triglycerides differ from the other lipids.

You will see how inflammation and C-reactive protein are associated with risk of heart disease and heart attack. Examine the role of blood clots and coronary artery spasms in triggering heart attacks.

You will learn which risk factors (like age and family history) can’t be changed, although knowing about them can motivate you to take the preventive steps that can LOWER your risk of heart attack.

More important you will learn which risk factors are within your control. You’ll be able to set clear, practical goals for yourself with guidance from Johns Hopkins specialists. And you’ll discover what to do if you have risk factors like high blood pressure, abdominal obesity or metabolic syndrome working against you.

Learn the MOST IMPORTANT STEPS After a Heart Attack —

Steps That Could SAVE YOUR LIFE

A special feature in The 2012 Johns Hopkins Heart Attack Prevention White Paper details essential steps you should take if you experience the warning signs of a heart attack.

Let us assure you, there is no more powerful motivator to get your cholesterol, your blood pressure and your weight under control than the threat of undergoing a heart attack sometime in the future.

This is just one of many reasons to order your own copy of The 2012 Johns Hopkins Heart Attack Prevention White Paper and start putting it to good use right away.

Direct to you from Johns Hopkins Medicine

Since 1889, Johns Hopkins researchers have advanced the development of science and medicine, quickly transferring new knowledge from the research laboratory to the patient’s bedside. The School of Medicine is the largest recipient of biomedical research funds from the National Institutes of Health, and in 2003, Johns Hopkins University’s own Peter Agre, M.D., won the Nobel Prize in chemistry.

The White Papers give Johns Hopkins an effective, affordable way to extend new knowledge to the widest possible audience, benefiting countless men and women with serious medical concerns.

When it comes to the health of your heart, you should insist on knowing where your information comes from. Check the credentials of the experts who advise you before you decide whether they are worthy of your trust.

The 2012 Johns Hopkins Heart Attack Prevention White Paper draws on the vast resources and experience of The Johns Hopkins Hospital and the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. It gives Johns Hopkins specialists a forum to explore the combination of lifestyle adjustments and medical therapies that can slow the progression of heart disease and decrease your risk of heart attack or stroke.

Prepared by two of the most respected experts in the field

You can trust what you read in The 2012 Johns Hopkins Heart Attack Prevention White Paper. Coauthor Roger S. Blumenthal, M.D., is Professor of Medicine in the Division of Cardiology at The Johns Hopkins Hospital and the Director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. His interests include the development of new strategies to manage coronary heart disease risk factors and the noninvasive detection of coronary atherosclerosis.

Co-author Simeon Margolis, M.D., Ph.D., is Professor of Medicine and Biological Chemistry at the Johns Hopkins University School of Medicine and the medical editor of The Johns Hopkins newsletter, Health After 50.

Their impeccable credentials and reputations ensure that what you read is responsible, practical and useful in your quest for a healthier heart.

You can also be sure that it reflects the latest scientific research and clinical findings.

The expertise you need, in clear, plain English you can understand and use every day

The 2012 Johns Hopkins Heart Attack Prevention White Paper brings you the latest news you can use. It’s designed with YOU in mind, the busy person who has no time, money or energy to waste on old or inaccurate information, or heart attack “prevention strategies” that are really just myths or hype.

Drug-free steps to take RIGHT NOW to lower your risk of a heart attack

The right lifestyle changes can go a long way toward bringing down high blood pressure and cholesterol levels. These simple changes may be enough to let you avoid medication altogether. But if not, making a few well-chosen adjustments in your habits can boost the effectiveness of the medications you take, perhaps even reducing the dosage you require.

How to protect against heart attacks with fiber. Find out if you are getting the recommended daily amount.

What new research reveals about calcium supplements and your risk of coronary heart disease.

What about soy? Antioxidants? Limiting your sodium? Boosting your potassium intake? Learn effective ways to get your risk factors under control through the food choices you make every day.

 

What counts as “exercise?”

Do you have to break a sweat before it’s good for your heart?

You’ve heard it before: regular exercise can raise HDL cholesterol, control your weight, improve the work capacity of your heart, reduce your blood pressure and blood glucose and relieve stress.

So why is it so difficult to get up off the couch and get moving?

You’ll learn how often to exercise. Whether short bursts of activity can offer the same protection as longer exercise periods when it comes to reducing risk of coronary heart disease.

And you will read how to exercise safely — a must-see if you are concerned about having a heart attack or cardiac arrest during physical activity.

“Alcohol to protect my heart? I’ll drink to that!”

Should you? Will drinking alcoholic beverages really lower your risk of heart attack, as the headlines proclaim? The 2012 Johns Hopkins Heart Attack Prevention White Paper looks at how a small amount of alcohol can help raise “good” HDL cholesterol. Discover what the research says is “enough” alcohol to reduce your risk of heart attack, and what’s “too much.”

See your heart’s health in a whole new way

Because solid, authoritative medical research stands behind the recommendations of Johns Hopkins Medicine, each White Paper includes highlights of new studies that are relevant to you.

When you have The 2012 Johns Hopkins Heart Attack Prevention White Paper, you have the power to affect your health care as never before. Use what you learn to:

Recognize and respond to symptoms and significant changes in your heart health as they occur.

Make conscious, deliberate choices in what you eat and drink and do, based on what is known to lower the risk of cardiovascular disease.

Communicate effectively with your doctor. A helpful glossary takes the mystery out of “medical-speak.” Words like ischemia and ejection fraction will lose their power to intimidate or confuse you.

You will be better equipped to ask informed questions and to understand the answers.

Make the right decisions, based on a better understanding of the newest drugs, the latest surgical techniques and the most promising research.

Take control over your condition and act out of knowledge, rather than fear.

 

Who will benefit from this timely intelligence?

The fact that you are reading this suggests that you’re not willing to leave your fate in others’ hands. You want to know more. You need to know more. And you’re willing to seek out the best and most current information so you can raise important issues with your own doctors.

The 2012 Johns Hopkins Heart Attack Prevention White Paper will prove valuable to you if any of the following criteria describe your personal situation.

You are being treated for high cholesterol or high blood pressure or have other cardiovascular risk factors such as diabetes, smoking, obesity or a sedentary lifestyle.

You have a family history of heart disease and want to break the pattern.

You want to reduce the likelihood of needing bypass surgery or other invasive procedures.

You have already had a heart attack and want to avoid a second one.

You realize that first heart attacks often prove fatal to women because the early warning signs — which are different from men’s — may be misunderstood or ignored.

You live with or care for someone with cardiovascular risk factors and want to do everything possible to prevent a heart attack.

 

The specialists at Johns Hopkins created The 2012 Johns Hopkins Heart Attack Prevention White Paper to serve as your first line of defense against a heart attack. Special Bonus: Place your order today and we will include a free gift that could, literally, save your life.

 

The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease takes a comprehensive approach to the management of heart health. In the FREE Special Report that you can download when you pay now for The 2012 Johns Hopkins Heart Attack Prevention White Paper, the experts share practical, specific advice on how you can slow the progression of cardiovascular disease and decrease your future risk of heart attack, stroke, bypass surgery or angioplasty.

What you need to know is yours free in Tested, Proven Ways To Save Your Heart. It’s our gift to you, when you order and pay by credit card… yours to keep and use even if you decide to return The 2012 Johns Hopkins Heart Attack Prevention White Paper for any reason.

 

 

FREE Heart Attack Prevention Special Report: 

Tested, Proven Ways To Save Your Heart

Heart Attack Prevention Strategies

The #1 Way to Prevent a Heart Attack 

The importance of smoking cessation cannot be underestimated.

Walking Your Way to a Healthier Heart 

Johns Hopkins specialists outline the best ways for starting a walking program to maximize your heart health.

Action Plan When a Heart Attack Strikes 

The crucial symptoms to look out for (which can often be different in men and inAs you wi women) and what to do and NOT do if you or a loved one starts to show the telltale signs.

Cholesterol Busting Foods

The latest research on stanols, sterols, soy, fiber, and more.

A Drink a Day for Heart Health?

Moderate alcohol intake has been suggested as a way to ward off heart attack. This special report discusses the pros and cons.

 

You’ll get BOTH — The 2012 Johns Hopkins Heart Attack Prevention White Paper mailed to you and your free Special Report as an instant electronic download, all for only $19.95 plus shipping and handling.

YOUR FREE GIFT shows you how to walk your way to a healthier heart. Yes, you’ve heard it again and again: Walking is a good way to protect your heart. Everyone knows how to do it. It doesn’t cost anything, and you don’t need special equipment other than the right shoes.

Do you know what a group of men did to lower their risk of coronary heart disease by 18 percent? Tested, Proven Ways to Save Your Heart reveals their winning walking approach that yielded big benefits. You will also discover:

A safe way to get started, and what’s “enough” exercise to give you the heart protection you’re after.

Is faster better? How to set a healthy pace for maximum cardiovascular benefit, and warning signs that you’re pushing too hard.

How to determine your “target” heart rate zone so your walks give you significant cardiovascular benefits.

The walking style that boosts your calorie burning by up to 10 percent.

How to make your walking plan work with the weather and your lifestyle.

Cool-down stretches that keep you from feeling sore afterward.

 

And so much more!

But walking is just the beginning. Your free copy of Tested, Proven Ways To Save Your Heart gives you a truly effective way to conquer your heart’s worst enemy. Despite everything the public has been taught for the last 40 years about the dangers of tobacco, cigarette smoking is responsible for about 440,000 premature deaths each year in the United States.

Smoking, or living with a smoker, can undermine your best efforts to achieve a healthy heart. Only 5 to 10 percent of people successfully quit on their own, which is why the information in this free gift is so essential. Based on vast clinical experience and knowledge of the full range of medications and techniques to help you quit, Johns Hopkins doctors give you tools that raise your chances of quitting for good.

Learn the three things that, if used in combination, give you a far greater likelihood of kicking the habit.

The latest scientific thinking on nicotine replacement gum, skin patches, nasal sprays and inhalers.

Who’s a candidate for the medications that can help reduce cravings and withdrawal symptoms.

Tips for people who have tried (perhaps many times) before without lasting success.

Why avoiding alcohol can help you avoid cigarettes…

 

and so much more…

The sooner you take steps to reduce your heart attack risk, the better. Prevention remains your most powerful medicine. But knowing how to respond in an emergency-whether it involves you or someone you are with-can be crucial to survival.

When heart attack strikes…

be prepared with a fast and appropriate response.

As you will learn in your free copy of Tested, Proven Ways To Save Your Heart, what you do and what you don’t do during the first crucial minutes and hours following a heart attack can make all the difference in the outcome.

Did you know that a third of all people having a heart attack never experience any chest pain at all? Your Johns Hopkins-designed “Action Plan When a Heart Attack Strikes” alerts you to the range of warning signs, including the less common ones that are more likely to occur in women.

At what point should you call an ambulance? When are you better off driving the person to the hospital instead of waiting for the ambulance to arrive? What information must the emergency personnel have right away? How do you handle the person in denial, who insists, “You’re overreacting” or “There’s nothing wrong?”

I hope you never need to use this information at all. But you’ll be much better prepared to respond calmly and effectively when you have your free gift, Tested, Proven Ways To Save Your Heart, on hand.

SOURCE:

http://www.johnshopkinshealthalerts.com/contact_us/

 

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

 

Leptin is considered to have an important role in reproductive functions, including menstrual-cycle regulation, pregnancy, and lactation. The absence of leptin action caused by functional mutations in the leptin gene (LEP) or the leptin receptor gene (LEPR) has been linked to infertility in rodents and humans. A pregnancy was reported in a woman despite absent leptin signaling.

In 1998, it was reported the case of a morbidly obese patient with a rare homozygous LEPR mutation, which was shared by several affected siblings. The mutation was found in the patient’s blood and adipose tissue, indicating no evidence of chimerism. She had been followed for morbid obesity since early childhood, with abnormal compulsive-feeding behaviors and reduced levels of growth hormone and thyrotropin. She entered puberty late, with irregular cycles after the age of 17 years. Repeated evaluations of sex-hormone levels were considered to be normal after the age of 18 years. The patient underwent abdominoplasty at the age of 16 years and gastric-bypass surgery at the age of 24 years. Six months after gastric bypass, her weight had decreased from 220 kg (485 lb) to 170 kg (375 lb), with a concurrent decrease in the body-mass index (the weight in kilograms divided by the square of the height in meters) from 81 to 62. She was counseled regarding contraception and was prescribed oral contraceptives. Two years after gastric bypass, just before an unplanned pregnancy, she had no diabetes, hypertension, respiratory disorders, or other recognized complications of obesity.

Ultrasonographic examinations during pregnancy were considered normal except for suspected macrosomia in the third trimester. The patient’s total weight gain during pregnancy was 50 kg (110 lb) from a prepregnancy weight of 180 kg (397 lb). Routine screening for gestational diabetes was normal. Although occasional elevated blood sugar levels were documented during the pregnancy, the glycated hemoglobin level in the third trimester was 5.6%. At 37 weeks 5 days of gestation (on the basis of first-trimester ultrasonography), the patient delivered a son by elective cesarean section, which was performed because of breech presentation and suspected macrosomia under epidural anesthesia after the administration of glucocorticoids for fetal lung maturation. The birth weight was 3720 g (8.2 lb), and the length was 50 cm (19.7 in.); the head circumference was 36.5 cm (14.4 in.), which was above the 90th percentile. The patient’s postpartum course was complicated by a wound infection. The infant’s neonatal course was complicated by hypoglycemia, hypocalcemia, and jaundice requiring phototherapy. The patient briefly breast-fed her child. The child’s growth and development have been normal; his weight at 1 year was 14 kg (31 lb).

This case of a natural pregnancy in a woman with a homozygous LEPR mutation calls into question the belief that leptin function is critical to reproductive function.

 

Source References:

 

http://www.nejm.org/doi/full/10.1056/NEJMc1200116

 

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Reporter: Aviva Lev-Ari, PhD, RN

October 24, 2012

Sequoia Supercomputer Pumps Up Heart Research

Tiffany Trader


Cardioid code imageThe Cardioid code developed by a team of Livermore and IBM scientists divides the heart into a large number of manageable pieces, or subdomains. The development team used two approaches, called Voronoi (left) and grid (right), to break the enormous computing challenge into much smaller individual tasks.Source: LLNLThe world’s fastest computer has created the fastest computer simulation of the human heart.

The Lawrence Livermore National Laboratory‘s Sequoia supercomputer, a TOP500 chart topper, was built to handle top secret nuclear weapons simulations, but before it goes behind the classified curtain, it is pumping out sophisticated cardiac simulations.

Earlier this month, Sequoia, which currently ranks number one on the TOP500 list of the world’s fastest computer systems, received a 2012 Breakthrough Award from Popular Mechanics magazine. Now the magazine is reporting on Sequoia’s ground-breaking heart simulations.

Clocking in at 16.32 sustained petaflops (20 PF peak), Sequoia is taking modeling and simulation to new heights, enabling researchers to capture greater complexity in a shorter time frame. With this advanced capability, LLNL scientists have been able to simulate the human heart down to the cellular level and use the resulting model to predict how the organ will respond to different drug compounds.

Principal investigator Dave Richards couldn’t resist a little showboating: “Other labs are working on similar models for many body systems, including the heart,” he told Popular Mechanics. “But Lawrence Livermore’s model has one major advantage: It runs on Sequoia, the most powerful supercomputer in the world and a recent PM Breakthrough Award winner.”

The simulations were made possible by an advanced modeling program, calledCardioid, that was developed by a team of scientists from LLNL and the IBM T. J. Watson Research Center. The highly scalable code simulates the electrophysiology of the heart. It works by breaking down the heart into units; the smaller the unit, the more accurate the model.

Until now the best modeling programs could achieve 0.2 mm in each direction. Cardioid can get down to 0.1 mm. Where previously researchers could run the simulations for tens of heartbeats, Cardioid executing on Sequoia captures thousands of heartbeats.

Scientists are seeing 300-fold speedups. It used to take 45 minutes to simulate just one beat, but now researchers can simulate an hour of heart activity – several thousand heartbeats – in seven hours.

With the less sophisticated codes, it was impossible to model the heart’s response to a drug or perform an electrocardiogram trace for a particular heart disorder. That kind of testing requires longer run times, which just wasn’t possible before Cardioid.

The model could potentially test a range of drugs and devices like pacemakers to examine their affect on the heart, paving the way for safer and more effective human testing. But it is especially suited to studying arrhythmia, a disorder of the heart in which the organ does not pump blood efficiently. Arrhythmias can lead to congestive heart failure, an inability of the heart to supply sufficient blood flow to meet the needs of the body.

There are various types of medications that disrupt cardiac rhythms. Even those designed to prevent arrhythmias can be harmful to some patients, and researchers do not yet fully understand exactly what causes these negative side effects. Cardioid will enable LLNL scientists to examine heart function as an anti-arrhythmia drug enters the bloodstream. They’ll be able to identify when drug levels are highest and when they drop off.

“Observing the full range of effects produced by a particular drug takes many hours,” noted computational scientist Art Mirin of LLNL. “With Cardioid, heart simulations over this timeframe are now possible for the first time.”

The Livermore–IBM team is also working on a mechanical model that simulates the contraction of the heart and pumping of blood. The electrical and mechanical simulations will be allowed to interact with each other, adding more realism to the heart model.

It’s not entirely clear why a national defense lab took on this heart simulation work. Fred Streitz, director of the Institute for Scientific Computing Research at LLNL, would say only that “there are legitimate national security implications for understanding how drugs affect human organs,” adding that the project stretched the limits of supercomputing in a manner that is relatable to the American people.

The cardiac modeling work was performed during the system’s “shakedown period” – the set-up and testing phase – and the team had to hurry to finish in the allotted time span. Once Sequoia becomes classified, it’s unclear if it will still be available to run Cardioid and other unclassified programs, although access will certainly be more difficult since the machine’s principle mission is running nuclear weapons codes.

Sequoia is an integral part of the NNSA’s Advanced Simulation and Computing (ASC) program, which is run by partner organizations LLNL, Los Alamos National Laboratory and Sandia National Laboratories. With 96 racks, 98,304 compute nodes, 1.6 million cores, and 1.6 petabytes of memory, Sequoia will help the NNSA fulfill its mission to “maintain and enhance the safety, security, reliability and performance of the U.S. nuclear weapons stockpile without nuclear testing.”

The Cardioid simulation has been named as a finalist in the 2012 Gordon Bell Prize competition, awarded each year to recognize supercomputing’s crowning achievements. Research partners, Streitz, Richards, and Mirin, will reveal their results at the Supercomputing Conference in Salt Lake City, Utah, on November 13.

SOURCE:

http://www.hpcwire.com/hpcwire/2012-10-24/sequoia_supercomputer_pumps_up_heart_research.html

Human heart simulated on world’s fastest supercomputer

October 29, 2012 | By 

Before the U.S. government cloaks the operations of the Sequoia supercomputer for classified nuclear arms analyses, scientists have tapped the world’s fastest computer for an unprecedented simulation of the human heart. With the aid of the supercomputer, according to an HPC Wire report, researchers have been able to model the heart down to the cellular level and simulate how the organ would react to certain drugs.

The supercomputer has been performing simulations of the heart with a modeling program, Cardioid, from researchers at Lawrence Livermore National Laboratory (LLNL) and IBM’s T.J. Watson Research Center, HPC Wire reported. The computing power and capabilities of the modeling program have advanced heart modeling from simulations of a handful of heartbeats to thousands. It enables researchers to get closer to the real thing as they boost their capacity to capture activities in the heart at finer levels of detail and complexity.

Drugmakers have spent billions of dollars on studies to improve their understanding of the heart, and computer simulations offer a way for researchers to gauge the potential impacts of a compound before testing it in living subjects. Researchers believe that Cardioid could help them understand the activity and potential side effects of drugs for an inefficient heart-pumping condition known as an arrhythmia, which can trigger congestive heart failure and other medical problems.

“Observing the full range of effects produced by a particular drug takes many hours,” Art Mirin, an LLNL computational scientist, noted, as quoted by HPC Wire. “With Cardioid, heart simulations over this timeframe are now possible for the first time.”

SOURCE:

http://www.fiercebiotechit.com/story/human-heart-simulated-worlds-fastest-supercomputer/2012-10-29

 

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Cancer Genomics – Leading the Way by Cancer Genomics Program at UC Santa Cruz

Reporter: Aviva Lev-Ari, PhD, RN

UPDATED ON 6/17/2013

UCSC Designing Social Network-type Model for Analyzing Cancer Data

June 17, 2013
 

NEW YORK (GenomeWeb News) – Seeking to make the masses of cancer sequence data that is being generated more useful for researchers, investigators at University of California, Santa Cruz, plan to use a $3.5 million grant from the National Cancer Institute to create a new platform for organizing and accessing these data.

The UCSC group plans to create a method for making the raw sequence information in repositories like the university’s Cancer Genomics Hub more useful for investigators seeking to make clinical predictions about how cancer mutations respond to drugs, for example.

The aim of the project will be to develop a new database called the Biomedical Evidence Graph, or BMEG, which will use a graph database structure, like Facebook does, to enable swift access to complex and interconnected datasets.

Principal investigator Joshua Stuart, a UCSC associate professor of engineering, likened the difficulty for many investigators of using raw sequence data to average computer users trying to work directly with binary code.

“Your web browser doesn’t understand zeros and ones. There are layers and layers of software programs between that and what you see on a web page. We need to do the same thing for DNA sequences to reach the higher levels of interpretation needed for scientific discovery,” Stuart said in a statement.

Stuart said that a platform similar to what social networks like Facebook use offer a “natural way” to represent data from tumor samples based upon the connections between their molecular profiles.

CGHub, which launched last year to house data from The Cancer Genome Atlas consortium and similar projects, holds thousands of genome sequences from individual patients and access is highly controlled and limited to approved projects.

BMEG, however, will not require such security because it will host higher-level data from analyses of the raw genome sequencing. This will enable a broader group of investigators to use and analyze these datasets without having to download massive files to their computers.

“TCGA researchers have built a lot of great tools for data analysis, and we need to get those installed in the BMEG so the rest of the world can engage in that higher level analysis,” Stuard said. “The idea is to build a shared knowledge base and create a playground where lots of researchers can interact, test their algorithms, and compare results.”

The BMEG will be located with the CGHub servers at the San Diego Supercomputer Center, and investigators will be able to run their analyses as apps on the BMEG, UCSC said.

SOURCE

http://www.genomeweb.com//node/1242591?hq_e=el&hq_m=1590835&hq_l=3&hq_v=e1df6f3681

Five3, maker of cancer genomics software, takes off from UCSC labs

October 29, 2012 | By 

A group from the University of California, Santa Cruz (UCSC), has embarked on a new project to commercialize cancer genomics software through a new startup company called Five3 Genomics. The company has attracted a few of the biggest names in genomics and biotech to serve as advisers.

Recent software applications have enabled scientists to analyze cancer genomic data to track molecular changes in cells, spotting some of the triggers that cause tumors to grow. Led by CEO and co-founder Steve Benz, Five3 Genomics plans to sell its cancer genomics software to healthcare companies and pharmaceutical firms. Drugmakers could use the company’s software to discover new targets for cancer therapies, while hospitals could use the technology to put patients on existing drugs that home in on the molecular triggers of their cancer.

Benz and his fellow co-founders have a crack group of bioinformatics and biotech experts to help guide their startup. They’ve called on their UCSC mentors, David Haussler and Joshua Stuart. Haussler’s lab has participated in some of the most pioneering efforts in genomics over the past couple of decades, including the Human Genome Project that raced to decode an entire human genome. Also, Dr. Patrick Soon-Shiong, who has made billions of dollars in biotech, is serving as a scientific adviser.

“We’re working with academic collaborators to build out the platform and starting conversations with pharmaceutical companies and insurance companies,” Benz, who recently wrapped up his doctorate at UCSC, told the Santa Cruz Sentinel newspaper. “It’s a great opportunity to be able to take this technology and commercialize it so that it can be used to help patients.”

SOURCE:

http://www.fiercebiotechit.com/story/five3-maker-cancer-genomics-software-takes-ucsc-labs/2012-10-29

UCSC grad students launch cancer genomics company in Santa Cruz

By Sentinel Staff Report

Santa Cruz Sentinel

Posted:   10/24/2012 04:11:37 PM PDT

SANTA CRUZ — The co-founders of Five3 Genomics, a new biotech company based in Santa Cruz, are former graduate students in the Baskin School of Engineering at UC Santa Cruz, where they helped develop innovative cancer genomics software.

Their company, which has signed a license agreement with UCSC, offers software and services for cancer researchers, pharmaceutical companies, and health-care organizations. Its goal is to provide the data processing and analysis required for personalized cancer therapy, in which treatments are matched to the specific genetic aberrations found in an individual patient’s cancer cells.

“We’re working with academic collaborators to build out the platform and starting conversations with pharmaceutical companies and insurance companies,” said CEO Steve Benz, who completed his doctorate in bioinformatics this year. “It’s a great opportunity to be able to take this technology and commercialize it so that it can be used to help patients.”

In addition to Benz, the co-founders of Five3 Genomics include Chief Technical Officer Zachary Sanborn and Chief Scientific Officer Charles Vaske. All three of them worked as graduate students with UC Santa Cruz bioinformatics experts David Haussler and Joshua Stuart, who are doing pioneering work in the field of cancer genomics. Haussler, a professor of biomolecular engineering and Howard Hughes Medical Institute investigator, said that Benz, Sanborn, and Vaske were “brilliant gradstudents.”

“Working at UCSC they were exposed to the cutting edge in computational genomics,” Haussler said. “They played a key role in developing our cancer genomics program.”

Vaske, who earned his doctorate in 2009, and Benz were lead developers of a software program from Stuart’s lab called Paradigm. Stuart, a professor of biomolecular engineering, has been a close collaborator with Haussler on cancer genomics projects, including The Cancer Genome Atlas funded by the National Institutes of Health and two cancer research “Dream Teams” funded by Stand Up To Cancer and other organizations.

Paradigm, one of the core technologies for Five3 Genomics, is used to understand which molecular pathways are affected by the genetic changes in a patient’s cancer cells. This information can be used in a clinical setting to guide therapeutic decisions and by pharmaceutical companies to identify new targets for drug development.

“On the pharmaceutical side, we can provide indications for new uses for drugs that are already out there, as well as identify targets for new drugs,” Benz said.

Sanborn, who will finish his doctorate this year, worked in Haussler’s lab on a DNA sequence analysis program called BamBam, which is used to identify the genetic changes in cancer cells. Sanborn and Benz also contributed to the development of the UCSC Cancer Genome Browser in Haussler’s lab.

The scientific advisers for Five3 Genomics include Haussler and Stuart, as well as Dr. Patrick Soon-Shiong, a surgeon, medical researcher, and biotechnology entrepreneur, and Dr. Margaret Tempero, deputy director and director of research programs at the UCSC Helen Diller Family Comprehensive Cancer Center.

“It’s particularly gratifying to see this UCSC research transition to a commercial product, so these cutting-edge techniques can begin to benefit the public as quickly as possible,” said Bruce Margon, vice chancellor for research at UCSC.

SOURCE:

http://www.santacruzsentinel.com/localnews/ci_21846767

Biotech billionaire’s supercomputer cuts cancer analysis to 47 seconds

October 4, 2012 | By 

Dr. Patrick Soon-Shiong, a surgeon and biotech mogul, has spotlighted a supercomputer-based system and network to rapidly transfer and analyze cancer genetic data in mere seconds as opposed to the weeks or months of previous approaches. The supercomputer crunches genetic data from a tumor with results on abnormalities in 47 seconds, and the high-speed fiber-optic network Soon-Shiong has championed transfers samples in shy of 18 seconds, according to an announcement Wednesday.

Soon-Shiong’s L.A.-based company NantHealth has joined forces with Verizon, Intel, Hewlett-Packard, Blue Shield of California and other players to advance a national system to enable rapid sharing of genomic information among cancer doctors, aiding physicians in making the right call on treatments for patients based on the characteristics of their tumors. It’s a big deal because lack of such information contributes to misdiagnoses.

Via NantHealth and other vehicles, Soon-Shiong has worked on integrating a variety of digital technologies to revolutionize scientific research and medicine. As Reuters reports, he’s poured more than $400 million from his estimated fortune of more than $7 billion into building the fiber-optic network. His nonprofit is working on connecting sequencing centers, medical research hubs and hospitals to the network to create an infrastructure for these groups to share data from big science endeavors such as The Cancer Genome Atlas.

Soon-Shiong built most of his fortune with the sales of Abraxis BioScience to Celgene ($CELG) in 2010 for $2.9 billion and APP Pharmaceuticals to Germany’s Fresenius two years earlier for billions. (Abraxis developed Celgene’s anti-cancer drug Abraxane.) He’s now reportedly the richest man in Los Angeles, where he owns a piece of the NBA’s Los Angeles Lakers and has been connected with efforts to bring an NFL franchise back to the city.

SOURCE:

http://www.fiercebiotechit.com/story/biotech-billionaires-supercomputer-cuts-cancer-analysis-47-seconds/2012-10-04

Bringing genomic medicine into clinical practice by placing supercomputers in the hands of physicians at point of care

WASHINGTON—-Dr. Patrick Soon-Shiong, Chairman of NantHealth and the Chan Soon-Shiong Institute for Advanced Health announced a revolutionary advance in cancer treatment that will reduce the necessary time for analysis from 8 weeks to an unprecedented 47 seconds per patient. For the first time, oncologists can compare virtually every known treatment option on the basis of genetics, risk, and cost – before treatment begins, not after.

Alongside Senator Bill Frist, MD, of the Bipartisan Policy Center and J. Michael McGinnis, MD of the Institute of Medicine and Doctors Helping Doctors, Dr. Soon-Shiong reported on the successful real-time analysis of the largest collection of tumor genomes in the United States, of 6,017 cancer genomes from 3,022 patients with 19 different cancer types, in the record time of 69 hours. Genomic analysis has taken an average of 8 to 10 weeks to complete. That delay leads not just to less efficient, more costly care, but sometimes to the wrong course of treatment altogether – and, thus, higher mortality. “Incorrect care that leads to loss of life is unacceptable,” said Dr. Soon-Shiong, “and from today onward, it will no longer be necessary.”

Oncologists currently prescribe a course of cancer treatment based on the anatomical location of the cancer. Yet a patient with breast cancer could benefit from the positive results discovered from a patient with lung cancer, if the underlying molecular pathways involving both cancers were the same. The inability to utilize genomic sequencing to guide treatment has been due to the inability to convert a patient’s DNA into actionable information in actionable time.

But by collaborating with Blue Shield of California, the Chan Soon-Shiong Institute for Advanced Health, the National LambdaRail, Doctors Helping Doctors, Verizon, Bank of America, AT&T, Intel, and Hewlett-Packard, NantHealth has built a supercomputer-based high-speed fiber network that will not only provide thousands of oncology practices with life-saving information, but do so in exponentially faster time. “Doctors will finally be able to provide higher-quality treatment in a dramatically more efficient, effective, and affordable manner,” says Dr. Soon-Shiong.

“It currently takes approximately two months and tens of thousands of dollars to perform the sequencing and analysis of a single cancer patient’s genome. We can’t reduce the cost of care and improve outcomes in cancer if we don’t have the capability to know the right treatment for the right patient before treatment begins. We needed a national supercomputing infrastructure that brings genomic medicine into clinical practice. By placing supercomputers in the hands of physicians, that need is now a reality,” said Dr. Soon-Shiong.

Accuracy will also be radically improved. Among NantHealth’s partner oncologists utilizing its fact-based software platform (eviti – http://www.eviti.com) the number of cases where doctors have made incorrect recommendations has dropped from 32% to virtually zero“With this patient-centered, fact-based approach to collecting and analyzing data, millions more patients will have a better chance of beating cancer,” Dr. Soon-Shiong emphasized. Over the past 12 months over 2,000 oncology practices representing 8,000 oncologists and nurses have successfully installed and utilized this fact-based (eviti) software platform, positively impacting thousands of cancer patients lives.

THE RESEARCH PROCESS

In July 2012, NantWorks’ scientific team (Five3 Genomics – http://www.Five3Genomics.com) collected 6,017 tumor and germline exomes, representing 3,022 cancer patients with 19 unique cancer types. The sample collection included: 999 breast cancer; 1.156 kidney and bladder cancer; 985 gastrointestinal cancer; 744 brain cancer; 745 lung cancer; 670 ovarian, uterine and cervical caner; 436 head and neck cancer; 177 prostate cancer; 70 melanoma cancer; and 35 blood tumor samples.

This massive amount of data totaled 96,512 gigabytes and was successfully transferred and processed via our supercomputing, high-speed fiber netowrk in 69 hours. This overall transfer speed represents a stream of one sample every 17.4 seconds, and the supercomputer analysis for genetic and protein alterations between the tumor and normal sample completed every 47 seconds per patient.

Given the nation’s estimated cancer rate of 1.8 million new cases in 2012, this infrastructure now brings the capability of analyzing 5,000 patients per day.

He noted that medicine has continued to make dramatic advances, but the delivery of medicine has lagged far behind, stuck in a world where information is trapped, patterns get missed, and patients suffer. Powered by advanced supercomputing technology and wireless mobile health, the network has become one of country’s fastest genomic platforms with connectivity to over 8000 practicing oncologists and nurses. “This revolution in healthcare is long overdue – converging 21st century medical science with 21st century technology,” Dr. Soon-Shiong concluded.

Through NantHealth’s genomic analysis network, doctors can finally make cancer treatment more efficient, more effective, and more affordable for more patients. And with public and private partners equally as committed to reshaping the way doctors deliver healthcare and treat cancer, there are no limits to what this health information breakthrough might lead to for all cancer patients.

A network of major cancer centers including those at City of Hope, John Wayne Cancer Institute, and Methodist Hospital in Houston, have contributed to this collection of over 6,000 genomes, which also included the entire collection of exome samples from The Cancer Genome Atlas.

About NantWorks

The core mission of NantWorks, LLC, is to converge a wide range of technologies to accelerate scientific discoveries, enhance research and improve healthcare treatment and outcomes. Founded and led by Dr. Patrick Soon-Shiong, NantWorks is building an integrated fact-based, genomically-informed, personalized approach to the delivery of care and the development of next generation diagnostics and therapeutics. For more information, see http://www.nantworks.com.

Contacts

NantWorks, LLC
Jen Hodson
310.405.7539
jhodson@nantworks.com

SOURCE:

http://www.fiercebiotechit.com/press-releases/launch-nations-fastest-genomic-supercomputing-platform-reduces-cancer-genom

Research cache in works

by Emily Gersema – Jan. 28, 2012 01:29 PM

The Republic | azcentral.com

Supercomputing supports genetic, cancer research in Arizona: compare patient cases to tailor care

A massive building near Phoenix Sky Harbor International Airport is now home to a supercomputer that one day is expected to store clinical-research reports, medical records and the decoded genetic makeup of millions of patients and their cancers.

Having this vault of medical information is a dream for doctors, specialists and researchers who are trying to tailor medical care to the individual needs of their cancer patients. Despite huge advances in research and medicine, doctors have no one-stop shop for up-to-date clinical-trial results, other medical cases and genetic maps of their patients.

With access to this massive library, cancer doctors potentially could specify with precision the dosages of medicines, chemotherapy and radiation therapy for their patients by comparing those cases to those of other patients with similar genetic makeups and similar cancers.

In effect, this supercomputer could be a gateway to personalized medical care, as its creator, billionaire scientist Patrick Soon-Shiong, envisions it. His staff at CSS Institute for Advanced Health in California, which owns the project, and supporters of personalized medicine said the vault also could help reduce doctor error in the diagnosis and treatment of patients.

Better treatments and more accurate diagnoses could help lower the cost of medical care and enable patients to get treatment at home instead of at the hospital, they said.

The presence of the supercomputer could put Phoenix on the cutting edge of medical research and treatment. The path to these potential medical breakthroughs, however, is fraught with privacy concerns. Patient advocates fear the project could open a pathway to exploitation if patient information isn’t confidential. They want assurances that the institute would require patient consent to obtain records, the records would be kept private and the project would be under close regulatory oversight.

The engine: A supercomputer

While the word “supercomputer” evokes an image of a giant computer, the machine located in the Phoenix storage site resembles a large herd of smaller computers that have been linked to one another.

“It used to be a one big monolithic thing,” said Anoj Willy, of the CSS Institute. “But now what we’re able to do is take lots of general-purpose computers and band them to create a big, superprocessing engine.”

The CSS Institute project, which involves equipment and products from Hewlett-Packard and Intel Corp., is in its earliest stages, Willy said. The institute plans to focus data collection on genetic research and cancer.

The endeavor would create at least 50 jobs with annual salaries of about $75,000. Soon-Shiong also would invest at least $200 million in development, construction, machinery and equipment to build the electronic-data-storage facility.

The institute is in the process of signing agreements with various institutions that have been sequencing genomes — the maps of DNA strands that make up living things.

Bob Peirce, senior vice president of Soon-Shiong’s Nant Holdings in Los Angeles, said that while scientists have made strides in human genomic sequencing, the maps of these sequences are scattered at different sites around the world, depending on which institution decoded them.

Researchers have not yet decoded the whole human genome, Peirce said. They have each decoded snippets.

The lack of a complete map and a one-stop shop for the genomic information for doctors and researchers impedes their progress in personalized medical treatment, he said.

This means genomic sequences currently aren’t “relevant to the average patient or the average doctor,” Peirce said.

Creating a complete map of the human genome would require a massive, computerized data center, like the one being built by Soon-Shiong in Phoenix — to decode what scientists estimate are 3 billion pairs of DNA strands.

In addition, Soon-Shiong wants the supercomputer and its data centers, including one planned for Scottsdale, to aid in mapping the genetic makeup of individual patients’ cancerous cells.

“We need to be in a position where we can analyze the genome of the cancer and determine the genome of the host patient (to treat them),” Peirce said.

Peirce offered assurances that the data would be highly secured to guard against hackers. The data could be accessed by people who are deemed “authorized users,” he said, which could include the patients themselves who are trying to monitor their conditions and care. The institute has been working with a “chief technical officer,” who worked at the Pentagon, on securing the data centers and information they contain, Peirce said. He declined to name the officer.

The concern: Privacy

Edward Abrahams, president of the Personalized Medicine Coalition, a non-profit group in Washington, D.C., said researchers are on the cusp of creating medical care tailored to each person’s needs, and they can reach that with a supercomputer.

But they are faced with several challenges. Chief among them is patient privacy, he said.

The federal Health Insurance Portability and Accountability Act guards patient privacy, but its reach is limited. Patient information is kept private within the realm of health care — at the doctor’s office, the hospital and with the patient’s insurance company, said Bob Gellman, a privacy expert in Washington, D.C.

“An institution like this (CSS Institute) is not covered by health-privacy laws,” Gellman said. “It’s not a health-care provider. It’s not an insurer.”

Gellman said a worst-case scenario would involve a patient sharing genetic information with a company or organization, only to have it misused or exploited by another party.

“The information when it sat in the health-care system — when it sat in your doctor’s office — had all kinds of protections,” Gellman said. “But if you give the information with your consent to somebody else, then someone could just go to that third party and say, ‘Give me all your information.’ “

In that scenario, the records and data are out of the patient’s control and are unprotected.

Individuals trying to solve the health problems of their autistic children, for example, may want to participate.

“That may be a perfectly rational decision.” Gellman said. “But for people who don’t know or aren’t aware of that (institution’s) motivation … you might agree to give this information, and 20 years later, you’re in litigation with somebody or you’re applying for a job and it comes up.”

 

Read more: http://www.azcentral.com/arizonarepublic/business/articles/2012/01/26/20120126medical-research-cache-in-works.html?nclick_check=1#ixzz2AjfTgdsf

http://www.azcentral.com/arizonarepublic/business/articles/2012/01/26/20120126medical-research-cache-in-works.html

Cancer Research targets human genome breathrough with supercomputer

Platform Computing LSF integrated with genetic sequencing technology

By Antony Savvas | Published: 16:04 GMT, 09 December 11 | Computerworld UK


A new supercomputing workload management system is aiding scientific work by Cancer Research and the Cambridge Research Institute’s human genome project.

Cancer Research UK is using Platform Computing’s LSF software to improve cluster efficiency and reduce IT costs on the CRI genome research.

By integrating Platform LSF with a new advanced genetic sequencing platform, the institute has already gained greater insight into genetic cancer mutations that will lead to scientific breakthroughs in the areas of cancer diagnosis, treatment and prevention, said Cancer Research.

“Platform LSF gives us the means to produce and manage a wealth of gene sequencing data that we could only have dreamed about previously,” said Peter Maccallum, head of IT and scientific computing at Cancer Research UK in Cambridge. “This has already lead to tangible published work looking into breast cancer, and is proving its worth in helping our researchers further the understanding of how cancers progress.”

Prior to implementing Platform LSF, CRI’s 21 research groups employed separate computing resources in separate locations, which drove up server costs, reduced utilisation rates and increased server maintenance.

By orchestrating workloads and managing CRI’s research applications in a single data centre, Platform LSF has enabled CRI to save approximately £50,000 by removing hardware and maintenance duplication across each location, while increasing the amount of data processed. Cancer Research says the institute can now direct more computing resources directly to its research teams “to use in a more timely and cost efficient manner”.

CRI has already saved the equivalent in man hours of one full-time employee by integrating Platform LSF, says Cancer Research. As a result, the institute plans to scale Platform LSF internally by adding more servers as compute requirements increase.

CRI is also collaborating with Platform Computing to architecturally support cross-organisation systems for HPC (high performance computing) clusters, that will enable CRI to collaborate with other research organisations in order to meet the growing demand for genomics research.

In other recent medical technology news, scientists at Cambridge University are developing a computer system that can read vast amounts of scientific literature, make rapid connections between facts and develop hypotheses. Cambridge University said most biomedical scientists cannot keep on top of reading all of the publications in their field, let alone an adjacent field. As a first step to solving the problem, Cambridge has developed its CRAB text-mining tool.

SOURCES:

http://www.cio.co.uk/news/3324141/cancer-research-targets-human-genome-breathrough-with-supercomputer/


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New England Compounding Center (NECC): Tracking the Sources of Fungal Infections

Reporter: Alan F. Kaul, R.Ph., Pharm.D,, M.S., M.B.A, FCCP

The cause of the outbreak or fungal infections caused by contaminated steroids prepared by NECC has now been confirmed and treatment guidelines for those patients affected are in place.  Unfortunately, the toll in human lives and suffering cannot be rectified.  Clearly, compounding pharmacies are licensed by each state to produce products to meet individual patient needs. They are not legally licensed to manufacture drugs for mass distribution as is a pharmaceutical manufacturer that is licensed and inspected by the FDA.

The question of how to preclude further human disasters such as this is not yet resolved.  Painting all compounding pharmacies as unreliable as some have suggested does an enormous discredit to those pharmacists operating safe and reliable facilities where sterility testing meets or exceeds recommended standards. Political grandstanding also does a disservice towards working towards a viable answer. Should the Pharmacy Compounding Accreditation Board (PCAB), an organization that inspects and certifies that its members meet or exceed USP Chapter 797 standards be given deemed status like The Joint Commission or other similar accrediting organizations to accredit compounding pharmacies? Should state Boards Of Registrations in Pharmacy of Public Health Departments be funded for additional staff to monitor and inspect sterile compounding pharmacies? If so, will the additional expense be paid by the state, the compounding pharmacies, or the patients requiring the specially prepared drugs? Ultimately, the taxpayers will be required to pay for the requisite safeguards.  While the answer is still unresolved, careful though should be given to all possible options including a combination of them in moving forward.  The status quo is not an acceptable solution to meet the needs of providing safe and effective drugs to the public.

Investigations have now confirmed that NECC is the pharmacy linked to the deadly outbreak of fungal infections caused by Exserohilum rostratum, Aspergillus fumigatus, and Cladosporium species. An estimated 14,000 patients in 23 states received steroidal injections between May 21 to September 26, 2012 from lots of drugs prepared by NECC on May 21, June 29, and August 10, 2012. These three suspected lots of drugs prepared from steroids contained 17,676 doses were shipped to 75 locations. Three hundred forty-four infections including meningitis and those of the joints and 25 deaths have been attributed to the contaminated drugs.  As of October 22, 2012, there were 54 patients with CDC confirmed fungal meningitis. Of those, 52 were due to Exserohilum rostratum and one each due to Aspergillus fumigatus, and Cladosporium species.

Several hospitals including Saint Joseph Mercy Ann Arbor Hospital (Ypsilanti, MI), a Baltimore-area emergency room, Saint Thomas Hospital (Nashville, TN) independently noted patients presenting with symptoms including headaches, sensation to light, and neck stiffness, vertigo, double-vision, and loss of muscle co-ordination. In some patients, spinal taps were suggestive of meningitis and treatment was begun. However, infectious disease specialists were unable to identify the pathogen causing the infections. In late summer, across the United States, the same pattern appeared; patients with life-threating infections and an unknown cause. In North Carolina, a 77 year-old generally healthy female patient received the third of thee epidural injections for back pain. In September, she began experiencing terrible headaches. After multiple trips for medical care and being misdiagnosed with migraines and undergoing a brain scan, a family member insisted that she be hospitalized until they could diagnose her illness. A spinal tap was performed and spinal fluid was cultured. Meningitis of an unknown cause was diagnosed.

In Tennessee a man in his 50’s who initially responded to treatment for meningitis and went home returned to Vanderbilt University Medical when his infection reappeared. The patient presented visibly ill and had unintelligible speech. Dr. April Petit an infectious disease specialist ordered the laboratory to test for unusual microbes and also fungi.  The later generally is found in immunocompromised patients. The laboratory reported that the cerebrospinal fluid culture grew Aspergillus.  After again reviewing the patient’s medical history, Dr. Petit noted that the patient had received an epidural steroid injection at the Saint Thomas Outpatient Neurosurgery Center several weeks prior to the onset of his symptoms.  She contacted the Tennessee Department of Health on September 18.

The TN Department of Health contacted Saint Thomas infection prevention staff and learned that another patient who had received an epidural steroid injection at the same facility followed a similar clinical path. Saint Thomas closed its Outpatient Neurosurgery Department on September 20 and TN notified the CDC.  State health officials in TN conducted an inspection of the Saint Thomas Outpatient neurosurgery Department to try to determine the etiology of the infection. Some considerations included improper infection control procedures, contaminated equipment, and contaminated drug.

Within a few days, several more cases of rare fungal meningitis was identified that developed between July 30 and September 18 and the TN Department of Health notified the MA Department of Public Health. The patients shared four commonalties, one being that they ad received an injection of methylprednisolone acetate manufactured by NECC.  On September 25, MA state regulators requested NECC provide a list of all medical centers that had received shipments of the suspect steroid.  They learned that the three suspect lots of drugs totaling 17,676 doses had been shipped to 75 centers.

As the CDC conducted its investigation of sites that had received the drug, they learned that other cases outside of TN had occurred including North Carolina and Michigan.  The CDC issued a health advisory.  Because of the rarity of fungal meningitis, few researchers and clinicians were accustomed to dealing with it. CDC convened an expert advisory panel to develop recommended treatment guidelines.  In addition to the initial discovery of Aspergillus fumigatus, thesubsequent cases were discovered to be caused principally by the black mold, Exserohilum rostratum.  Experts concurred that while cases caused by the former fungus were rare, cases caused by the later were even rarer and treatment options were not well identified. Many effected patients were elderly and had other co-morbidities further complicating distinguishing symptoms and making the choice of pharmacotherapy with drugs often associated with serious side effects even more difficult.

Multidisciplinary teams quickly developed expertise at Saint Joseph Mercy Ann Arbor where 66 patients were being treated.  The team included the Chief Medical Officer, pharmacists, emergency room physicians, infectious disease specialists convened for daily discussions and updates.  Drug regimens for each patient were finely tuned and a special clinic was opened to assist patients in managing their disease.

As the saga continued, more patients in multiple states were identified and treated. Unfortunately, the epidemic had already taken its grim toll.

http://www.cdc.gov/hai/outbreaks/currentsituation/

http://www.fda.gov/Drugs/DrugSafety/FungalMeningitis/default.htm

The United States Food and Drug Administration (FDA) continues to reiterate that there should be follow-up with patients who meet the following three conditions:

  1. The medication used was an injectable product purchased from or produced by NECC, including an ophthalmic drug that is an injectable used in conjunction the eye surgery, or a cardioplegic solution,
  2. The medication was shipped by NECC on or after May 21, 2012, and
  3. The medication was administered on or after May 21, 2012.

On October 22, 2012, the FDA made available a list of customers (no product information available) of NECC from May 21, 2012 sorted by state which can be found at:

http://www.fda.gov/downloads/Drugs/DrugSafety/FungalMeningitis/UCM325467.pdf

On October 23, 2012, the Centers for Disease Control and Prevention (CDC) issued a an Official Health Advisory Issuance of Guidance on Management of Asymptomatic Patients Who Received Epidural or Paraspinal Injections with Contaminated Steroid Products. CDC continues to recommend against treating using antifungal prophylaxis for treating exposed asymptomatic patients without a diagnostic testing indication meningitis. They indicate that the greatest risk of developing an infection is within the first six weeks 942 days) after injection. As an increased benefit from prophylaxis has not been demonstrated from currently available data, additional monitoring of these patients should be considered.

http://emergency.cdc.gov/HAN/han00330.asp

http://bostonglobe.com/lifestyle/health-wellness/2012/10/27/doctors-piece-together-rare-cases-fungal-meningitis-uncover-outbreak/55SIHvy58Pf8lCB0yFvpHJ/story.html

Outbreak baffled doctors until they saw common cause

By  Carolyn Y. Johnson   |   G L O B E S T AF F        O C T O B E R  2 8 ,  2 0 1 2

JEFF KOWALSKY FOR THE BOSTON GLOBE

Rhonda Hall, who had a steroid injection, talked with Anurag Malani, infectious disease specialist at a

Michigan hospital.

It was Labor Day weekend when the first patients began to trickle into an Ypsilanti, Mich., hospital complaining of headaches, sensitivity to light, and neck stiffness. Laboratory tests of the patients’ spinal fluid strongly suggested meningitis and physicians started treatment.

But in a cluster of offices on the third floor, four of Saint Joseph Mercy Ann Arbor Hospital’s infectious disease specialists wrestled with a puzzle: Why couldn’t the laboratory identify the microbe causing the infection?

 Later that week and some 500 miles away, a 51­ year­ old woman developed a powerful headache radiating into her face and headed to a Baltimore ­area emergency room. She was discharged after a normal brain scan, but returned the next day with distressing symptoms: double vision, nausea, vertigo, and a loss of muscle coordination. As her condition worsened, a spinal tap provided no clues to the underlying cause.

And then in mid­ September, Dr. Robert Latham at Saint Thomas Hospital in Nashville, Tenn., found himself perplexed by the case of a woman who returned to the hospital after a treatment for meningitis stopped working. Lab tests showed signs of a raging infection, but similarly, he could not identify the culprit.

At hospitals scattered across the country, it was the horror story of the waning days of summer. Teams of physicians faced the same medical mystery — patients with life­ threatening infections with an unknown cause. There were subtle hints that they were dealing with a highly unusual illness, and astute clinicians and state and federal health officials worked to connect the dots. Ultimately, they would discover that these seemingly isolated cases were the leading edge of an outbreak of a fungal meningitis so rare that many doctors will never see a case in their lifetimes.

 The cases would quickly be linked to three batches of an injected steroid produced by a Framingham compounding pharmacy, but by that time 14,000 people in 23 states had received the injections for back and joint pain. More than 300 have fallen ill, and 25 have died.

Still immersed in treating the illness, most doctors have not had time to reflect on it. But Latham compared the initial confusion, frustration, and growing alarm to the early 1980s, before HIV had been identified as the cause of AIDS. The impact of a tainted drug could never be compared to that global epidemic, but at Saint Thomas, where 38 patients have now been treated, the medical team had the same feeling of being overwhelmed by an unknown that was bigger than anyone imagined.

 “When the HIV patients first started presenting, we were all scratching our heads, saying, ‘What in the devil is this?’ ” Latham said. “Those of us here at Saint Thomas are having an experience similar to San Francisco General in the early 1980s, when young men were walking in” with pneumonia and cancer.

This time, the patients walking in were mostly middle­age and elderly, with signs of meningitis.

The struggle for answers

Elwina Shaw of Denton, N.C., received the third of a set of epidural injections for back pain at the end of August. A vibrant 77­year­old, Shaw was generally healthy, said her daughter, Dawn Frank, aside from a little bit of knee pain and the back trouble. She wanted back surgery, but she had been steered instead toward the shots to see whether they would help.

Shaw was working in her garden one day in September when she got a terrible headache, Frank recalled. Shaw went to the doctor, and at first was told she was having migraines. But they didn’t go away. She went to the hospital for a brain scan, but it still wasn’t clear what was wrong. She was sent home, Frank said, and was told it might be a virus.

Finally, on September 25, Frank brought her mother back to the hospital, determined that doctors would not send her away until they could figure out what was wrong. Near midnight, she remembers, they did a lumbar puncture, drawing out a sample of spinal fluid.

Frank prayed it would not be bad. Shaw’s 80 ­year ­old husband, Rex, needed her. A talented seamstress, eloquent writer, and a woman of great faith, she filled their home and lives with grace and love. She never drew attention to herself, and had always embraced being a homemaker and mother.

 The test results were clear: meningitis of unknown cause. Unbeknownst to her physicians and her family, Elwina Shaw had joined the constellation of cases that were challenging doctors and wrenching families in other states.

In Michigan, patients who responded initially to treatment for meningitis returned to the hospital, worse. In Maryland, the 51­year­old woman’s spinal fluid was tested for bacterial infection and viruses ranging from West Nile to herpes as medical teams tried to treat her, according to a report published in the  Annals of Internal Medicine . Within a week and a half of being admitted to the hospital, she was brain dead. In Tennessee, doctors were struggling to figure out how to help the woman who had seemed to recover, then relapsed.

Dr. Varsha Moudgal, an infectious disease specialist at Saint Joseph Mercy Ann Arbor in Michigan, said physicians there had been mulling over several unusual aspects of their handful of cases. Some patients seemed almost too well, Moudgal said, explaining that meningitis patients with the kind of sky­high counts of immune cells and extremely low glucose levels doctors measured would typically have more symptoms, such as altered mental abilities.

“They came in and didn’t appear to be as ill as their cerebrospinal fluid picture suggested,” Moudgal said. “They were talking to us. They were sitting up.”

Others had severe symptoms but their lab tests suggested their infections were not that bad.

The doctors turned to specialists in microbiology and pathology, asking them to rack their brains for better diagnostic methods. Physicians scoured the medical literature to see whether past cases could teach them how to treat their growing cluster of patients. Dr. Anurag Malani said he heard rumbles of a case at another hospital that echoed theirs.

“We knew something was wrong, but it was hard to put a finger on it,” Malani said. “In hindsight, I think a lot of other places were feeling the same frustration.”

Meanwhile, in Tennessee, Dr. April Pettit, an infectious disease specialist at Vanderbilt University Medical Center, had been struggling with the same disturbing pattern: A man in his 50s with what appeared to be meningitis. He initially responded to treatment, went home, and then returned, the infection careening out of control.

 When he came back, she reported in the  New England Journal of Medicine this month, he was visibly ill and his speech unintelligible. Searching for answers, she told the laboratory to test for unusual microbes, such as fungi, even though such infections are quite rare, usually occurring in people with suppressed immune systems.

“On morning rounds, Dr. Pettit gets a call from the microbiology laboratory,” said Dr. William Schaffner, an infectious disease specialist at Vanderbilt who is familiar with the case. “She steps out to get the call, and she receives the information the cerebrospinal fluid has grown a fungus: aspergillus. She is dumbfounded.”

A common denominator

Pettit reviewed her patient’s history, to see whether there was anything unusual, anything that could explain why an otherwise healthy, middle­aged man with no immune system problems could have gotten such a rare type of meningitis. Several weeks earlier, she learned, he had received an epidural steroid injection at Saint Thomas Outpatient Neurosurgery Center. It was the only thing that stood out. She contacted the Tennessee Department of Health.

Dr. Marion Kainer of the health department immediately got in touch with the infection prevention staff at Saint Thomas. She told them of the man in his 50s, whose disease had followed much the same trajectory as their patient — and who had also received an injection. Latham knew his patient had also gotten an epidural injection at the hospital’s neurosurgery clinic, but previously he had no reason to connect it to her symptoms.

“The fact we had two people with strange presentations, related to the epidural injection, I hope would have been a bellwether for us,” Latham said. But that day, they got an even clearer message that something larger was going on: Another person had been admitted with similar symptoms. That person had also had an injection at the same place.

Saint Thomas closed its Outpatient Neurosurgery Center on Thursday, Sept. 20, and Tennessee notified the Centers for Disease Control and Prevention in Atlanta. Latham accompanied state health officials on an inspection of the facility to see whether there were any clues as to where the infection had come from: Did the clinic have the proper infection ­control policies and procedures? Was there a chance equipment had been contaminated? Could it have been a contaminated drug?

 By that Sunday, other probable cases had been identified in Tennessee, and the next day the Tennessee Department of Health contacted their counterparts in Massachusetts. Late in the evening, the Tennessee officials told the Bay State regulators of six rare fungal meningitis cases that had developed between July 30 and Sept. 18 in their state. The patients had at least four things in common: one being that they had received an injection of methylprednisolone acetate made by New England Compounding Center.

A day later, state regulators asked the owners of the Framingham compounding pharmacy to compile a list of all the medical centers that had been shipped medication from three batches of the steroid that federal officials had flagged as suspicious. The lots, prepared on May 21, June 29, and Aug. 10, the officials learned, had been shipped to 75 locations — and they contained 17,676 doses.

The next day, Sept. 26, the company voluntarily recalled the products, but there was still no firm connection between the drugs and the outbreak.

Then, physicians at the High Point Regional Health System in North Carolina, where Elwina Shaw was being treated, received a call from the CDC. The High Point Surgery Center was among the places that received doses of the drug. The agency official asked whether there were any patients with symptoms similar to the Tennessee cases, according to hospital spokeswoman Tracie Blackmon. High Point did have such a patient, the hospital confirmed.

The CDC later said in a health advisory that it was that first case outside of Tennessee that was “possibly indicating contamination of a widely distributed medication.” Frank said her family was told her mother’s case helped point the finger at the contaminated drug. “The steroid was the common denominator,” Frank said.

The doctors in Michigan began to hear news reports of what was going on in Tennessee. They began to realize the common thread was the epidural injections their patients had received at a nearby clinic.

Treating an outbreak

Pinpointing the source of the infection was only the first step. Public health officials now realized that many more people were likely to be hospitalized in the coming weeks, but they had little idea how to treat them. Fungal meningitis occurs infrequently, and the circle of researchers who study such infections is small.

 The CDC convened a panel of experts to develop advice for physicians on what symptoms to watch for, how to best treat it, and when to start antifungal medications. Complicating matters was the fact that while the initial case in Tennessee involved a fungus called Aspergillus fumigatus, the subsequent cases were mainly caused by a black mold called Exserohilum rostratum.

Cases of meningitis caused by aspergillus were rare, say specialists in fungal diseases, but cases caused by black mold were even more so, making the outbreak almost entirely untrodden medical ground. The large number of elderly victims was another challenge, because many had chronic conditions that could make it difficult to distinguish symptoms or that make them unable to tolerate the harsh drugs.

Expertise rapidly developed at the centers that were hardest hit. At Saint Joseph Mercy Ann Arbor, where 66 patients had been treated as of Friday, there was a daily 9 a.m. “huddle” of health care providers, followed by a call that drew together people from across the hospital, from the chief medical officer to pharmacists to emergency room doctors to the infectious disease specialists.

Drug regimens were fine­tuned to diminish side effects, and a special clinic was set up to help patients manage the disease.

Patients will have to take the antifungal drugs for a minimum of three months — and possibly as long as a year.

More staff were brought in to help manage the flood of people who came to be tested for meningitis. On their busiest day, 66 spinal taps were drawn; during the last month, a couple hundred have been performed, Malani said.

Three patients have died, but two fell ill before the meningitis cases were connected to a fungus.

By the time Rhonda Hall showed up at the hospital a week and a half ago, systems and procedures were in place and the pace had slowed. The 49­year­old bus driver from Brighton, Mich., was in an accident a year ago that still causes her pain. She had recently had surgery on her left ankle and got a steroid injection in her hip.

Soon after, Hall found herself clutching the side of her mattress just to get out of bed, and she realized that it wasn’t just an after­effect of the surgery. Something was wrong with her hip.

After hearing about the contaminated injections on the news, she called and learned she had gotten one of the bad shots. She was diagnosed with a bone infection.

“I was very scared in the beginning,” Hall said last week, just before going into surgery to flush out the infected joint. “Now it’s to the point . . . I want it over with so I can start healing and feeling better.”

The lessons learned by physicians came too late for Elwina Shaw. During her time in the North Carolina hospital, Shaw had two strokes, her daughter said, but she was able to write her name in cursive and walk afterward. Her family was hopeful.

But her condition worsened, and she died Friday, Oct. 19. On that day, the CDC reported that 271 people were infected, 21 deceased.

Carolyn Y. Johnson can be reached at  cjohnson@globe.com. Follow her on Twitter

@carolynyjohnson.

© 2012 THE NEW YORK TIMES COMPANY

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