NINR Symptom Science Research Symposium

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NINR Symptom Science Research Symposium

GOOD MORNING TO ALL OF YOU AND WELCOME I’M DR. PATRICIA GRADY, DIRECTOR OF THE NATIONAL INSTITUTE OF NURSING RESEARCH, IT IS EXCITING AND EXTREMELY HIGH PLEASURE TO WELCOME YOU HERE TODAY FOR OUR SYMPTOM SCIENCE RESEARCH SYMPOSIUM, WHICH THROUGHOUT THE DAY WILL HIGHLIGHT INTRAMURAL SCIENTIFIC ACTIVITIES AND THE COLLABORATIONS THAT WE HAVE ACROSS THE NATIONAL INSTITUTES OF HEALTH AND OTHER ORGANIZATION RESPECT SURROUNDING NIH SINCE OUR ESTABLISHMENT 30 YEARS AGO NINL SUPPORTED RESEARCHERS WHO ADVANCE SCIENCE, PARTICULARLY IN THE AREAS OF BUILDING A SCIENTIFIC FOUNDATION FOR CLINICAL PRACTICE, PREVENTING DISEASE AND DISABILITY, MANAGING AND ELIMINATING SYMPTOMS CAUSED BY ILLNESS WHICH WILL BE OUR FOCUS TODAY AND ALSO ENHANCING END OF LIFE AND PALLIATIVE CARE OUR MISSION IS ACCOMPLISHED THROUGH THE INSTITUTE’S SUPPORT AN CONDUCT OF CLINICAL AND BASIC RESEARCH ON HEALTH AND ILLNESS ACROSS THE LIFESPAN OUR FOCUS IS UNIQUE IN NIH, IT CUTS ACROSS HEALTH AND BEHAVIORAL SCIENCE AREAS, PERHAPS BEST EXEMPLIFIED BY WORK IN SYMPTOM SCIENCE AND ALSO OUR WORK IN END OF LIFE AND PALLIATIVE CARE RESEARCH WORKS TO TREAT, MANAGE AND PREVENT MANY DIFFERENT ILLNESSES AND CONDITIONS ALSO PRIMARILY BUILDING A BASE FOR CLINICAL PRACTICE THE DIVISION OF INTRAMURAL RESEARCH HAS BUILT STRONG SCIENTIFIC PROGRAM BY SUPPORTING RESEARCH THAT FOCUSES PRIMARILY ON UNDERSTANDING UNDER LYING BIOLOGICAL MECHANISMS OF A RANGE OF SYMPTOMS THEIR EFFECT ON PATIENTS AND HOW PATIENTS RESPOND TO INTERVENTION LIKE THEIR COUNTERPARTS IN THE EXTRAMURAL COMMUNITY, NINR’S INTRAMURAL SCIENTISTS ARE DEEPLY ENGAGED IN ADVANCING THE SCIENCE OF WELLNESS AND QUALITY OF LIFE AS AN EXAMPLE OF THAT, EXPANDING CAPACITY AND PROVEN VALUE OF OUR OMICS, PARTICULARLY FOCUSED ON PROTEOMICS AND MICROBIOMICS FOR SYMPTOM MANAGEMENT THE INTRAMURAL SCIENTISTS ARE ACTIVELY APPLYING METHODOLOGIES TO UNDERSTAND SYMPTOMS OF ACUTE AND CHRONIC ILLNESS INCLUDING FATIGUE IN CANCER TREATMENT, COMPLEX GASTROINTESTINAL DISORDERS AND RELATED TO NEUROLOGICAL TRAUMA, AREAS REFLECTED IN TODAY’S PROGRAM AND HAS DEVELOPED SYMPTOM SCIENCE MODEL TO GUIDE RESEARCH IN THIS AREA, BEGINS WITH IDENTIFYING A COMPLEX SYMPTOM CHARACTERIZED INTO A PHENOTYPE FOLLOWED BY APPLICATION OF GENOMIC AND OTHER DISCOVERY METHODOLOGIES TO IDENTIFY POTENTIAL TARGETS FOR THERAPEUTIC AND CLINICAL INTERVENTIONS THIS MODEL IS A FRAMEWORK FOR TRAINING AND CAREER DEVELOPMENT YOU’LL HEAR MORE NINR IS DEVELOPING A CENTER USING THIS MODEL TO ELIMINATE OR REDUCE SYMPTOM BURDEN AS A TRANS-NIH RESOURCE, THIS SYMPTOM SCIENCE CENTER WILL PROVIDE A HUB WHERE COLLABORATIVE TEAMS OF INTERDISCIPLINARY INVESTIGATORS CAN ADDRESS SYMPTOM RESEARCH CHALLENGES SUCH AS THOSE POSED BY MULTIPLE CHRONIC ILLNESSES THE CENTER WILL EXPAND THE EXPERTISE OF SYMPTOM SCIENCE, MENTOR EARLY STAGE CLINICIANS AND SCIENTISTS AND PROMOTE DISCOVERY THAT INTEGRATES DATA TO INFORM PERSONALIZED APPROACHES TO SYMPTOM MANAGEMENT NINR SUPPORTED RESEARCH TO DEVELOP, IMPROVE PERSONALIZED STRATEGIES TO TREAT AND PREVENT SYMPTOMS ACROSS DIVERSE POPULATIONS AND SETTINGS THAT WILL FACILITATE CLINICAL MANAGEMENT OF ILLNESS AND LEAD TO MORE PRODUCTIVE LIVES I’M PLEASED SYMPTOM SCIENCE IS A PATH TO PRECISION HEALTH AND WILL BE DISCUSSED TODAY IN THE THREE SCIENCE PANELS YOU’LL BE HEARING I ENCOURAGE YOU TO PARTICIPATE IN THESE DISCUSSIONS BUT ALSO TO CONTINUE TO CLARIFY AND REFINE CONCEPT AND PROCESSES OF SYMPTOM SCIENCE THROUGH YOUR OWN RESEARCH TO HELP MOVE PRECISION HEALTH INTO EVERYDAY PRACTICE AGAIN, THANKS TO ALL OF YOU FOR BEING HERE AND FOR THOSE WATCHING ONLINE WE LOOK FORWARD TO A VERY INTERESTING AND FORMATIVE AND PRODUCTIVE SOMEDAY NOW I’LL INTRODUCE MY — MY PLEASURE TO TO YOU DR. ANN CASHION, DIRECTOR OF INTRAMURAL PRE-SEARCH PROGRAM, GENERAL OMIC AND ENVIRONMENTAL COMPONENTS ASSOCIATED WITH ORGAN TRANSPLANTATION, USES THE NIH SYMPTOM SCIENCE MODEL TO IDENTIFY BIOMARKERS TO PREDICT

AT-RISK PROGRAMS HER MASTER’S IS FROM THE UNIVERSITY OF ARKANSAS AND Ph.D. FROM UNIVERSITY OF TENNESSEE HEALTH SCIENCES CENTER PLEASE JOIN ME IN WELCOMING DR CASHION [APPLAUSE] >> THANK YOU, DR. GRADY, FOR OPENING TODAY’S SYMPOSIUM WITH SUCH AN IMPORTANT REMINDER OF THE SERVICE NINR AND ITS COLLABORATORS ACROSS THE INSTITUTES AND CENTERS PERFORM FOR THE NATION AND THE GLOBE RESEARCH WITHIN NINR’S INTRAMURAL RESEARCH PROGRAM ENCOMPASSES MANY AREAS OF INTEREST UNDER THE OVERALL FOCUS OF SYMPTOM SCIENCE, THESE TOPICS INCLUDE BIOBEHAVIORAL RESEARCH, DIGESTIVE DISORDERS, NEUROSCIENCE, CLINICAL BIOMARKERS, BRAIN INJURY, NEUROMUSCULAR SYMPTOMS AND DATA VISUALIZATION, DEVELOPING THIS FOUNDATION FOR INDIVIDUALIZED SYMPTOM MANAGEMENT STRATEGIES, NINR INTRAMURAL SCIENTISTS PERFORM INNOVATIVE SYMPTOM SCIENCE RESEARCH TO DETERMINE THE UNDERLYING BIOLOGICAL AND BEHAVIORAL MECHANISMS OF SYMPTOMS ASSOCIATED WITH THE VARIETY OF DISEASES AND CONDITIONS NINR’S SCIENTIFIC FOCUS UNITES BIOLOGICAL AND BEHAVIORAL SCIENCES, REQUIRING AN EMPHASIS ON PATIENT OUTCOMES, RATHER THAN TAKING A DISEASE ORIENTED APPROACH NURSING SCIENCE IS APPLICABLE ACROSS ILLNESSES AND CONDITIONS AND NURSE SCIENTISTS OFTEN WORK IN TEAM SETTINGS TO CONDUCT AND LEAD INTERDISCIPLINARY RESEARCH NINR’S INTRAMURAL SCIENTISTS ARE PARTICULARLY ADAPT AT FORMING RESEARCH HUBS, AND ARE LEVERAGING RESEARCH HUBS TO PROMOTE NOVEL FORAY’S INTO SYMPTOM RESEARCH, TODAY SYMPTOM SCIENCE RESEARCH SYMPOSIUM, A PATH TO PRECISION HEALTH, WE’LL BE HIGHLIGHT BE NINR ADVANCES AND COLLABORATIONS ACROSS THE NATIONAL INSTITUTES OF HEALTH AND OTHER ORGANIZATIONS NOW I WOULD LIKE TO PRESENT OUR KEYNOTE SPEAKER FOR THE SYMPOSIUM, NIH DEPUTY DIRECTOR FOR INTRAMURAL RESEARCH, DR MICHAEL GOTTESMAN, WHO HAS BEEN DEPUTY DIRECTOR FOR INTRAMURAL RESEARCH SINCE 1993 AT NIH, CURRENTLY ALSO CHIEF OF THE LABORATORY OF CELL BIOLOGY IN THE NATIONAL CANCER INSTITUTE, AND HAS SERVED AS ACTING DIRECTOR AND ACTING SCIENTIFIC DIRECTOR OF THE NATIONAL CENTER FOR HUMAN GENOME RESEARCH AS DEPUTY DIRECTOR FOR INTRAMURAL RESEARCH AT NIH, DR GOTTESMAN HAS INITIATED AN NIH-WIDE LECTURE SERIES AND REFORMULATED TENURE AND REVIEW PROCESSES IN THE INTRAMURAL PROGRAM HE IS ALSO INSTITUTED TRAINING PROGRAMS FOR UNDERREPRESENTED MINORITIES AND DISADVANTAGED STUDENTS AND A CLINICAL RESEARCH TRAINING PROGRAM FOR MEDICAL STUDENTS AND EARLY CAREER CLINICAL INVESTIGATORS PLEASE JOIN ME IN WELCOMING DR GOTTESMAN TO THE STAGE [APPLAUSE] >> GOOD MORNING WHEN PAT AND ANN ASKED ME IF I WOULD GIVE A KEYNOTE ADDRESS TO THE INTRAMURAL PROGRAM FOR THE NURSING INSTITUTE I SAID ABSOLUTELY THIS WOULD BE FUN AS YOU’VE HEARD, I’VE BEEN DEPUTY DIRECTOR FOR INTRAMURAL RESEARCH FOR 24 YEARS NOW, SHORTER THAN THE DURATION OF THE EXISTENCE OF THE INTRAMURAL PROGRAM AND NURSING INSTITUTE SO I’VE GOTTEN TO SEE AN INCREDIBLE EVOLUTION AND REVOLUTION IN THE THINKING ABOUT WHAT NURSING RESEARCH MEANS, AND DEVELOPMENT OF WHAT YOU WILL SEE TODAY AS AN EXTRAORDINARILY INTERESTING AND UNIQUE PROGRAM I THINK IN TERMS OF WHAT BOTH NIH OFFERS AND WHAT THE WORLD HAS SEEN BEFORE SO I THOUGHT I’D START WITH SOME HISTORICAL NOTES SOME PEOPLE HERE MAY NOT ACTUALLY KNOW ABOUT THE ROOTS OF THE NURSING INSTITUTE SINCE I LIVED THROUGH SOME OF THIS I THOUGHT I WOULD SHARE IT WITH YOU SO THE CONGRESS IN ITS WISDOM ESTABLISHED A NATIONAL CENTER FOR NURSING RESEARCH IN 1985, AND THE BILL CONTAINING THAT ESTABLISHMENT WAS VETOED BY RONALD REAGAN, WHO WAS THEN PRESIDENT OF THE UNITED STATES THAT VETO SUPPORTED BY THEN DIRECTOR JIM WINEGARDEN AT THE

NIH WAS OVERRIDDEN BY THE CONGRESS SO THE NATIONAL CENTER FOR NURSING RESEARCH WAS ESTABLISHED AND I HAVE TO SAY THAT AT THAT TIME THERE WAS SKEPTICISM NOT ONLY AMONG EXECUTIVE LEADERSHIP IN THE GOVERNMENT BUT ALSO AT THE NIH ABOUT WHAT EXACTLY NURSING RESEARCH WAS, AND HOW IT FIT IN WITH THE VIEW THAT WE DID MECHANISTIC STUDIES ABOUT DISEASE THAT WOULD RESULT IN CURE WE DIDN’T FOCUS MUCH ON CARE OF PATIETS OR SYMPTOM MANAGEMENT AS HAS BECOME THE GOAL OF THE NURSING INSTITUTE NONE OF THIS OF COURSE SHOULD SURPRISE NURSES NURSING ITSELF GREW OUT OF WAR AND STRIFE, AND NURSES HAVE ALWAYS BEEN TOUGH IN SUPPORTING IMPORTANCE OF WHAT THEY DO FOR EXAMPLE, YOU KNOW ABOUT FLORENCE NIGHTINGALE AND THE CRIMEAN WAR, AND THE RESULTS OF WORLD WAR II ALSO STRENGTHENED THE NURSING PROFESSION IN THE UNITED STATES BUT THE CONCEPT OF NURSING AS A RESEARCH HOME DIDN’T DEVELOP REALLY UNTIL THE NIH ESTABLISHED THE CENTER FOR NURSING RESEARCH NOW, ALTHOUGH WINEGARDEN WAS INITIALLY RESISTANT IT TURNED OUT HE IN FACT GAME A SUPPORTER OF THE NURSING INSTITUTE, AND HE DID HIS VERY BEST TO FIND REALLY TALENTED PEOPLE TO SET UP THE PROGRAM INITIALLY IT HAD AN EXTRAMURAL FOCUS, BUT EVENTUALLY AN INTRAMURAL PROGRAM WAS ESTABLISHED AND I THINK THAT OVER TIME THE NURSING INSTITUTE HAS BECOME A KIND OF MISSING LINK BETWEEN THE BASIC SCIENCE RESEARCH THAT’S DONE AT THE NIH IN THE LABORATORIES AND IN THE CLINICS AND THE RESEARCH THAT’S ESSENTIAL TO DELIVER CARE TO OUR PATIENTS AS YOU’VE HEARD AND WILL HEAR THROUGHOUT THE DAY IN A PRECISE WAY, THAT RESPONSE TO THE NEEDS OF INDIVIDUAL PATIENTS SO ONE EXAMPLE IN FACT OF THAT CONNECTION BETWEEN THE DISEASE ITSELF AND THE CARE OF PATIENTS CAME WITH THE AIDS EPIDEMIC WHERE THE NURSING CENTER AT THAT POINT TOOK A LEAD IN CARING FOR AIDS PATIENTS, AND THIS WAS — THIS IS A DISEASE WHICH WAXED AND WANED OVER SEVERAL YEARS BUT PEOPLE EVENTUALLY BECAME VERY DEBILITATED, THERE WILL A LOT OF BAD SYMPTOMS ASSOCIATED WITH THE DISEASE AND THE NINR SHOWED STRIPES IN TAKING THIS ON AND DOING A WONDERFUL JOB HELPING PATIENTS THROUGH THIS CRISIS IN 1988, THERE WAS A COLLABORATIVE INTRAMURAL RESEARCH PROGRAM ON SYMPTOM MANAGEMENT FOR AIDS PATIENTS WHICH WAS JOINED WITH NIAID, ANOTHER THEME IN MY COMMENTS THAT A LOT OF MAJOR EFFORTS OF THE NURSING INSTITUTE HAVE BEEN DONE WITH VERY STRATEGIC AND IMPORTANT COLLABORATION WAS OTHER INSTITUTES AT THE NIH, INTRAMURALLY AND EXTRAMURALLY A COLLABORATION WAS ESTABLISHED WITH NCI CONCERNING CARE OF CANCER PATIENTS CANCER PATIENTS AS YOU KNOW UNDERGO REALLY SERIOUS THERAPIES THAT CAN THEMSELVES BE DEPRESSING, CAN CAUSE ALL KINDS OF SYMPTOMS INCLUDING DEPRESSION AND ANXIETY AND LITTLE WAS KNOWN ABOUT THE UNDERCURRENTS OF THESE DISORDERS AND HOW TO TREAT THEM AND YOU’LL SEE TODAY THAT THERE’S A FAIR AMOUNT OF CONTINUING EFFORT TO UNDERSTAND WHAT ARE THE UNDERLYING CAUSES OF SYMPTOMS THAT MAKE DISEASE NOT ONLY THE DISEASE ITSELF BUT MAKE THE SUFFERING THAT’S ASSOCIATED WITH DISEASE SO THE INTRAMURAL PROGRAM OF THE NATIONAL CENTER FOR NURSING RESEARCH WAS ESTABLISHED BY THE DIRECTOR, THEN DIRECTOR OF THE CENTER, AIDA SUE HENSHAW IN 1992, EVEN IN $1,992 THE BUDGET WAS NOT A LOT OF MONEY HENSHAW RECRUITED CAROLYN MURDAW TO BUILD THE PROGRAM, AND SHE DID SHE STARTED HONOLULU AGING STUDY IN HAWAII TO EXAMINE IMPACT ON CAREGIVERS, USUALLY FEMALE FAMILY MEMBERS OF DEMENTIA OCCURRING IN AGING MEN THIS WAS A CLEVER MOVE SINCE OF COURSE NIH WAS FULL OF SUCH PEOPLE, BECAUSE — JUST AN ASIDE — BECAUSE POPULATION-BASED STUDIES ARE THINGS THAT NIH INTRAMURAL DOES VERY WELL AND IN FACT I’M JUST WRITING NOW AN ESSAY ON WHAT POPULATION-BASED SCIENCE AT THE NIH HAS CONTRIBUTED TO PUBLIC HEALTH, IT’S PRETTY EXTRAORDINARY HOW MANY REALLY IMPORTANT CONTRIBUTIONS HAVE BEEN MADE BY THE INTRAMURAL PROGRAM AND I THINK STARTING THE NURSING INSTITUTE WAS MORE OF AN

EPIDEMIOLOGY PROGRAM WAS A GREAT IDEA THE OTHER THING IS THAT THE ESTABLISHMENT OF THE INTRAMURAL PROGRAM WAS A STATEMENT BY THE NURSING INSTITUTE, THAT HAS PERSISTED WITH DR. GRADY AT THE HELM THAT NURSING RESEARCH IS A REALLY IMPORTANT THING THAT YOUNG NURSING STUDENTS SHOULD BE THINKING ABOUT THEY SHOULD EDUCATE THEMSELVES TO BE ABLE TO DO RESEARCH, THAT RESEARCH IN NURSING WAS AN ESSENTIAL COMPONENT OF THE DEVELOPMENT OF THE FIELD DR. HENSHAW ESTABLISHED THE CLINICAL THERAPEUTICS LABORATORY AND THE LABORATORY FOR THE STUDY OF HUMAN RESPONSES TO HEALTH AND ILLNESS AS PARTS OF THE THEN INTRAMURAL PROGRAM SO LET’S SKIP A BUNCH OF YEARS THERE WERE UPS AND DOWNS OVER THAT TIME I REMEMBER MANY OF THEM IN DETAIL BUT DR. GRADY BECAME DIRECTOR OF THE INSTITUTE, A VERY STRONG DIRECTION FORWARD IN SUPPORTING EXCELLENCE OF SCIENCE AND THE INTRAMURAL PROGRAM WAS INITIATED PART OF THIS WAS THE REALLY QUITE DELIBERATE AND STRATEGIC INTEGRATION OF THE NURSING INSTITUTE INTO THE WHOLE INTRAMURAL PROGRAM AT THE NIH, AND YOU CAN SEE PRESENT TODAY AMONGST OUR PANELISTS IF YOU LOOK AT THE POSTERS YOU’LL SEE ALL KINDS OF STRATEGIC COLLABORATIONS WHICH INDICATE MULTIPLE INSTITUTES HAVE BEEN WILLING AND IN FACT ENTHUSIASTIC ABOUT JOINING WITH THE NURSING INSTITUTE IN DEVELOPING IMPORTANT NEW PROGRAMS AND IN ADDITION TO BEING COLLABORATIVE THE NURSING INSTITUTE HAS BEEN QUITE INNOVATIVE IN MANY WAYS I REMEMBER WHEN FRANCIS COLLINS BECAME INITIALLY DIRECTOR OF THE NATIONAL — THEN NATIONAL CENTER FOR HUMAN GENOME RESEARCH, AND HE BEGAN TO WORRY ABOUT GENETIC COUNSELING HE SAID, WE ONLY HAVE LITERALLY A HANDFUL OF TRAINED GENETIC COUNSELORS BUT IN THE FUTURE VIRTUALLY EVERYONE IS GOING TO HAVE THEIR DNA SEQUENCE AND THEY WILL NEED INFORMATION AND THE NURSING INSTITUTE REALIZED AT THAT POINT THAT THE LIKELY PEOPLE WHO WOULD BE ON THE FRONT LINES IN RESPONDING TO PATIENTS’ NEEDS FOR INFORMTIONS WERE NURSES, NURSE PRACTITIONERS NURSING INSTITUTE STARTED A PROGRAM FOR GENETIC COUNSELING AND BROUGHT IN OVER THE SUMMER MANY NURSES INTERESTED IN LEARNING GENETIC COUNSELING AND THEY HAVE TRAINED QUITE A NUMBER OF PEOPLE WHO I THINK CONTRIBUTE OVERALL TO THE EFFORT TO MAKE SURE PEOPLE — THE PUBLIC UNDERSTANDS THE NATURE OF GENETIC DEFECTS I THINK NINR AT LEAST FROM MY POINT OF VIEW IS EXTREMELY HELPFUL IN ESTABLISHING THE LASKER PROGRAM, THE SCHOLARS PROGRAM TO BRING EXCEPTIONALLY TALENTED CLINICAL INVESTIGATORS TO THE NIH, WAS VERY EARLY EMBRACED BY THE NURSING INSTITUTE, MAYBE EARLIER THAN ANY OTHER INSTITUTE, EFFORTS WERE MADE TO RECRUIT PEOPLE INTO THE PROGRAM AND JESSICA GIL WHO YOU’LL HEAR FROM LATER TODAY WHO LEADS THE NINR TISSUE INJURY BRANCH WAS THE SECOND RECRUIT TO THE PROGRAM IN FACT, I JUST MET WITH SOME OF MY COLLEAGUES WITH JESSICA TO KIND OF THINK ABOUT HOW THE PROGRAM IS WORKING, HOW WE WOULD CHANGE IT IN THE FUTURE AND BOTH HER ADVICE AND THE ADVICE OF THE LEADERSHIP OF NINR TAKE VERY SERIOUSLY IN UNDERSTANDING HOW WE CAN ENCOURAGE YOUNG PEOPLE TO COME IN AND BECOME CLINICAL INVESTIGATORS NOW, ABOUT THREE YEARS AGO, I INITIATED WITH DR. COLLINS A LONG-TERM LOOK AT FUTURE PLANNING FOR THE INTRAMURAL PROGRAM WE CALL THIS A LONG-TERM PLAN IT INVOLVES QUITE A NUMBER, VIRTUALLY ALL THE INSTITUTE, AND WE GOT TOGETHER TO THINK ABOUT FUTURE DIRECTIONS FOR INTRAMURAL RESEARCH THESE WOULD NOT BE EXCLUSIVE BUT THEY WOULD BE AREAS IN WHICH WE HAD PARTICULAR STRENGTH AND I HAVE TO SAY THE NURSING INSTITUTE PLAYED A VERY BIG ROLE IN VARIOUS DISCUSSIONS BECAUSE MANY OF THE THINGS WE WERE THINKING ABOUT, THEY STARTED AS BASIC SCIENCE PROJECTS BUT THEY WERE TRANSLTIONAL AND THEY EXTENDED INTO THE LABORATORIES AND CLINICS AT THE NIH THE NURSING INSTITUTE REALLY IS THE GLUE THAT CONNECTS OUR BASIC RESEARCH IN OUR LABS TO OUR CLINICAL CARE IN FACT, SEVERAL OF THE PROJECTS THAT WE CAME UP WITH I THINK WERE PARTLY MOTIVATED BY THE INTERESTS OF THE NURSING INSTITUTE AND FOR SURE WILL HAVE INVOLVEMENT OF THE NURSING INSTITUTE IN THE FUTURE, ONE OF WHICH WAS A MAJOR CENTER ON CHRONIC INFLAMMATION, THE NIH, AND YOU’LL HEAR ABOUT INVESTIGATORS IN THE NURSING INSTITUTE WHO ARE WORKING IN VARIOUS ASPECTS OF THAT PROGRAM BOTH ON THEIR OWN AND IN COLLABORATION WITH OTHER NIH SCIENTISTS, AND THE SECOND HAD TO DO WITH COMPULSIVE BRAIN DISORDERS

THE EVIDENCE IS WE’RE GETTING CLOSER TO UNDERSTANDING THE NETWORKS INVOLVED IN THESE DISORDERS, MANY OF WHICH REALLY RELATE TO VARIOUS SYMPTOMS THESE ARE DISORDERS OF APPETITE, DRUG ABUSE, DISORDERS LIKE OBSESSIVE COMPULSIVE DISORDER AND I THINK THE NURSING INSTITUTE WILL AGAIN PLAY A ROLE BECAUSE THESE ARE THE KINDS OF SYMPTOMS THAT LEAD PATIENTS FIRST OF ALL THAT CAUSE DISEASE BUT ALSO AFFECT THE WAY PATIENTS RESPOND TO DISEASE SO IN ADDITION TO WHICH THERE ARE SEVERAL OTHER OVERALL PROJECTS THAT I’M SURE THE NURSING INSTITUTE WILL BE DEEPLY INVOLVED IN WHAT IS THE FUTURE MUCH NURSING RESEARCH AT THE NIH? I THINK IT IS VERY CLEAR THAT MORE AND MORE RESEARCH IS NEEDED AS WE TRANSLATE WHAT WE UNDERSTAND HAPPENING IN THE LABORATORIES, IN OUR BASIC CLINICAL RESEARCH TO MUCH MORE USEFUL APPLICATIONS TO HUMAN POPULATIONS WE HAVE AN AGING AND INCREASINGLY DIVERSE POPULATION PAIN IS A MAJOR ISSUE THIS IS AN ISSUE THE PRESIDENT OF THE UNITED STATES HAS LISTED AS ONE OF HIS MAJOR GOALS TO FIND ALTERNATIVE WAYS TO TREAT PAIN THAT ARE NON-ADDICTING ADDICTION IS MAJOR PROBLEM YOU’LL HEAR AGAIN TODAY ABOUT VARIOUS EFFORTS TO MANAGE THESE KINDS OF SITUATIONS NURSING RESEARCH IS INTEGRAL SORT OF MISSING LINK IN THE NIH INTRAMURAL PROGRAM TO CONNECT THE BASIC SCIENCE WE DO TO THE PRACTICE OF MEDICINE AND NURSING NOW, THROUGH IT ALL WE NEED A BETTER UNDERSTANDING OF THE ENVIRONMENTAL INFLUENCES THAT AFFECT DISEASE AND THE INTERACTION BETWEEN MOLECULAR MECHANISMS AND THESE ENVIRONMENTAL INFLUENCES LOOKING AT THE POSTERS AND I’M SURE LISTENING TO THE TALKS TODAY YOU’LL SEE THAT THOSE LINKS ARE STARTING TO BE MADE BY THE VERY TALENTED INVESTIGATORS WHO ARE NOW IN THE NURSING INTRAMURAL RESEARCH PROGRAM SO LET ME JUST SAY THAT SYMPTOMATOLOGY, WHICH IS ONE OF THE FOCUSES OF TODAY’S TALK, OF COURSE AN ESSENTIAL COMPONENT OF THE NURSING INSTITUTE, IS REALLY THE FORELEADING EDGE OF THE DISEASES WE STUDDIETY NIH MOSTLY PATIENTS PRESENT WITH SYMPTOMS AND PHYSICIANS AND NURSES ARE DEDICATED TO FIGURING OUT MOLECULAR CAUSES AND HOW TO MANAGE THE SYMPTOMS, AND THAT’S THE SUBJECT — AN IMPORTANT SUBJECT OF RESEARCH THAT YOU’LL BE HEARING ABOUT SO YOU’LL HEAR ABOUT THE ROLE OF THE GUT, LIVER, BRAIN AXIS AND INFLAMMATION, GLUTAMATERGIC INFLUENCE ON FATIGUE, RESPONSE TO CHEMOTHERAPY AND CANCER ITSELF AND IDENTIFYING BIOMARKERS TO IMPROVE CLINICAL CARE OF PATIENTS WITH BRAIN INJURY, TOPICAL IMPORTANT ISSUES FOR WHICH RESEARCH REALLY HAS BEEN LACKING UNTIL THE EFFORTS OF NURSING INSTITUTE SO LET ME FINISH BY SAYING A COUPLE WORDS ABOUT LEADERSHIP IN THE NURSING INSTITUTE I MENTIONED DR. GRADY, CURRENT DIRECTOR, WHO REALLY HAS BEEN A VISIONARY IN SUPPORTING AND MOVING AHEAD THE INTRAMURAL PROGRAM HERE AND ANN CASHION WHO FOR SEVERAL YEARS HAS BEEN SCIENTIFIC DIRECTOR AND HAS BROUGHT CLARITY I WOULD SAY AND LEADERSHIP SKILLS TO MANAGE INCREASINGLY IMPORTANT INTRAMURAL PROGRAM THESE FOLKS ARE IN ADDITION TO BEING LEADERS ARE INTERACTIVE AND COLLABORATIVE THERE ARE MANY, MANY WAYS IN WHICH I TURNED TO BOTH OF THEM TO HELP WITH ISSUES SUCH AS ASSURING EQUITY OF WOMEN AT THE NIH, CREATION OF LECTURE SERIES THAT REPRESENT ALL OF THE POPULATIONS HERE, AND EFFORTS TO REORGANIZE AND MODERNIZE OUR IRB SYSTEM AND I THANK YOU BOTH, THOSE ARE JUST SMALL NUMBER OF EXAMPLES, FOR THE MANY THINGS WE WORKED ON TOGETHER TO END, I THINK THERE’S A GREAT FUTURE IN NURSING RESEARCH AND IN THE NINR INTRAMURAL PROGRAM AT THE NIH AND I’M SURE THIS WILL BE A WONDERFUL DAY TO CELEBRATE ALL THE ACHIEVEMENTS AND ALL THE THINGS THAT COME IN THE FUTURE THANK YOU [APPLAUSE] >> THANK YOU, DR. GOTTESMAN, FOR YOUR REMARKS TODAY AND SUSTAINED SUPPORT OF NINR INTRAMURAL PROGRAM NOW I WOULD LIKE TO INTRODUCE THE MODERATOR OF OUR FIRST PANEL THIS MORNING, DR. WENDY HENDERSON, CHIEF OF THE NINR DIGESTIVE DISORDERS UNIT, HER INTERESTS IN SYMPTOMATOLOGY IN PATIENTS WITH GASTROINTESTINAL

AND LIVER DISORDERS STEMS FROM HER CLINICAL AND RESEARCH EXPERIENCES AT THE CHILDREN’S HOSPITAL OF PITTSBURGH SHE EARNED HER Ph.D. IN NURSING FROM THE UNIVERSITY OF PITTSBURGH, WHERE SHE WAS ALSO A CLINICAL AND TRANSLATIONAL SCIENCE INSTITUTE FELLOW AFTER COMPLETING TWO YEARS OF POSTDOCTORAL TRAINING, AS A STAFF SCIENTIST IN THE INTRAMURAL PROGRAM AT NINR, DR HENDERSON WAS APPOINTED AS AN ASSISTANT CLINICAL INVESTIGATORS IN 2009 AND JOINED THE NINR TENURE TRACK FACULTY IN 2011 SHE AND HER PANEL WILL BE DISCUSSING THE ROLE OF GUT, LIVER, BRAIN AXIS ON INFLAMMATION ADDICTION AND INFECTION DR. HENDERSON? >> GOOD MORNING SO WE BEGIN OUR MORNING WITH A DISCUSSION ON THE ROLE OF THE GUT, LIVER, BRAIN AXIS ON INFLAMMATION ADDICTION AND INFECTION AND I WELCOME MY TWO CO-PANELISTS, DR. COLLEEN HADIGAN AND DR. LORENZO LEGGIO THANK YOU FOR JOINING ME THIS MORNING THANK YOU, DR. CASHION THANK YOU, DR. GRADY WE’LL COME BACK TO THIS MIC I’M GOING TO TRY ALL THE DIFFERENT BUTTONS THANK YOU SO AS DR. GRADY WAS SPEAKING EARLIER ABOUT THE SYMPTOM SCIENCE MODEL, I’D LIKE TO FRAME WHAT I’M TALKING ABOUT, WHAT MY PANEL WILL BE REFERRING TO AS WELL WE’VE TALKED ABOUT SYMPTOM SCIENCE, BUT SPECIFICALLY IT’S COMPLEX SYMPTOMS THAT OUR PATIENTS TELL US ABOUT THAT WE HEAR THEM COMPLAIN ABOUT, AND THAT WE WANT TO HELP THEM WITH MY GOAL AS AN INTRAMURAL INVESTIGATOR IS TO CAREFULLY PHENOTYPE INDIVIDUAL SYMPTOMS TO DISCOVER BIOMARKERS THAT ARE ASSOCIATED WITH THESE COMPLEX SYMPTOMS AND THEN TO IMPLEMENT WITH CLINICAL APPLICATION THE WAY THAT I OPERATIONALIZE THIS WITHIN THE DIGESTIVE DISORDERS UNIT I’M CHIEF OF WITHIN NINR IS FOCUSED ON DIGESTIVE DISORDERS, MY CLINICAL EXPERTISE WHAT YOU HEAR TIME AND TIME AGAIN REGARDLESS OF THE PARTICULAR DISEASE ENTITY IS THAT THERE IS A STRESS-INDUCED PHENOMENON PRIOR TO THE PATHOLOGY THAT ENSUED AS WE THINK ABOUT THIS YOU ALL PROBABLY HAVE AN EXAMPLE IN YOUR MIND WHEN YOU CAN THINK OR IMAGINE THAT A STRESS-INDUCED TIME CAME BEFORE THE ACTUAL PATHOLOGY SO THE G.I. SYMPTOMS, THESE ARE MANY AND VARIED WE ALL KNOW WHAT THEY ARE RIGHT? IN TERMS OF STRESS-INDUCED SYMPTOMS THEY CAN INCLUDE CONSTIPATION, DIARRHEA, CHANGES IN APPETITE THE MODEL AS I OPERATIONALIZE INCLUDES PHENOTYPIC CHARACTERIZATION, PERSONALIZED PROFILE AND SPECIFIC TARGETED TREATMENTS AS WE WALK THROUGH THIS DURING MY PRESENTATION I WANT YOU TO KIND OF PUT THIS IN YOUR MIND’S EYE THERE ARE KEY FACTS STRESS AFFECTS INTESTINAL HEALTH ACROSS THE LIFESPAN BUT 20% RECORDS STRESS-INDUCED G.I SYMPTOMS, THE SINGLE MOST COMMON CAUSE FOR EMERGENCY ROOM VISITS, TOP TEN REASON FOR OUTPATIENT VISITS ACROSS MUST BE DISCIPLINES, $3 BILLION IN COSTS ANNUALLY, AND AFFECTS ACROSS THE LIFESPAN FROM PRE-TERM BIRTH TO BEING OVERWEIGHT TO LATER PHENOMENON IN THE LIFESPAN IN ORDER TO IMAGINE STRESS-INDUCED SYMPTOMS, SPECIFICALLY CHRONIC ABDOMINAL PAIN, MY PRIMARY AREA OF INTEREST, WE NEED TO DEVELOP A TOOL THAT COULD MORE CAREFULLY PHENOTYPE OUR PATIENTS AND MEASURE THEIR SYMPTOMS SO ONE OF THE THINGS THAT I WAS ABLE TO DO WITH THE TEAM HERE IN THE INTRAMURAL RESEARCH PROGRAM WAS DEVELOP THE G.I. PAIN POINTER AND THIS PARTICULAR INNOVATION ALLOWS FOR — LET ME USE THIS, FOR THOSE ONLINE — ALLOWS FOR PATIENTS TO POINT TO WHERE IT

HURTS, DIAL UP HOW MUCH IT HURTS, AND THEN USE DIFFERENT PAIN DESCRIPTORS AS WELL AS CAPTURES HEART RATE AND BLOOD PRESSURE IN REAL TIME THEY PICK THEIR BODY TYPE, MALE OR FEMALE, NORMAL OR OVERWEIGHT AND TANNER STAGING, USEFUL FOR NURSES IN THAT PATIENTS WHO SPEAK DIFFERENT LANGUAGES OR ARE UNABLE TO SPEAK IF INTUBATED OR OTHERWISE ARE ABLE TO TELL US SYMPTOMS IN REAL TIME AND BEYOND THAT WE’RE ABLE TO DETECT DIFFERENCES SO BEHIND THIS DIAL YOU NOTICE IT ISN’T 0-10 SCALE THERE’S 100 DATA POINTS BEHIND HERE THAT THE PATIENT DOESN’T SEE NECESSARILY, SO THEY CAN SAY HOW MUCH PAIN THEY HAVE AND WE’LL BE ABLE TO DETECT 30% CHANGE WITH OUR INTERVENTION NOW THAT WE HAD A TOOL TO DETECT SUBJECTIVE AND OBJECTIVE CHANGES IN CHRONIC ABDOMINAL PAIN WE NEEDED A CAREFULLY PHENOTYPED PATIENT COHORT WITH AN UNMET NEED, THE COHORT IS IRRITABLE BOWEL SYNDROME WHAT I FOUND IN MY CLINICAL PRACTICE IS OVER HALF OF MY PATIENTS THAT I WOULD SEE AS A PEDIATRIC NURSE PRACTITIONERS COMPLAINED OF PAIN IN UNDETERMINED ORIGIN THAT MET CRITERIA FOR IRRITABLE BOWEL SYNDROME THE HYPOTHESIS WAS PAIN IGNITED BY STRESS AND STRESS SYMPTOMS WOULD YIELD TO INCREASED INTESTINAL PERMEABILITY, MICROBIAL TRANSLOCATION AND INCREASED ABDOMINAL MAIN IT’S A TWO BY TWO DESIGN WITH HEALTHY CONTROLS NORMAL WEIGHT OR OVERWEIGHED WITH AND WITHOUT CHRONIC PAIN SYMPTOMS, PHENOTYPICALLY OF YOU IRRITABLE BOWEL SYSTEM, MALE AND FEMALE HERE IS DATA FROM OUR INITIAL COHORT FOR THE DATA YOU’LL SEE TODAY YOU CAN SEE WE HAVE ABOUT DOUBLY MATCHED CONTROLS WITH IRRITABLE BOWEL SYNDROME, DIARRHEA AND CONSTIPATION, 50-50 MALE AND FEMALE, GREATER D.C. AREA, AGE OF APPROXIMATELY 27 YEARS OF AGE NEXT THING WE NEEDED NOW THAT WE HAVE A PROTOCOL IS WITHIN THAT PROTOCOL TO EXPERIMENTAL INDUCE SYMPTOMS WE DEVELOPED THROUGH THE PHARMACY OF NIH IS A BRAIN GUT TEST SOLUTION WE NAMED IT TOO WHICH WAS FUN AND SO WHAT THE TEST SOLUTION INCLUDES IS SUCROSE, MANNITOL PATIENTS DRINK 100 mLs IN THE CLINICAL CENTER AND MEASURE OVER A FIVE-HOUR PERIOD YOU ARE NEAR EXCRETION SUCROSE THROUGH THE STOMACH SUSRALOSE IN THE COLON WE FOUND DIFFERENCES WHICH ARE REVERSE OF WHAT THE LITERATURE HYPOTHESIZED SHOWING IRRITABLE BOWEL SYNDROME PATIENTS ACTUALLY DID NOT HAVE INCREASED PERMEABILITY, AND THEY ACTUALLY HAD DECREASED PERMEABILITY OF NON-ABSORBABLE SUGAR CALLED SUCRALOSE WE’RE CURIOUS IF YOU WOULD REFER PATIENTS WHAT WE FOUND INTERESTING THE INDUCED VISCERAL PAIN AS QUANTIFIED BY THE G.I. PAIN POINTER, THAT’S THE INDUCED VISCERAL PAIN SCORE YOU SEE HERE ON THE Y-AXIS, YOU CAN SEE DIFFERENCES IN IRRITABLE BOWEL PATIENTS, MORE SO IN THOSE OVERWEIGHT, A SIGNIFICANT WEIGHT EFFECT WITH IRRITABLE BOWEL, 20 TIMES MORE LIKELY TO GET SYMPTOMS OF ABDOMINAL PAIN FROM THE TEST SOLUTION THAN OVERWEIGHT HEALTHY CONTROLS LIKEWISE WE MEASURE STRESS, MARKERS BIOLOGICALLY THIS IS SERUM CORTISOL THE SIZE OF THE BALL IS REFLECT I REFLECTIVE OF AMOUNT OF PAIN OR VISCERAL PAIN FROM TEST SOLUTION YOU CAN SEE HERE THAT THE LARGEST BALL OR THE LARGEST AMOUNT OF SYMPTOMS IS OVER HERE IN THE RED BALL WITH THE HIGHEST AMOUNT OF BODY FAT, AND ALSO IN OUR OVERWEIGHT HEALTHY PATIENTS NOTICE BLUNTING OF CORTISOL, DON’T HAVE INCREASED CORTISOL LEVELS SO MOVING DOWN OUR HYPOTHESIS OF THE STRESS WITH ALTERED PERMEABILITY LEADING TO

MICROBIAL TRANSLOCATION AND ABDOMINAL PAIN WE NEEDED THIS MODEL OF MICROBIAL TRANSLOCATION AND HOW TO LOOK SPECIFICALLY AT MICROBIAL TRANSLOCATION WITHIN THE CAREFULLY PHENOTYPED COHORT WHILE HERE IN THE CLINICAL CENTER OF NIH WHAT WE MEASURED IS LIPO POLYSACCHARIDE, ENDOTOXIN WE MEASURE METABOLITE — THE BINDING PROTEIN, LPS BINDING PROTEIN FROM THE LIVER, AS WELL AS — SORRY — SOLUBLE CD14 AND IFABP, WHICH MEASURES THE TRACT, PILOT FINDINGS UNDER PREPARATION FOR PUBLICATION FOUND NO DIFFERENCE IN THE IFABP, DID FIND SIGNIFICANT DIFFERENCE IN OUR IRRITABLE BOWEL DIARRHEA COHORT FOR LDP AND TRENDS IN THE SOLUBLE CD14 WHY THIS IS IMPORTANT IN TERMS OF HYPOTHESIS IS POTENTIALLY WITH MICROBIAL TRANSLOCATION MAY ACTIVATE MACROPHAGE ACTIVATION AND WE’LL HAVE MORE DISCUSSION ABOUT THIS LATER IN THE PRESENTATIONS TODAY WHICH WOULD LEAD TO OTHER PHENOMENON AS WE HAD THIS SIGNAL OF ALTERED PERMEABILITY, COLONICALLY, THE REVERSE OF WHAT WOULD BE HYPOTHESIZED IN OUR CAREFULLY PHENOTYPED COHORT, AS WELL AS OTHER MARKERS OF MICROBIAL TRANSLOCATION WE MOVED ON TO A FULL ANALYSIS, MICROARRAY ANALYSIS IN THE BLOOD OF THE PATIENTS IN OUR PROTOCOL AND WHAT WE FOUND WHICH IS VERY INTERESTING AND THIS IS A PATHWAY ANALYSIS FROM WHOLE BLOOD IS WE FOUND SPECIFICALLY LISOSOME TO BE PRESENT IN THE COHORT GIVEN THIS IS WHOLE BLOOD WITH A MARKER OF LISOSOME, KNOWN TO BE BACTERIA CIDAL SPECIFICALLY FOR GRAM POSITIVE, IT WAS PRESENT CIRCULATING IN THE PERIPHERY SO ABOUT THE TIME WE WERE LOOKING FOR THIS ALL THIS KNOWLEDGE ABOUT EXTRACELLULAR VESICLES BECAME APPARENT AND SO WE BROUGHT IN AN EXPERT FROM THE NETHERLANDS TO TEACH US QUANTIFICATION IN OUR LAB WHAT WE DID WAS EXTRACTED FROM PLASMA OF THE BLOOD FROM OUR PARTICIPANTS AND WE ISOLATED EXTRACELLULAR VESICLES WE CONFIRMED THESE WERE VESICLES VIA ELECTRON MICROSCOPY WITH COLLABORATION WITH NHLBI IN THEIR CORE FACILITY AND STAINED THEM FOR MARKERS OF VESICLES INCLUDING CD9 AND WE ALSO STAINED FOR LISOSOME AND OTHER MARKERS FOR ORIGINS SO MUCIN 1 AND 2 TELL US FROM IT’S G.I TRACT POTENTIALLY FOR THESE MARKERS IN THE BLOOD AND OTHER CONTROL MARKERS SO THIS IS VERY EXCITING NOT ONLY COULD WE FIND EVIDENCE VIA MICROARRAY AND WHOLE BLOOD BUT ALSO IN THE EXTRACELLULAR VESICLE FRACTION WE FOUND LYSOSOME WHAT DOES THAT MEAN AND HOW IS THAT USEFUL IN TERMS OF OUR RESEARCH? SO WHAT WE DID THEN IS BASED ON THE PATHWAY, ONE INDICATED CELLULAR MOVEMET DESIGNED AN EXPERIMENT IN OUR LAB, GREW UP PETRI DISH ESSENTIALLY, GREW THEM AND DID WHAT’S CALLED A SCRATCH WOUND ASSAY WHERE YOU JUST SCRATCH THE CELLS AND THEN YOU PUT DIFFERENT PRODUCTS LYSOSOME, INCREASED THE GROWTH OF THE EPITHELIAL CLONIC CELLS BACK TOGETHER AND WE PUBLISHED THESE FINDINGS.& THEN WE TESTED THESE USING ANALYSIS, WITH AND WITHOUT THE LYSOZYME, LOOKED AT PROTEIN AND RNA IN REAL TIME, THESE ARE THE MARKERS WE FOUND DIFFERENTIALLY REGULATED LYSOZYME IS FOUND IN BREAST MILK, TEARS, MUCOSA OF G.I TRACT, AN INTERESTING MARKER WITH PATIENTS WHO GOT PAIN FROM THE TEST SOLUTION WE’RE INTERESTED IN THE NEXT STEPS WHAT DOES IT LEAD YOU TO, THE NEXT QUESTION WOULD BE THE MICROBIOME SEEMS RATHER OBVIOUS WE LOOKED AT MUCOSAL ADHERENT

MICROBIOME AND FOUND NO DIFFERENCE BETWEEN HEALTHY CONTROLS AND IRRITABLE BOWEL SPECIFICALLY HOWEVER DID FIND DIFFERENCE AND PUBLISHED THIS IN GUT MICRO, DYSBIOSIS BETWEEN IRRITABLE BOWEL PATIENTS AND IRRITABLE BOWEL PATIENTS THAT ARE OVERWEIGHT FINDINGS THAT WERE BUTERIC ACID RELATED, I’M OVERSIMPLYIFYING WITH COLLABORATORS FROM THE UNIVERSITY OF MICHIGAN A WELL ESTABLISHED CHRONIC STRESS MODEL WHERE ANIMALS ARE PUT ON AN ISLAND AND WATER COMES UP AND MAKES THEM STRESSED, AND WE MEASURE THEIR COLONIC SENSITIVITY AND STOMACH CONTRACTIONS, AND THEY ARE ON THE ISLAND FOR ONE HOUR A DAY FOR TEN DAYS THIS MIMICS AND IRRITABLE BOWEL STRESS-LIKE STATE WHERE THEY HAVE INCREASED MOTILITY AND SO FORTH, INCREASED MARKERS WE LOOKED AT THE MUCOSAL ADHERENT MICROBIOME, RNA EXPRESSION, AND FOUND DIFFERENTIAL EXPRESSION SPECIFICALLY IN THESE WATER AVOIDANCE OR STRESSED ANIMALS COMPARED TO CONTROLS, SPECIFICALLY NOT TO SPEAK ABOUT THE PARTICULAR MICROBES OR TACTILE OPPORTUNITIES, WHAT THEY ARE DOING WHICH IS REALLY MY INTEREST IN TERMS OF FUNCTIONAL RELEVANCE AND HOW THAT CAN BE APPLIED TO HUMANS IS THAT WHAT THEY ARE ACTUALLY DOING, THESE COMBINATIONS ARE BUTERIC ACID PRODUCING, SIMILAR TO OUR HUMAN FINDINGS SO THEN WHAT WE DID IS WE TOOK THIS BACK TO OUR CELL MODEL AND WE CHRONICALLY STRESSED OUR COLONIC EPITHELIAL CELLS OVER A PERIOD OF DAYS AND THEN WE ADDED BUTYRATE, SO BUTYRIC ACID, AND MEASURED THE PERMEABILITY OF THESE CELLS AND SHOWED INDEED THAT IT WASN’T JUST THE STRESS BUT IT’S THE COMBINATION OF THE STRESS WITH BUTYRATE THAT CAUSED THIS ALTERED PERMEABILITY OF THE CELLS WE DEMONSTRATED THIS ALSO VIA IMMUNOFLUORESCENCE, AND OCCLUDEN WHICH YOU’LL SEE HERE IN GREEN AND ZO1 IN RED IS THE STAINING OF THE TIGHT JUNCTIONS THAT KEEP THE CELLS TOGETHER SO THESE ARE TRANSMEMBERASE PROTEINS, WE HAVE NICE BARRIERS WHEN YOU ADD, WHEN YOU SEE PLUS THE BY-PRODUCT OF THE MICROBIOME YOU HAVE EVEN MORE BREAKDOWN, JUST TO GIVE YOU BRIEFLY AN EXAMPLE OF THIS THESE ARE THE UNTREATED CELLS, THE BLUE IS DAPY SHOWING HEALTHY CELLS FOR NUCLEOSTAINING, YOU CAN SEE THE NICE TIGHT JUNCTIONS HERE FOR UNTREATED THIS IS A Z STACK VERSUS CHRONIC STRESSED CELLS YOU SEE THE NICE TIGHT JUNCTION STAINING OF THE ZO1 AND OCCLUDIN YOU SEE VACUOLES WHERE THE TIGHT JUNCTIONS WOULD HAVE BEEN SO WHAT IS IN THOSE VACUOLES? WE’RE AFTER IT I DON’T HAVE THE DATA FOR YOU NOW BUT I HOPE TO IN THE FUTURE WE FOUNT DIFFERENTIAL microRNA SIGNATURE, WHAT’S SMALL ENOUGH TO BE IN THE VACUOLES IS microRNA WE’RE LOOKING FOR THIS SIGNATURE WITHIN THOSE VERY SMALL EXTRACELLULAR VESICLES AND HOPE TO HAVE MORE INFORMATION WE HAVE WORK TO DO, TARGETED TREATMENT I’M MOST INTERESTED IN STRESS EFFECT ON INTESTINAL HEALTH AND ACROSS THE LIFESPAN I HAVE A LOT OF PEOPLE TO ACKNOWLDGE, MANY OF WHICH ARE IN THIS ROOM OR LISTENING ONLINE MY KEY MENTOR MARGARET HIGHCAMPER FROM EXTRAMURAL WHO IS CO-HI OF THE BRAIN GUT NATURAL HISTORY PROTOCOL AND KATHLEEN HADIGAN, FRONT AND CENTER, WHEN I FIRST CAME INTERVIEWING LOOKING FOR A MENTOR WHO CARED ABOUT PATIENTS LIKE I DID AND NINR WHO HAS BEEN SUPPORTING ME FOR ALMOST TEN YEARS NOW AS A STAFF SCIENTIST, AND ASSISTANT CLINICAL INVESTIGATORS, MOST GRATEFUL FOR

PATIENTS AND THE OTHER NURSE SCIENTISTS WHO HAVE BEEN SO GIVING SO THANK YOU [APPLAUSE] >> NOW I WOULD LIKE TO INTRODUCE DR. COLLEEN HADIGAN, WITH A MEDICAL DEGREE FROM JOHNS HOPKINS MEDICAL SCHOOL, AND MPH FROM HARVARD SCHOOL OF PUBLIC HEALTH SINCE 2006 HAS BEEN LEADING CLINICAL RESEARCH INITIATIVES IN THE INTRAMURAL NIAID HIV PROGRAM, IN 2011 BECAME DEPUTILY CLINICAL MANAGER OF NIH CLINICAL CENTER HIV OUTPATIENT CLINICAL PATIENT RESEARCH CLINIC, AND IN ADDITION DR. HADIGAN HEADS PEDIATRIC G.I. HEPATOLOGY AND CONSULT SERVICE FOR NIH CLINICAL SERVICE, AN ACTIVE COLLABORATORS IN SUPPORT OF NUMEROUS INVESTIGATIONS, MORE THAN THAT AN ASTUTE CLINICIANS WHO LISTENS TO HER PATIENTS AND IS A SINCERE PATIENT ADVOCATE AS WELL AS MENTOR EXTRAORDINAIRE DR. HADIGAN [APPLAUSE] >> THANK YOU FOR THAT VERY GENEROUS INTRODUCTION I HOPE I CAN LIVE UP TO THAT SO TODAY I WAS GOING TO SPEAK WITH YOU ABOUT FATTY LIVER DISEASE PARTICULARLY IN THE CONTEXT OF HIV, MAY AREA OF RESEARCH, BUT MANY THINGS APPLY TO FATTY LIVER DISEASE IN THE GENERAL POPULATION WHICH IS A GROWING PROBLEM AS IS OUR GROWING WAISTLINE PROBLEM WHICH I’M GOING TO TALK ABOUT SO I TRIED TO ORGANIZE BY PREVENTION, DIAGNOSIS AND MANAGEMENT TO KIND OF GO THROUGH ALL THE STAGES OF A DISEASE PROCESS AND SO JUST AS A REMINDER HOW CAN WE DO PREVENTION WITHOUT FIRST BEING ABLE TO DEFINE AN AT-RISK POPULATION WE WOULD TARGET OUR PREVENTION TO, TO KNOW WHO IS GOING TO BE AT RISK FOR DEVELOPING THE PROBLEM THEN WE HAVE TO BE ABLE TO IDENTIFY MODIFIABLE RISK FACTORS, IF THERE’S NOTHING WE CAN DO TO CHANGE IT I’M NOT SURE IT’S WORTH PUTTING EFFORT TOWARDS IT BUT THERE ARE STRATEGIES TO DECREASE BURDEN OF DISEASE THE PROBLEM OF FATTY LIVER IS BELIEVED TO BE INCREASED IN THE HIV POPULATION AND JUST TO GET MY NOMENCLATURE STRAIGHT, NAFLD IS REFERRING TO FAT STORAGE IN THE LIVER ALL TALK ABOUT NASH, SUGGESTING PRESENCE OF FAT IN THE LIVER HAS LID TO INFLAMMATION AND INJURY TO THE LIVER BUT SIMPLE NAFLD OCCURS IN 13 TO 50% OF COHORTS, RISK FACTORS HAS BEEN THE SAME WE KNOW TO EXIST IN THE GENERAL POPULATION, SO INCREASED BMI, METABOLIC SYNDROME WITH INSULIN RESISTANCE AND DYSLIPIDEMIA AND GENETIC RISK FACTORS WITH SNP PNPL 3 WHICH INCREASES RISK, MONOGENETIC RISK FACTOR THAT CAN INCREASE IT THIS IS DATA FROM THE MAX COHORT, A VERY LARGE COHORT OF HIV MEN, UNINFECTERRED MATCH CONTROLS HIGHER IN HIV NEGATIVE THAN HIV INFECTED, REASURING TO US BUT FOR THOSE WHO HAD FATTY LIVER, INCREASED RISK OF POSITIVE GENE BEING IN PEACH, ONE HIV-ASSOCIATED DRUG ASSOCIATED WITH IT CALLED DDI, WHICH FORTUNATELY ISN’T USED OFTEN ANYMORE SO THE MECHANISMS OF NAFLD MANY OVERLAP WITH THE GENERAL POPULATION IS THERE ANYTHING UNIQUE ABOUT HIV? WE CAN SEE HIV SPECIFIC FACTORS, A LOT OF EFFORT DETERMINING WHETHER OR NOT THERE’S ANTIRETROVIRAL MEDICATIONS WITH TOXICITY, IMMUNOSUPPRESSION, IMMUNE ACTIVATION OR OPPORTUNISTIC INFECTION OR HIGH PREVALENCE OF CO-INFECTION WITH HEPATITIS C THIS IS A LOVELY SCHEMATIC OF FATTY LIVER PUBLISHED BY ANNA MAY DEAL AND HER GROUP HOW DOES FAT GET INTO THE LIVER? THREE KEY WAYS, ABSORPTION THROUGH ININTESTINAL TRACT, DE NOVO LIPO GENESIS, THE LIVER CAN

MAKE FAT WHEN WE BREAK DOWN FAT CELLS FREE FATTY ACIDS CAN BE ABSORBED AND TAKEN INTO THE LIVER OUTCOME DEPENDS ON HOW THE LIVER USES FAT, OXIDATION AND BREAKDOWN, PACKAGING AND EXPORT IN TRIGLYCERIDE OR STORAGE IN THE FAT CELLS AND THAT’S WHERE WE GET INTO TROUBLE WHEN THERE’S EXCESS IN THE CELLS IN HIV, THERE HAVE BEEN SOME REALLY GOOD ELEGANT RESEARCH, STARTING AT THE BEGINNING OF THE EPIDEMIC TO INDICATE INFECTION ITSELF INTERFERES WITH THESE PROCESSES SO USING STABILIZE ISOTAUPE GROUP, A THREE TO FOUR-FOLD INCREASE IN DE NOVO LIPO GENESIS IN PEOPLE’S HIV-INFECTED, PRE-DATING ANTIRETROVIRAL THERAPY, IT WAS THE HIV VIRUS DOING THIS WE SEE PATIENTS IN CLINIC WITH HYPER TRIGLYCERIDE WE FOUND SOME COLLATERAL DAMAGE FROM OUR MEDICATIONS WAS THAT PROTEASE INHIBITORS FOR INSTANCE COULD INCREASE FAT CELL LYPOLYSIS, AND OTHER ANTIRETROVIRAL, SO THE NET EFFECT WAS POTENTIAL INCREASE IN SEVERE FATTY LIVER WHEN THERE’S FAT AND EXCESS ENERGY IN A CELL, WHAT DETERMINES IT TO THEN BECOME A PROBLEM TO GO ON TO DEVELOP INJURY WHETHER IT’S INFLAMMATION, SCARRING, OR REGENERATION THAT LEADS TO THE RISK OF HEPATOCELLULAR CARCINOMA, THERE ARE VARIOUS FACTORS THAT TELL US HOW THIS HAPPEN IN THIS SCHEMA, OVERLAP WITH HIV ONE KEY AREA IS ONCE THE FAT IS THERE OXIDATIVE STRESS, CELL DEATH AND POSSIBLY DYSBIOTA AND WHAT WENDY WAS SPEAKING ABOUT WITH GUT INFLAMMATION COULD BE A STRESSOR ON HEPATOCITE LEADING CYCLE OF INJURY THAT THEN RECRUITS HEPATIC CELL ACTIVATION THAT LEADS TO FIBRO GENESIS AND SCAR TISSUE, INAPPROPRIATE WOUND HEALING AND ULTIMATELY INCREASE RISK OF HEPATOCELLULAR CARCINOMA HIV IS ASSOCIATED WITH DIFFERENT AREAS OF CREATING THESE — STIMULATING THIS CYCLE OF INJURY AND THERE ARE OTHER NEWER MARKERS BEING LOOKED AT INCLUDING SONIC HEDGE LOG LIGAND, MOTIVATES A CELL TO PROGENITOR ACTIVATION TO LEAD TO CARCINOGENESIS BUT ONE OF THE KEY POINTS IN NOTING THIS IS THAT IN ALL OF THE RESEARCH THAT’S BEEN DONE IN NAFLD AND NASH, THE AMOUNT OF FIBROSIS PREDICTS MORBIDITY AND MORTALITY THAT WE’RE TRYING TO PREVENT OR AVOID NOW, OBESITY AND OVERWEIGHT IS A GROWING PROBLEM IN HIV AND SO THIS IS HIGHLIGHTING THE FACT AN EPIDEMIC THAT WAS PREVIOUSLY DESCRIBED BY DR. GOTTESMAN EARLIER TODAY, SEVERE WASTING AND DEVASTATION, IS NOW PRESENTING MORE AND MORE WITH OBESITY AND OVERWEIGHT SO THE NA-ACCORD IS LARGE COLLABORATION OF COHORTS OF PATIENTS WITH HIV BETWEEN U.S. AND CANADA AND WE HAVE BEEN SEEING DOUBLING IN THE RATES OF OBESITY AND INDIVIDUALS PRESENTING TO START ANTIRETROVIRAL THERAPY WHEN WE FOLLOW AFTER STARTING THERAPY WE SEE HIGH RATES OF DEVELOPMENT OF OBESITY AND SO THIS IS POTENTIALLY NOW IN A VERY IMPORTANT CONTRIBUTOR TO LIVER INJURY IN THIS POPULATION NAFLD, SIZE MATTERS, A LARGE COHORT OF 77,000 INDIVIDUALS IN SOUTH KOREA WITHOUT RISK FACTORS, HIGH ALCOHOL INTAKES OR LIVER DISEASE, CATEGORIZE PARTICIPANTS BY BMI, ASIAN STANDARD SO REFERENCE POPULATION 18-22.9 IS CONSIDERED NORMAL WEIGHT THIS IS OVERWEIGHT THIS IS CONSIDERED OBESE BY ASIAN STANDARDS YOU SEE THERE’S A 3 1/2 FOLD INCREASE RISK OF DEVELOPING NAFLD FOR THE GROUP OVERWEIGHT HERE IS A KEY FACTOR WE HAVE TO BE ABLE TO IDENTIFY PERHAPS BOTH IN OUR HIV POPULATION AND GENERAL POPULATION FOR BEING AN IMPORTANT TARGET FOR PREVENTING FATTY LIVER HOW DO WE DIAGNOSE IT? WE ALSO HAVE TO BE ABLE TO HAVE

EFFECTIVE AND IDEALLY NON-INVASIVE WAYS OF MEASURING LIVER FAT AND SO WE CAN DO THIS WITH LIVER ULTRASOUND, MORE RECENT DEVELOPMENTS USING A CONTROLLED ATTENUATION PARAMETER OR CAP, SHOWN HERE, THE DEVICE THAT USES ULTRASOUND TECHNOLOGY TO CREATE A WAVE SIGNAL TO TELL US HOW STIFF THE LIVER IS CAN BE USED TO GIVE US A SENSE OF HOW MUCH FAT IS IN THE LIVER HERE OF COURSE THE NIH WE HAVE ACCESS TO MR SPECTROSCOPY, FINER DETAIL, USED AS RESEARCH TOOL TO QUANTIFY LIVER FAT WHEN NECESSARY WE MAY HAVE TO DO MORE INVASIVE TESTS OR DO IS A LIVER BIOPSY SO HOW DO WE KNOW WHEN TO BIOPSY SOMEBODY? THE ASSOCIATE FOR STUDY OF LIVER DISEASE SUGGESTS WHEN THERE’S AN INCREASED RISK FOR NASH OR ADVANCED FIBROSIS OR CREATING ETIOLOGY OR COEXISTING LIVER DISEASE, ALSO NON-INVASIVE FIBROSIS TESTING WHICH THE NAFLD SCORE, BASED ON STANDARD LAB VALUES TYPICAL DONE IN CLINIC IN A PATIENT PRESENTING WITH CONCERN AS WELL AS TRANSIENT ELASTO GRAPHY TO COMPLEMENT OTHER NON-INVASIVE TOOLS MY COLLEAGUES DR. MORRIS LOOKED AT INDIVIDUALS WITH ELEVATION IN OUR CLINIC, INDIVIDUALS WITH HIGH AST OR ALT FOR A PERIOD OF TIME, WRITTEN OFF, OH, PROBABLY DUE TO HIV OR A LITTLE BIT OF TOXICITY FROM MEDS, THESE PATIENTS DIDN’T HAVE HEPATITIS C OR ANY OTHER FORM OF HEPATITIS AND WEREN’T HEAVY ALCOHOL DRINKERS YET 55% OF THEM ON BIOPSY HAD NASH, ALMOST 20% HAD BRIDGING FIBROSIS, ALMOST ALL THE PATIENTS WITH FIBROSIS HAD THIS PICTURE, INSULIN RESISTANCE AND OBESITY YOU SEE HERE THAT, AGAIN, BY WHO HAD ADVANCED FIBROSIS OR NASH ON BIOPSY, A SEE SALIENT WAS LOW CHOLESTEROL OR PRESENCE OF METABOLIC SYNDROME IMPORTANTLY THOUGH WE DIDN’T SEE SIGNIFICANT RELATIONSHIPS TO HIV ASSOCIATED FACTORS SUCH AS DURATION OF HIV, CD4 COUNT OR IMMUNOSUPPRESSION WITH CD4 NADIR OR OPPORTUNISTIC INFECTION THERE ARE NO FDA APPROVED TREATMENTS FOR NAFLD AT THIS POINT DESPITE A LARGE GROUP, A NETWORK OF INDIVIDUALS RESEARCHING THIS TOPIC LIFESTYLE MODIFICATION NEEDS CONSIDERATION WHY? BECAUSE THERE HAVE BEEN AT LEAST 20 STUDIES LOOKING AT DIET, WEIGHT LOSS, EXERCISE OR SOME COMBINATION OF THEM, 13 OF THE 20 RANDOMIZED CONTROL TRIALS FROM 6 TO 12 MONTHS, 18 OF THE 20 STUDIES INCLUDED SUBJECTS OVERWEIGHT OR OBESE AS A SUBCATEGORY OF INDIVIDUALS WITH NAFLD BUT 19 OF THE 20 SHOWED IT REDUCED LIVER FAT WE ACTUALLY HAVE A TREATMENT DOESN’T NEED TO BE FDA APPROVED IT’S BEEN SHOWN IN EVIDENCE-BASED MEDICINE TO WORK, NOT WHAT WE LIKE TO HEAR, EASIER TO GIVE MEDICATION THAT IMMEDIATELY AFFECTS IT BUT THERE ARE THINGS WE CAN DO TO MANAGE FATTY LIVER WE NEED TO WORK HARDER AT FIGURING OUT HOW TO OPERATIONALIZE THOSE WEIGHT LOSS 3 TO 5% OR UP TO 10% CAN HAVE SIGNIFICANT IMPACT, STUDIES SHOW VITAMIN E CAN REDUCE NON-DIABETIC NASH, PIOGLITAZON, ALPHA AGONIST, WORK IN SOME BIOPSY PROVEN NASH AND OBVIOUSLY AVOIDING HEAVY VOLUME IS HELPFUL CO-FACTOR NASH WITH CIRRHOSIS NEEDS TO BE TREATED LIKE CIRRHOSIS SO YOU NEED TO REMEMBER TO USE AND DO HCC SCREENING WHAT’S ON THE HORIZON? I’M GOING TO SKIP OVER SUBSEQUENT SLIDES BUT THERE’S INVESTIGATION OF NEW AGENTS INCLUDING PPAR GAMMA, PIOGLITAZON, DATA SHOWS IT WORKS WELL IN AVOIDING NASH AND DIABETES PPAR ALPHA AND ELAFRINAR, BENEFITS IN FIBROSIS AND FAT REDUCTION, ADVANCING INTO PHASE 3 DRAILS, AND CENICRIVIROC IS

TARGETING FIBROSIS BUT FIBROSIS IS WHETHER WE WANT TO FOCUS ON REDUCING MORBIDITY AND MORTALITY RELATED TO NAFLD AND NASH, AND GROUP IS LOOKING TO SEE IF IT CAN HELP REDUCE LIVER FAT WITH THAT I’M GOING TO SKIP, CLOSE YOUR EYES, I DON’T WANT TO GO OVER, AROUND I COULD SHARE THIS DURING THE DISCUSSIO BUT MY KEY POINTS THAT I WANTED TO MAKE IS THAT FOR PREVENTION WE NEED TO FOCUS ON OBESITY, PREVENTING OR TREATING, CONSIDER HIV CO-FACTORS THAT MAY PREDISPOSE INDIVIDUALS TO NASH IF THEY ARE IN YOUR CLINIC THE GOOD NEWS IS ARV TOXICITY SEEMS TO BECOME LESS OF AN ISSUE, WE’VE GOTTEN BETTER ANTIRETROVIRAL MEDICATIONS WITH LESS HEPATOTOXICITY, LESS OF AN ISSUE IN THE FUTURE DIAGNOSIS, KEEP IT IN YOUR DIFFERENTIAL AND CONSIDER WHEN YOU SEE EVEN LOW GRADE AST AND ALT ELEVATION, USE NON-INVASIVE TOOLS THAT GET BETTER EVERY DAY AND EASIER TO USE, AND BIOPSY WHEN NECESSARILY PARTICULARLY IN INDIVIDUALS WITH HIV AND FOR MANAGEMENT FOCUS ON KIND OF LOW-HANGING FRUIT WITH OBESITY AND METABOLIC SYNDROME BUT THERE ARE MEDICATIONS ON THE HORIZON THAT MAY ALSO HELP TO AUGMENT OUR ABILITY TO TREAT IT WITH WEIGHT AND LIFESTYLE SO WITH THAT I WILL CONCLUDE THANK YOU [APPLAUSE] >> THANK YOU, DR. HADIGAN, FOR THAT INTERESTING PRESENTATION, AS WELL AS FOCUSING ON INTERVENTIONS AND WAYS OF SELF MANAGEMENT THAT WE AT NINR AND EXTRAMURAL/INTRAMURAL COMMUNITY CAN FOCUS OUR WORK OUR NEXT PANELIST IS DR. LORENZO LEGGIO, RECEIVED HIS M.D. AND Ph.D. FROM CATHOLIC UNIVERSITY OF ROME, MASTER’S FROM UNIVERSITY OF FLORENCE, ON ALCOHOL ABUSE IN JUNE OF 2012 JOINED THE INTRAMURAL RESEARCH PROGRAM, CHIEF OF THE SECTION ON CLINICAL PSYCHONEURO ENDOCRINOLOGY AND NEURO PSYCHOLOGY, THE ASSOCIATE DIRECTOR FOR CLINICAL RESEARCH FOR NIDA MEDICATION DEVELOPMENT PROGRAM, FOCUSING ON TREATMENT AND MEDICAL CONSEQUENCES OF ALCOHOL USE DISORDERS WITH THE SPECIAL FOCUS ON THE GUT BRAIN AXIS TO DEVELOP NEW TREATMENT WELCOME, DR. LEGGIO [APPLAUSE] >> OKAY THANK YOU SO MUCH FOR INVITING ME IT’S A PRIVILEGE TO BE HERE AT THIS VERY EXCITING SYMPOSIUM TODAY SO WHAT I’M GOING TO DO IS TO GIVE YOU A BRIEF OVERVIEW OF ADDICTION, IN PARTICULAR WHY WE’RE INTERESTED IN LOOKING AT THE GUT-BRAIN AXIS AS A WAY TO IDENTIFY TREATMENT FOR ALCOHOL USE DISORDER AND I WILL GIVE AN EXAMPLE OF WHAT WE’RE WORKING ON IN MY LAB HERE IN THE INTRAMURAL PROGRAM AS WENDY SAID, WE’RE TRYING TO DEVELOP A NEW MEDICATION, WE HAVE TAKEN THE SPECIFIC ANGLE THAT IS TO LOOK AT THE GUT-BRAIN AXIS TO IDENTIFY TREATMENT STEPPING BACK, A BRIEF OVERVIEW, ALCOHOL USE DISORDER IS A DRAMATIC MEDICAL PROBLEM IN FACT THE MOST RECENT DATA SHOWS ALMOST 14% OF PEOPLE IN THE UNITED STATES HAVE A LIFETIME ALCOHOL USE DISORDER, SORRY, CURRENT LIFETIME USE DISORDER IF YOU LOOK AT LIFETIME ALCOHOL USE DISORDER, ACTUALLY THE NUMBER GOES UP TO ALMOST 30% SO ALMOST 1 OUT OF 3 PEOPLE IN THE UNITED STATES HAS A LIFETIME DIAGNOSIS OF ALCOHOL USE DISORDER ALSO, ALCOHOL IS ONE OF THE MOST HARMFUL DRUGS INDEED IF WE CONSIDER HARM TO USERS, ALSO HARM TO OTHERS, ALCOHOL IS THE MOST HARMFUL DRUG HARM TO OTHERS INCLUDE FOR EXAMPLE DOMESTIC VIOLENCE, GUN VIOLENCE, CAR ACCIDENTS THE GOOD NEWS IS IN THE PAST DECADE THE UNDERSTANDING OF NEUROBIOLOGICAL PATHWAYS THAT REGULATE CAN BE HEAVIER WITHOUT GOING INTO THE DETAILS BECAUSE OF THE SAKE OF TIME THIS SLIDE SUMMARIZES THE KNOWLEDGE WE HAVE ON THE NEUROBIOLOGICAL

REASONS WHY SOME PEOPLE DEVELOP ALCOHOL USE DISORDER THIS INFORMATION IS KEY BECAUSE IT MAY HELP US TO IDENTIFY NEW TARGETS AND TO DEVELOP NEW MEDICATIONS TO HELP OUR PATIENTS WITH ADDICTION AND IN PARTICULAR WITH ALCOHOL USE DISORDER IN FACT A VARIETY OF MEDICATIONS HAS BEEN TESTED IN THE PAST DECADE SOME HAVE BEEN EVEN APPROVED BY THE FDA FOR THE TREATMENT OF ALCOHOL USE DISORDER BUT THE PROBLEM IS THAT WE ONLY HAVE THREE MEDICATIONS APPROVED BY THE FDA ALSO THESE MEDICATIONS DON’T WORK FOR EVERY PATIENT THERE’S URGENT NEED TO IDENTIFY NEW TARGETS TO DEVELOP A NEW MEDICATION SO HOW WE CAN SCHEMATICALLY THINK ABOUT MEDICATION FOR ALCOHOL USE DISORDER IS TO TALK ABOUT WAVES OF DEVELOPMENT, THE FIRST IS FDA-APPROVED THE SECOND WAVE IS REPRESENTED BY MEDICATIONS WHICH ARE ALREADY IN THE MARKET FOR OTHER INDICATIONS BUT THEY ARE NOT USE DISORDER BUT SOME OF THESE MEDICATIONS HAVE SHOWN IN ANIMAL MODELS AND PHASE 2 AND EVEN PHASE 3 TRIALS SOME SIGNAL OF EFFICACY THESE MEDICATIONS INCLUDE GABAPENTIN, VIRONECLEN THE THIRD WAVE IS PRELIMINARY RESEARCH ON NEW TARGETS THAT WE COULD USE AS A WAY TO IDENTIFY IN IDENTIFY AND DEVELOP NEW MEDICATIONS IN THE INTRAMURAL PROGRAM WE’RE FOCUSED ON THE THIRD WAVE OF MEDICATION AND WE SPECIFICALLY ARE FOCUSED ON THE GET-BRAIN AXIS WHY? FROM A NEUROBIOLOGICAL ENDPOINT, FROM A KEY SCIENTIST IN THE FIELD FROM MOUNT SINAI WE KNOW THERE’S A SIGNIFICANT OVERLAP BETWEEN NEUROCIRCUITRIES IN THE BRAIN THAT REGULATE FOOD INTAKE AND REWARD AND CAN BE HEAVIER IN ALCOHOL ADDICTION FROM BENCH TO BEDSIDE, WE ALSO KNOW THE STRUCTURE DOES EXIST COMING FROM THE VOLKOW LAB WHERE THEY HAVE SHOWN THAT THE CHANGE IN THE DOPAMINE D2 RECEPTOR IN PATIENTS WITH OBESITY ARE ALSO PRESENT IN A VERY SIMILAR WAY IN PATIENTS WITH ADDICTION INCLUDING ALCOHOL USE DISORDER AGAIN, THIS IS JUST AN EXAMPLE MOVING FROM CLINICAL EXPERIMENTAL MEDICINE TO CLINICAL PRACTICE, WE KNOW THAT THE PATIENTS WITH ALCOHOL USE DISORDER OFTEN HAVE A COMORBIDITY WITH EATING DISORDERS AND WE KNOW IN CLINICAL PRACTICE WHEN WE TREAT OUR PATIENTS WITH ALCOHOL USE DISORDERS WITH MEDICATIONS WHICH ARE APPROVED BY THE FDA OR USE OFF-LABEL TO TREAT THESE PATIENTS WE ALSO SEE FOR SOME OF THESE MEDICATIONS IN PARTICULAR PROFOUND EFFECTS ON APPETITE, FOOD INTAKE AND WEIGHT SO AL TOGETHER THIS BUILDS OUR RATIONALE TO LOOK AT GUT-BRAIN AXIS AS A NEW WAY TO IDENTIFY NEW MEDICATIONS WE’VE LOOKED SPECIFIC NEUROENDOCRINE SIGNALING, THAT’S WORK IN PROGRESS A GLP-1, EXPANDING BEYOND NEUROENDOCRINE SIGNALING, PLANNING TO DO A WORK ON THE BARIATRIC SURGERY, JUST GOT APPROVAL TO PERFORM A GUT MICROBIOTA WORK ON ALCOHOL USE DISORDER, POSTDOC OF MINE IS LEADING THIS PROJECT, AND I THINK ALSO THIS PROJECT IS A PERFECT EXAMPLE WITH DR GOTTESMAN WHAT TALKING BEFORE ON THE IMPORTANCE OF COLLABORATION, IN FACT DR. HENDERSON IS A KEY COLLABORATOR IN OUR GUT MICROBIOME WORK AND WE’VE TAKEN FULL ADVANTAGE OF HER EXPERTISE WHAT I’M GOING TO DO TODAY IS ACTUALLY FOCUS ON SOME PAST WORK AND SOME ONGOING WORK WITH SOME UNPUBLISHED DATA ON ONE OF THESE TOPICS, HOW OUR LAB IS APPROACHING THIS TOPIC AND AGENDA FOR THOSE WHO ARE NOT FAMILIAR WITH GHRELIN, IT’S A HORMONE PRODUCED BY THE STOMACH, UNIQUE BECAUSE GHRELIN GOES THROUGH THE POSITION, THE GUT ENZYME IS ABLE TO ACT IN THE BRAIN THROUGH THE NERVE AND DIRECTLY THROUGH — WELL, BECAUSE OF ITS ABILITY TO CROSS THE BLOOD-BRAIN BARRIER, AND IN ADDITION TO HYPOTHALAMUS,

THE KEY IN FOOD INTAKE AND FOR THE REWARD, BUT ALSO ARE IMPORTANT IN ALCOHOL INTAKE AND ALCOHOL REWARD SO CONSISTENT WITH THE OVERLAP BETWEEN NEUROCIRCUITRY THAT REGULATES FOOL AND ALCOHOL, THE QUESTION WAS WHETHER GHRELIN IS ALSO PLAYING A ROLE IN ALCOHOL BEHAVIOR A VARIETY OF STUDIES SUPPORTED THAT, IN PARTICULAR GHRELIN DEMONSTRATION IN ANIMAL MODELS OF EXCESSIVE ALCOHOL USE GHRELIN ADMINISTRATION INCREASES ALCOHOL INDUCED LOCOMOTOR ACTIVITY AND DOPAMINE RELEASED IN THE ACCUMBENS WHEN YOU BLOCK THE RECEPTOR, ALL THIS BEHAVIOR IN THE PARAMETERS GO DOWN, AND ALSO THE BLOCKADE RESULTS IN REDUCTION IN ALCOHOL INTAKE PREVALENCE AND IMPORTANT HERE THIS DATA COMES FROM INDEPENDENT LABS USING DIFFER RENT ANIMAL MODELS AS A CLINICIAN OUR JOB IS RELAY THIS INFORMATION FROM BENCH TO BEDSIDE THE FIRST STEP TO LOOK AT GHRELIN LEVELS, ENDOGENOUS GHRELIN LEVELS IN ALCOHOL DEPENDENT PEOPLE AND FOUND THE GHRELIN LEVELS POSITIVELY CORRELATE WITH CRAVING AND RELAPSE THOSE ALCOHOL DEPENDENT PEOPLE WITH HIGHER GHRELIN HAVE A HIGHER CRAVING FOR ALCOHOL, MORE LIKELY TO RELAPSE BY CONTRAST THOSE WITH LOWER GHRELIN HAVE LOWER CRAVING FOR ALCOHOL AND MORE LIKELY TO MAINTAIN ABSTINENCE CONSISTENT WITH PREVIOUS DATA BUT IMPORTANT LIMITATION HERE IS NUMBER ONE THEY SHOW CORRELATION BUT NOT CAUSALITY NUMBER TWO CRAVING WITH RETROSPECTIVE MEASURE THE NEXT STEP IS WHETHER GHRELIN ADMINISTRATION MAY INCREASE ALCOHOL CRAVING TO DO SO WE PERFORMED A FIRST STUDY WHERE WE DID AN EXOGENOUS GHRELIN ADMINISTRATION, INTRAVENOUS IN ALCOHOL DEPENDENT INDIVIDUALS, WE DID SO IN OUR LABORATORY SETTING HERE ON THE FIRST FLOOR IN OUR OUTPATIENT CLINIC, THE IDEA IS TO ASSESS GHRELIN IN REAL TIME IN A CONTEXT AS CLOSE AS POSSIBLE TO REAL WORLD THIS WAS A DOUBLE BLIND PLACEBO CONTROLLED RANDOMIZED CONTROL WITH HEAVY DRINKING ALCOHOL DEPENDENTIZED RANDOMIZED TO RECEIVE ALCOHOL, STARTED TO EXPOSE TO ALCOHOL CUES BUT ALSO TO JUICE CUES AS NON-ALCOHOLIC HEPATOCYTIC CONTROL, ASSESSING GHRELIN IN REAL TIME THERE WAS INCREASING URGE TO DRINK ALCOHOL SPECIFICALLY HIGHEST DOSE OF GHRELIN SIGNIFICANTLY MORE EFFECTIVE COMPARED TO PLACEBO, NON-OBESE ALCOHOL DEPENDENTENT PEOPLE, THE EFFECT IS SPECIFIC BECAUSE WE DIDN’T SEE SIMILAR EFFECT FOR URGE TO DRINK JUICE NOW, THIS PARADIGM, PEOPLE ARE EXPOSED TO CUES, BUT NOT ALLOWED TO DRINK ALCOHOL SO THE NEXT QUESTION WAS WHETHER GHRELIN FUSION MAY LEAD TO INCREASED INTAKE THE POSTDOC IN MY LAB LEADING THE PUBLICATION, WHAT WE DID WAS ANOTHER DOUBLE BLIND PLACEBO CONTROLLED WITH 11 PEOPLE HERE THE EXPERIMENT WITH NIAAA USING PROGRESSIVE RATIO THE FIRST REASON, WE WANT TO TAKE OUT THE BIOENVIRONMENT AND TAKE OUT THE TASTE AND VISUAL AND TACTILE AND OLFACTORY CUES GHRELIN IS QUITE INVOLVED IN MEAL INITIATION, AN IMPORTANT CUE WHEN GHRELIN PLAYS ON ROLE IN OUR BRAIN WHAT WE WANT TO DO HERE WAS TO CHALLENGE OUR KNOWLEDGE ON GHRELIN AND SEE WHETHER IN SPITE OF TAKING OUT THE BAR ENVIRONMENT AND IN SPITE OF TAKING OUT THE CUES WE COULD STILL SEE PHARMACOLOGICAL EFFECT IN INCREASING ALCOHOL SELF ADMINISTRATION COMPARED TO PLACEBO THERE WAS

SIGNIFICANT INCREASE IN NUMBER OF INFUSION EXPRESSED AS PERCENTAGE OF CHANGE FROM PLACEBO TO GHRELIN, .71 WE SHOWED GHRELIN INFUSION HAS EFFECT ON DRINKING AND CAVING BUT THE QUESTION IS ARE THE CLINICIAN WHO WANTS TO HELP PEOPLE TO STOP DRINKING IS HOW CAN WE USE THIS INFORMATION TO DEVELOP NEW MEDICATION ONE OF THE APPROACH IS TO BLOCK THE RECEPTOR, THIS IS CHALLENGING WE WERE ABLE TO ACCESS THE DRUG USING THE COMPOUND FROM PFIZER, THIS WAS AN LED BY NCATS, WE APPLIED AND GOT THE GRANT IN COLLABORATION WITH INTRAMURAL, TESTING THE GHRELIN WITH ANING A — WITH AN AGONIST WE COMPLETED THE FIRST PART, MY LAB IS LEADING THE PUBLICATION THE FIRST QUESTION WAS SAFETY A NEW COMPOUND, PFIZER ONLY TESTS IN FIRST IN MAN PHASE 1A STUDIES, WE WANT TO DO A PHASE 1B DRUG-ALCOHOL INTERACTION STUDY BECAUSE PFIZER DIDN’T HAVE ANY DRUG-ALCOHOL INTERACTION, THE FDA IS VERY METICULOUS, WE’RE METICULOUS IN PROTECTING OUR PATIENTS ANOTHER FACTOR BEFORE TESTING INTERACTION OF DRUG AND ALCOHOL IN HUMANS WE PERFORMED CLINICAL EXPERIMENTS, SAW THERE WAS NO IMPORTANT INTERACTIONSING, AFTER THE GREEN LIGHT FROM THE PRE-CLINICAL STUDIES TESTED THIS COMPOUND IN A PHASE 1B DRUG-ALCOHOL INTERACTION WITH 12 NON-TREATMENT SEEKING HEAVY DRINKERS AND FINISHED, RECENTLY ANALYZED, ACROSS THREE CONDITIONS, TWO DOSES AND PLACEBO, NOT SERIOUS ADVERSE EVENTS TOLERABILITY EXCELLENT WE DON’T SEE DIFFERENCE IN ALCOHOL BIPHASIC EFFECTS, TO STUDY STATE DON’T SEE DIFFERENCE IN SIDE EFFECTING SUGGESTING IT IS SAFE WITH ALCOHOL, THE GREEN LIGHT TO MOVE TO PHASE 2A, TWO SUBJECTS ENROLLED WE HOPE TO CONTINUE THIS RESEARCH TO HAVE AN ANSWER IN A COUPLE OF YEARS BY NOW TO SUMMARIZE OUR GHRELIN RESEARCH FIRST WE SHOW A RELATIONSHIP BETWEEN GHRELIN AND CRAVING, THEN WE MOVE TO A CAUSALITY LINK IN HUMANS SHOWING THE PHARMACOLOGICAL INDUCED HIGHER GHRELIN STATUS LEADS TO INCREASED CRAVING AND INCREASED ALCOHOL ADMINISTRATION AND HAVE SAFETY DATA ON THE NOVEL GHRELIN RECEPTOR INVERS AGONIST WITH HEAVY DRINKERS A THANKS TO COLLABORATORS, PEOPLE IN MY LAB, DR. MARY LEE, AND OTHERS, OUR MANAGER AND STUDENTS, AND FINALLY THANKS TO OUR FUNDING SOURCE, IN PARTICULAR NIAAA, AND THANKS AGAIN FOR INVITING ME [APPLAUSE] >> WHAT AN EXCELLENT PANEL TO START WITH THANK YOU SO MUCH TO WENDY AND LORENZO AND COLLEEN FOR YOUR FANTASTIC PRESENTATIONS [APPLAUSE] WE’LL NOW OPEN THE FLOOR FOR QUESTIONS THERE ARE MICROPHONES IN BOTH AISLES AND PLEASE MAKE YOUR WAY TO ONE OF THESE MICROPHONES TO CONTRIBUTE TO THE DISCUSSION WE’D LIKE TO GET AS MANY QUESTIONS AS POSSIBLE, SO PLEASE BE BRIEF ON YOUR QUESTIONS I WILL TAKE THE — WHILE WE’RE WAITING FOR PEOPLE TO GET UP TO THE MICROPHONE I WILL TAKE THE LIBERTY OF ASKING THE FIRST QUESTION ONE OF THE PARTICULAR EMPHASIS OF TODAY IS TO SHOW THE ACROSS-INSTITUTE COLLABORATION, CROSS-DISCIPLINE COLLABORATION AND I’M FREQUENTLY ASKED THIS QUESTION HOW DO YOU ENCOURAGE THIS TEAM SCIENCE? IF YOU HAVE ANY TIPS ON HOW TO MEET PEOPLE ACROSS INSTITUTES, HOW TO DIRECT THAT SO YOU’RE BUILDING THE PARTNERSHIPS GIVEN THE TIME THAT YOU HAVE? BECAUSE I KNOW YOU EACH HAVE VERY BUSY PROTOCOLS AND ACTIVITY SCHEDULES, SO IF YOU COULD BRIEFLY ADDRESS THAT >> KEEP MY SHORT BECAUSE I LIKE TO TELL STORIES WHEN I FIRST INTERVIEWED, I STARTED TO TELL IT EARLIER AND CUT MYSELF OFF WHEN I FIRST CAME AND WAS RECRUITED TO BE A STAFF

SCIENTIST IN THE INTRAMURAL PROGRAM OF THE NIH FOR NINR, THE FIRST THING I DID WAS REACH OUT TO OTHER NURSE SCIENTISTS TO FIGURE OUT HOW DOES THIS WORK, THE ENVIRONMENT, WHO PLAYS WELL IN THE SANDBOX AND WHAT DO I NEED TO KNOW THE FIRST INDIVIDUAL WAS DR YAKEEM VOSS WHO SAID COLLEEN HADIGAN IS HERE, THERE ARE 1600 INDIVIDUALS DOING RESEARCH, RIGHT? 1600 PROTOCOLS, RIGHT? IT’S HUGE AND HARD TO FIND INDIVIDUALS BUT TO FIND INDIVIDUALS THAT CARE ABOUT THE SCIENCE AND THE PATIENTS AND CARE ABOUT OUR AREA OF INTEREST AND ARE RESPECTFUL TO NURSE SCIENCE, NURSING SCIENCE AND WHAT WE BRING TO THE TABLE, HAS SORT OF BEEN MY AREA THE OTHER THING IS SERENDIPITY WITH LORENZO, YOU RECALL WELL ON A FEDERAL HOLIDAY I WAS WORKING LATE, IT WAS DINNER TIME, 6:30 OR 7:00 I GET ON THE ELEVATOR TO GO TO THE PARKING GARAGE THE PLACE IS — OTHER THAN CLINICIANS VERY FEW PEOPLE ARE AROUND I GET ON THE ELEVATOR WHO IS THERE, ALREADY LORE LORENZO, YOU LOOK FAMILIAR WHAT IS YOUR AREA OF WORK? GUT-BRAIN-LIVER AXIS ONLY HERE AT THE NIH IN BUILDING 10 DO THESE SORTS OF THINGS HAPPEN LEARNING FROM THEM, THEY HAD BEEN HERE AND HAVE MENTORSHIPS AND ASKING THOSE QUESTIONS HOW THINGS ARE DONE WITHIN THIS ENVIRONMENT BUT THE OTHER PERSON I WENT TO AS A NURSE SCIENTIST, WHO ELSE HAS BEEN HERE AND DONE GENETICS AND GENOMICS IN THIS ATMOSPHERE? VISIT SUSAN DORSEY I WENT TO UNIVERSITY OF MARYLAND, KNOCKED ON SUSAN DORSEY’S DOOR I’M NEW HERE, WHAT DO I DO? SHE SAID YOU NEED TO KNOW HOW TO DO ALL THE ANALYSIS AND ALL THE GENETICS YOURSELF GO AND LEARN IT AND COME BACK THAT’S EXACTLY WHAT I DID SO EVERY BIT OF WHAT I DO IN MY LAB IS SOMETHING THAT WE CAN UNDERSTAND ON OUR OWN WITHOUT HAVING A Ph.D. IN GENETICS, BUT THEN BE ABLE TO LINK IT TO WHAT WE KNOW BEST WHICH IS OUR PATIENTS AND WHAT THEIR SYMPTOMS ARE SORRY IF I WENT TOO LONG >> I WOULD SECOND EVERYTHING THAT WENDY SAYS I MEAN, IT’S ABOUT FOLLOW THE SCIENCE YOU KNOW, SO MANY OF THE RESEARCH QUESTIONS AND COLLABORATIONS THAT I HAVE HAD HAVE COME FROM CLINICAL INTERACTIONS WHERE THERE’S SOME OBSERVATION NOTED IN A BUSY CLINIC, WHY ARE THESE PATIENTS PRESENTING WITH THIS AND TALKING TO THE PEOPLE WHO DO IT AND FOLLOWING THE LEAD UNTIL YOU FIND A GROUP THAT CAN PUT TOGETHER WHAT YOU NEED TO DO WE MCGYVER A LOT OF THINGS, UNTIL WE FIND THE RESOURCES SO, YEAH, KEEP YOUR EYES OPEN AND PAY ATTENTION >> YEAH, NOT MUCH TO ADD I GUESS THERE IS ALWAYS WHEN YOU ARE AN INVESTIGATOR THIS TRADEOFF, SHOULD BE A SILENT WORKER AND COLLABORATE IF YOU GO BACK TO YOUR CV, YOUR LAB AND DO DATA ANALYSIS, YOU SEE THE BEST WORK YOU HAVE PUBLISHED IF ANY COMES FROM COLLABORATION IT’S EVEN A FACTOR THAT WE HAVE DATA TO SUPPORT THAT >> THANK YOU QUESTIONS? >> THANK YOU FOR YOUR PRESENTATIONS INTRAMURAL, YOU ALWAYS HAVE DATA PRODUCED WITHIN YOUR DIVISION OR YOU HAVE SOME DATA FROM OTHER SOURCES AND WHETHER THOSE RECORD OR DATA IS THE — IS ALL CORRECT OR IS THERE ANY ERROR MISDIAGNOSIS OF LOCATION AND HOW DO YOU DEAL WITH POOR DATA? HOW DO YOU VERIFY IT? >> SO IS THE QUESTION ABOUT THE CLINICAL DATA OR RESEARCH DATA? YOU’RE ASKING ABOUT DATA VALIDATION AND SO FORTH? >> RIGHT >> OKAY SO THE BUILDING YOU’RE IN IS ACTUALLY A HOSPITAL AND SO THIS IS CALLED A CLINICAL CENTER OF THE NIH IT HAS CLIA-APPROVED LABORATORY AND DEPARTMENT OF LABORATORY MEDICINE, ICUs, FULLY FUNCTIONING HOSPITAL HOWEVER, EVERY PATIENT WHO COMES HERE IS ON A CLINICAL PROTOCOL SO FROM A CLINICAL DATA PERSPECTIVE, THAT DATA IS HOSPITAL, RIGHT? IF IT’S A HOSPITAL QUESTION IN TERMS OF COMPLETE BLOOD COUNT, ET CETERA, THAT’S HOW WE KNOW FROM A PATIENT SAFETY PERSPECTIVE THAT DATA IS CORRECT RESEARCH DATA, IT’S A GREAT QUESTION AND DEPENDS I DON’T KNOW IF MY OTHER COLLABORATORS AND MODERATOR OR PANELISTS COULD BETTER ANSWER

FOR ME IN MY LAB I LIKE TO HAVE IT VALIDATED AT AN OUTSIDE LAB IF POSSIBLE IF IT’S SOMETHING I INVENTED AND NO ONE CAN VALIDATE WE FIND A DIFFERENT METHOD TO VALIDATE FOR YOUR GHRELIN AND SO FORTH, DO YOU HAVE THAT SENT OUT TO A DIFFERENT FACILITY FOR EVALUATION? >> WELL, YOU MEAN FOR THE DRUG INFUSION? >> LIKE FOR DRUG LEVELS >> RIGHT NO, FOR THE DRUG LEVELS THERE IS NO CLIA CERTIFIED KIT FOR GHRELIN BECAUSE THERE ARE NO CLINICAL ACTIVATION, WE DO IN HOUSE BY USING COMMERCIAL KITS AVAILABLE >> IF WE COULD TAKE ONE MORE QUESTION BEFORE THE BREAK >> HI MY NAME IS (INDISCERNIBLE) FROM VIRGINIA COMMONWEALTH UNIVERSITY A QUESTION TO COLLEEN THANK YOU FOR THE WONDERFUL PRESENTATION AND THEN AT THE END OF THE, YOU KNOW, PRESENTATION, REGARDING THE MANAGEMENT OF THE (INDISCERNIBLE) AMONG THE HIV POPULATION YOU SUGGESTED WE WILL — WE HAVE TO MANAGE THE METABOLIC SYNDROME, AS WELL AS PROBABLY LARGELY DEPENDING ON THE LIFESTYLE MODIFICATION, AND THEN THAT KIND OF STRUCK ME THAT, OH, IT’S NOT EVEN HIV REGIMEN, IT’S NOT ONLY THAT, IT’S NOT EVEN (INDISCERNIBLE) REGIMEN, WE’RE DEALING WITH METABOLIC SYNDROME I UNDERSTAND METABOLIC SYNDROME IS UNDERLYING MAJOR CAUSE BUT THERE MUST BE SOMETHING THAT SPECIFICALLY DEALS WITH NAFLD AND ETIOLOGY SO IF YOU HAVE ANY SUGGESTIONS OR MORE FURTHER STAFF OF RESEARCH FOR SYMPTOM MANAGEMENT WHAT WOULD YOU SUGGEST? >> SO JUST TO BE CLEAR YOU’RE ASKING FOR NAFLD AND HIV MANAGEMENT? >> CORRECT >> MY GROUP IS ABOUT TO LAUNCH A FEW STUDIES TO ACTUALLY LOOK AT STRATEGIES FOR EITHER INTERMITTENT FASTING AS A WAY TO MANAGE WEIGHT AND IMPROVE BOTH WEIGHT, LIPIDS, AND INFLAMMATION AS WELL AS CALORIE RESTRICTION, WITH THE IDEA YOU COULD IMPLEMENT SOMETHING THAT WAS DOABLE FOR PATIENTS WHERE THEY WOULD ACTUALLY — WE WERE GOING TO MANAGE — ALSO MEASURE SYMPTOMS AND SOME QUALITY OF LIFE AND SYMPTOM SCALES IN THIS STUDY TO SEE IF IT CAN IMPROVE OVERALL FUNCTIONING AS WELL AS THESE METABOLIC FACTORS AND WE’LL BE MEASURING LIVER FAT TO SEE IF THAT IMPROVES AS WELL I STILL FEEL LIKE THAT’S THE MOST IMPORTANT THING WE CAN DO BECAUSE EVEN — THERE ARE GOOD DATA IN NON-HIV SETTINGS THAT INTERMITTENT FASTING AND CALORIE RESTRICTION REDUCES INFLAMMATION, A BIG DRIVER IN THE INJURY PIECE, SO WE’RE GOING TO BE LAUNCHING THAT HOPEFULLY IN THE NEXT YEAR >> THANK YOU SO MUCH >> AND THANK YOU FOR YOUR THOUGHTFUL QUESTIONS WE’RE NOW GOING TO TAKE A BREAK WE WILL START THE NEXT PANEL AT 10:45 SO I HOPE TO SEE YOU BACK THEN WELCOME BACK FROM THE BREAK I’M DR. ANN CASHION, THE SCIENTIFIC DIRECTOR OF NINR’S INTRAMURAL PROGRAM I WILL INTRODUCE, AND A FEW PEOPLE ARE TAKING A SEAT NOW BUT I’D LIKE TO GO AHEAD AND INTRODUCE OUR NEXT PANEL MODERATOR AND THE NEXT PANEL DR. LEOREY SALIGAN IS CHIEF OF NINR SYMPTOM BIOLOGY UNIT, RECEIVED HIS Ph.D. IN NURSING FROM HAMPTON UNIVERSITY, IN 2007 JOINED NINR AS A POSTDOCTORAL FELLOW IN THE SYMPTOM MANAGEMENT BRANCH WHERE HE BECAME A LEAD ASSOCIATE INVESTIGATOR OF A CLINICAL TRIAL INVOLVING INDIVIDUALS WITH FIBROMYALGIA DR. SALIGAN MAKES CONTRIBUTIONS TO NURSING, BY INITIATING INNOVATIVE CLINICAL TRIALS FOCUSED ON FATIGUE AND TRANSLATING MOLECULAR DISCOVERIES INTO PRACTICE IN ADDITION TO PUBLICATION RECORD HE’S BEEN ASKED TO CONDUCT SCHOLARLY PRESENTATIONS ON TRANSLATIONAL APPROACHES TO SYMPTOMS, RESEARCH BY VARIOUS RESEARCH SOCIETIES, ACADEMIC INSTITUTIONS, AND PROFESSIONAL ORGANIZATIONS ACROSS THE U.S. AS WELL AS INTERNATIONALLY HE AND HIS PANEL WILL BE

DISCUSSING THE ROLE OF INFLAMMATORY AND GLUTE MINUTE ERGIC PATHWAY ON FATIGUE >> I THANK THE MEMBERS OF THE PANEL FOR JOINING US TODAY, PROMINENT SCHOLARS WHO ARE GENEROUS WITH THEIR TIME TODAY AND MENTORING OVER THE YEARS OF PROGRAM RESEARCH OUR PANEL WILL TALK ABOUT THE ROLE OF INFLAMMATORY AND GLUTAMATERGIC FATIGUE, PROVIDING AN OVERVIEW OF RESEARCH PACKAGE HIGHLIGHTING THE COLLABORATION I’VE DEVELOPED WITH MENTORS ON THE PANEL AS WELL AS SCIENTISTS IN THE INTRAMURAL AS WELL AS EXTRAMURAL COMMUNITY SO MY PROGRAM OF RESEARCH HAS TWO AREAS OF FOCUS, THE FIRST IS LOOK AT THE TRAJECTORY AND CAUSES OF FATIGUE IN SPECIFIC CONDITIONS, SPECIFICALLY IN CANCER USING CLINICAL AND PRE-CLINICAL APPROACHES ALSO TO UNDERSTAND WHAT SYMPTOMS CO-OCCUR WITH FATIGUE, HOPING TO FIND DISTINCT AND SHARED FUNCTIONAL PATHWAYS OF FATIGUE TO IDENTIFY POTENTIAL THERAPEUTIC TARGETS THAT CAN ALLEVIATE THE SYMPTOMS SO AS YOU’RE FAMILIAR WITH THE SYMPTOM SCIENCE MODEL USING THIS WE KNOW WE HAVE A COMPLEX SYMPTOM WE ALL KNOW FATIGUE IS SUCH A COMPLEX SYMPTOM AND UNFORTUNATELY THERE’S NO CONSENSUS ABOUT ITS PHENOTYPE SO THE MAIN GOAL OF OUR PROGRAM IS TO REALLY CHARACTERIZE WHAT FATIGUE FROM A CLINICAL TRANSLATION THOSE KINDS OF PATIENTS WHO ARE RECEIVING RADIATION THERAPY WE WANT TO CHARACTERIZE WHAT RADIATION-RELATED FATIGUE IS AND USING THIS CHARACTERIZATION I WANTED TO DROP IDENTIFICATION OF CORRELATES USING PROOF-OF-CONCEPT STUDIES OR CLINICAL TRIALS IF THESE ARE TRUE BIOMARKERS OR CORRELATES OF RADIATION FATIGUE WHY STUDY FATIGUE AT ALL? IT’S COMMON AND I’M SURE, I HOPE NOT ALL OF YOU, WILL DEVELOP A FATIGUE AT THE END OF THE SYMPOSIUM [LAUGHTER] AND IT’S UNFORTUNATELY VERY COSTLY IN REAL CLINICAL POPULATIONS, A LOT OF PATIENTS GO TO EMERGENCY ROOM TO COMPLAIN ABOUT FATIGUE YET LITTLE IS KNOWN ABOUT THE MECHANISMS OF FATIGUE AND IT CO-OCCURS NOT WITH A LOT OF CONDITIONS AND A LOT OF SYMPTOMS, DEPRESSION THAT’S VERY HIGH AMONG DEPRESSED PATIENTS, EVEN IN PATIENTS OF PAIN, CHRONIC PAIN SPECIFICALLY AND CO-OCCURS WITH SLEEP DISTURBANCE AND COGNITIVE IMPAIRMENT NEGATIVELY INTERFERES WITH QUALITY OF LIFE AND IMPACTS DAILY FUNCTION, ESPECIALLY THOSE THAT ARE RECEIVING CANCER THERAPY AND IT CAN INFLUENCE TREATMENT OUTCOMES AND TO SOME EXTENT IT CAN ALSO CAUSE PHYSICAL DISABILITY SO THE FATIGUE HAS BEEN DEFINED, AS DISTRESSING PERSISTENCE PERCEIVED EXPERIENCE, AND AS MANY HAVE PROPOSED, IT IS COMPOSED OF MULTIPLE DOMAINS, A PHYSICAL TYPE OF FATIGUE, EMOTIONAL, COGNITIVE OR COMBINATION THIS IS NOT PROPORTIONAL TO RECENT ACTIVITY OR NOT RESOLVED BY SLEEP THERE ARE TWO MAIN THOUGHTS OUT THERE OF WHAT TYPES OF FATIGUE THERE ARE ONE IS OF COURSE PHYSICAL FATIGUE THAT’S ALL RELATED TO MUSCULAR TYPE OF OUTPUT AND THE OTHER TYPE IS CALLED CENTRAL FATIGUE, ASSOCIATED WITH COGNITIVE OR AFFECTIVE OR BEHAVIORAL IMPAIRMENT I STUDY CANCER RELATED, THE TRAJECTORY AND BIOLOGICAL COORDINATES A GREAT POPULATION TO STUDY BECAUSE ESPECIALLY DISEASE LIKE THE POPULATION I’M FOLLOWING, PROSTATE CANCER MEN WITH NON-METASTATIC DISEASE, RECEIVING LOCALIZED TREATMENT MOST OF THE TIME THESE ARE ACTIVE MEN, THEY COME IN WITH NO FATIGUE, RECEIVE RADIATION THERAPY, THEY DEVELOP FATIGUE DURING TREATMENT AND A SUBSET OF THEM DEVELOP CHRONIC FATIGUE YEARS OR MONTHS AFTER THEY COMPLETED THEIR RADIATION

THERAPY SO TO START MY PROGRAM, I DEVELOPED HYPOTHESIS GENERATING NATURAL HISTORY PROTOCOL TO FOLLOW PATIENTS WHO HAVE BEEN SCHEDULED TO RECEIVE RADIATION THERAPY I FOLLOW THEM AT BASELINE, WHICH IS BEFORE THEY GET TREATED, AND THEN DURING THEIR TREATMENT MOSTLY WEEKLY, AND MID-POINT AND COMPLETION THEY ARE TREATED FIVE TIMES A DAY, OFTENTIMES BETWEEN 38 DAYS TO 44 DAYS, DEPENDING ON THE STAGE OF THEIR DISEASE AND THEN I FOLLOW THEM ONE MONTH, THREE MONTHS, UP TO ONE YEAR AFTER THEY COMPLETED TREATMENT I OBTAIN SYMPTOM RATINGS, YOU KNOW, OBTAIN BLOOD FOR POTENTIAL — IDENTIFY POTENTIAL BIOLOGIC MARKERS ANEMIA HAS BEEN REPORTED TO INFLUENCE FATIGUE SO I ALSO OBTAIN CBC TO GET ANEMIA LEVELS BUT ALSO I ADDED MORE OBJECTIVE MEASURES TO SEE WHETHER IT CAN CORRELATE WITH SELF-REPORTED FATIGUE I ADDED A HAND GROUP DYNOMOMETRY, ACTIVEGRAPHY FOR SLEEP AND COMPUTERIZED TESTING INITIALLY BASED ON THE RESPONSES I RECEIVE FROM THE PATIENTS THAT HAVE ENROLLED SO FAR I HAVE TO IDENTIFY WHICH OF THESE RESPONSES ARE CLINICALLY SIGNIFICANT DAVID SELLER AFTER CONSULTING PUBLISHED MINIMALLY IMPORTANT DIFFERENCE BETWEEN TIME POINTS WHEN YOU LOOK AT FATIGUE SCORES, YOU SEE PROMISE EVEN FUNCTIONAL ASSESSMENTS OF CANCER THERAPY FATIGUE SUBSCALE I USE THAT TO TRACK TRAJECTORY OF FATIGUE FOR MY PATIENTS MOST ALL, GENERALLY ALL PATIENTS HAVE INTENSIFICATION OF IF FATIGUE AT MID-POINT, DAY 21, AND PERSISTS AT DAY 42 AT COMPLETION A SUBSET CONTINUES TO HAVE CHRONIC FATIGUE, PERSISTENT ONE YEAR AFTER COMPLETING RADIATION THERAPY THE LOWER THE SCORE THE WORSE THE FATIGUE I LOOKED AT WHAT THE CLINICAL VARIABLES WITH ASSOCIATED WITH FIRST IS ANEMIA ANEMIA WAS ASSOCIATED WITH FATIGUE AT MID-POINT, AND ALSO AT COMPLETION, WHICH HAS BEEN REPORTED IN THE PAST BUT AT ONE YEAR FATIGUE WAS NOT RELATED TO ANEMIA ALSO RELATED TO BODY WEIGHED NOR AGE, WHICH MOST OF THESE ARE OLDER GENTLEMEN IT’S CORRELATED WITH DEPRESSIVE SYMPTOMS, ALSO CORRELATED WITH GLOBAL PAIN AS WELL AS (INDISCERNIBLE) SYMPTOMS TO IDENTIFY BIOLOGIC CORRELATES I USE TWO HYPOTHESIS-GENERATING APPROACHES FIRST IS LOOK AT THE SERUM SAMPLES, 48 CYTOKINE PANEL, TO IDENTIFY WHICH OF THE CYTOKINES ARE DIFFERENTIALLY EXPRESSED IN THOSE COHORTS AFTER FDR CORRECTION ONE CYTOKINE WAS UPREGULATESSED OR INCREASED, IN THE CHRONIC FATIGUE COHORTS COMPARED TO THE NON-FATIGUERS, AND THIS IS TRAIL TRAIL IS A MEMBER OF THE TNF SUPER FAMILY, APOPTOSIS-INDUCING PROTEIN BUT THE OTHER APPROACH WAS ALSO A WHOLE GENOME MICROARRAY USING WHOLE BLOOD RNA, WE ALSO SAW THE UPREGULATION OF THE TRAIL DECOY RECEPTOR IN OUR CHRONIC FATIGUERS AT THAT TIME POINT AS I MENTIONED, AT THAT TIME POINT, FATIGUE WAS ASSOCIATED WITH URINARY SYMPTOMS, MEASURED BY ARA AND THE TRAIL CONCENTRATION IN THE SERUM WAS ALSO ASSOCIATED WITH SYMPTOMS, SEEMS NOT A SPECIFIC CORRELATE OF FATIGUE AND URINARY SYMPTOMS, REACHING OUT TO VALIDATE, AND THE GREAT QUESTION ABOUT VALIDATION OF DATA, I REACHED OUT TO OUR FRIENDS AND COLLEAGUES FROM GEORGETOWN UNIVERSITY WHO ALSO HAVE BIG COHORT OF PROSTATE CANCER PATIENTS WHO ARE RECEIVING THE SAME TREATMENT AND WE ASKED THEM TO ADMINISTER THE FATIGUE QUESTIONNAIRES, AND THEY WERE VERY KIND WE LOOKED AT THE DATA THEY COLLECTED AND SERUM THEY ALSO COLLECT THE FROM THEIR PATIENTS, AND WE SAW THAT AT TWO YEARS AFTER COMPLETING THE RADIATION THERAPY FROM THESE PATIENTS THE FATIGUE SCORES WERE, AGAIN, ASSOCIATED WITH TRAIL CONCENTRATION OF SERUM, BUT AT THAT POINT FATIGUE WAS NOT ASSOCIATED WITH URINARY SYMPTOMS AND URINARY SYMPTOMS IS NOT ASSOCIATED WITH TRAIL SO IT SEEMS LIKE TRAIL SEEMS TO TO BE A SPECIFIC CORRELATE OF FATIGUE

BUT NOT ON URINARY SYMPTOMS, PUBLISHED IN DESCRIBING RESEARCH WE NOT AT ONE TO TWO YEARS AFTER WE SAW TAMPA SEEING IN A COHORT OF PATIENTS WHO RECEIVED RADIATION THERAPY, AND IT’S RELATED TO HIGH CONCENTRATION OF TRAIL IN THEIR SERUM, AND WE FOUND THIS IN THE CYTOKINE AND ALSO DECOY RECEPTOR ALSO FOUND IN THE GENE EXPRESSION USING MICROARRAY LOGICALLY WE WANTED TO SEE THE TRAJECTORY OF TRAIL OVER TIME, SINCE WE HAVE THAT SAMPLE SO WE SAW THAT THE BEGINNING BOTH COHORTS, NON-FATIGUERS AND FATIGUERS HAVE THE SAME TRAIL LEVELS AT BASELINE AS WELL AS ONE MONTH, THREE MONTHS, SIX MONTHS, BUT AT ONE YEAR THEY TEND TO SEPARATE A LITTLE BIT SIGNIFICANTLY AND THE NON-FATIGUERS TEND TO HAVE LOWER TRAIL LEVELS AT THAT POINT SO WE FEEL THAT IN ORDER TO UNDERSTAND THIS FATIGUE AT ONE OR TWO YEARS AFTER COMPLETION, THE CHRONIC PERSISTENT FATIGUE, THERE HAS TO BE A CASCADE OF EVENTS THAT HAPPENS BEFORE FATIGUE IS DEVELOPED OR THIS TRAIL FATIGUE ASSOCIATION IS OBSERVED SO WE WANTED TO LOOK AT WHAT HAPPENED BEFORE THAT SO IN ORDER TO DO THAT WE HAVE TO DO A LOT OF STUFF FIRST WAS TO DEVELOP ANIMAL PROGRAM, THIS IS ACTUALLY VERY EXCITING, THE FIRST ANIMAL PROGRAM IN THE INTRAMURAL OF NINR SO WITH COLLABORATION WITH NHLBI WHO WAS VERY KIND TO PROVIDE ASSISTANCE IN THE PHENOTYPING CORE, WE WERE ABLE TO PHENOTYPE RADIATION-INDUCED PHENOTYPE MODEL, THAT HAS BEEN PUBLISHED NOW RECENTLY AND WITH DR. O’SHEA’S MENTORSHIP AND DR. SIEGEL’S HELP WERE ABLE TO OBTAIN A TRAIL RECEPTOR KNOCKOUT MICE AND NOW WE HAVE THAT, IN ORDER TO OBSERVE FATIGUE BEHAVIOR FROM THESE MICE AND WE ALSO REACHED OUT TO OUR FRIENDS FROM HARVARD WHO DOES A LOT OF PREDICTIVE MODELING, AND LOOKED AT GENE EXPRESSION DATA THAT WE HAVE DONE SO USING NOT ONLY FOLD CHANGE BUT ALSO RANKING THE GENES, DIFFERENTIALLY EXPRESSED GENES ACCORDING TO RATIO, WERE ABLE TO SEPARATE TRANSCRIPTOME PROFILE OF CHRONIC FATIGUERS AND THE FATIGUERS AND THE NON-FATIGUERS AND LOOKING AT BASELINE, THERE ARE A NUMBER OF GENES THAT ARE PREDICTIVE OF CHRONIC FATIGUE AT ONE YEAR AFTER RADIATION THERAPY COMPLETION AND MOST OF THESE GENES THAT ARE HIGHLY PREDICTIVE OF CHRONIC FATIGUE ARE RELATED TO GLUTAMATE RECEPTOR, AND WE FURTHER VALIDATED THIS GLUTAMATE RECEPTOR PREDICTOR GENES, EXPRESSLY RECEPTOR 5, PUBLISHED SEVERAL TIMES, AND SAW IT USING PCR EXPRESS OF THE GENE CAN BE DETECTED AT BASELINE AND ONE YEAR BUT NOT IN NON-FATIGUERS SO WE LOOKED FURTHER WHAT IS GOING ON? WE KNOW FROM OUR REVIEW OF LITERATURE, STATE OF SCIENCE, THERE’S A ROLE OF INFLAMMATION IN FATIGUE SO WE WANTED TO SEE WHETHER THERE’S A LINK BETWEEN THE GLUTAMATE SIGNALING AND INFLAMMATION THAT CAUSES THIS FATIGUE EXPERIENCE AND OF COURSE WITH THE RESOURCES AND MENTORSHIP OF DR. O’SHEA WERE ABLE TO REAL DIG DEEPER AND DO AN IN VITRO MODELING OF THIS ASSOCIATION SO WE SAW THAT THERE’S A TOXICITY OF RADIATION CAN T CELLS TO BACK UP THERE’S REALLY NOT A LOT OF LITERATURE OUT THERE THAT LOOKS AT GLUTAMATE SIGNALING AND INFLAMMATION SO THOSE THAT HAVE BEEN DONE HAVE BEEN DONE IN T LYMPHOCYTE T CELLS WE USED THAT MODEL AND SAW RADIATION KILLS T CELLS AND THEN WITH MGLOR ACTIVATED OR TREATED MGLOR AGONIST TREATED THERE’S CLUSTER OF MGLOR BUT WHEN WE ADD MGLOR ANTAGONIST T CELLS LOOK HEALTHY, NON-IRRADIATED CELLS IT’S VERY INTERESTING AND MORE IMPORTANTLY TO THE QUESTION, LINKED TO INFLAMMATION, WITH MGLOR AGONIST, ADDING AGONIST INTO THE

RADIATED T CELL SAW INCREASED RELEASE OF RANTIS, WHICH IS PRO INFLAMMATORY CYTOKINE BUT WHEN ANTAGONIST WAS ADDED SAW DECREASE IN RELEASE OF RANTIS, THERE MAY BE A LINK BETWEEN GLUTAMATE SIGNALING AND INFLAMMATION ASSOCIATED WITH FATIGUE EXPERIENCE THE GOOD THING ABOUT BEING IN NIH YOU HAVE SO MANY EXPERTS IN THE AREA YOU CAN JUST E-MAIL AND REACH OUT I LOOKED AT WHO IS THE EXPERT THAT HAS BEEN STUDYING GLUTAMATE RECEPTOR, GLUTAMATERGIV, AND HE HAS PUBLISHED WITH THE EFFECT OF KETAMINE IN MOOD DISORDERS KETAMINE IS A RECEPTOR ANTAGONIST I REACHED OUT TO HIM, AND THE FIRST PROGRAM, PATH OF COLLABORATION WAS TO DEVELOP A QUESTIONNAIRE, FATIGUE QUESTIONNAIRE, BECAUSE OF ALL THESE CLINICAL TRIALS THEY HAVE BATTERY OF TESTS THEY ADMINISTER TO THE PATIENTS BUT NONE OF THESE ARE SPECIFIC FATIGUE QUESTIONNAIRES SO WAS ABLE TO EXTRACT FATIGUE ITEMS FROM ALL THESE QUESTIONNAIRES AND DEVELOP THE BRIEF FATIGUE INVENTORY, PLEASE USE IT WE SAW THAT WITH THIS FATIGUE ITEM THERE’S ALSO RAPID ANTI-FATIGUE EFFECTS, 40 MINUTES AFTER KETAMINE INFUSION AND THIS LASTED FOR TWO DAYS SO WITH THIS WE WERE ABLE TO DEVELOP A PROOF OF CONCEPT CLINICAL TRIAL WITH THE MENTORSHIP FROM NIMH TO SEE WHETHER IT REALLY HAS AN EFFECT ESPECIALLY THOSE THAT HAD COMPLETED RADIATION THERAPY AND THIS IS STILL ONGOING, AND SO IF YOU HAVE PATIENTS THAT WANTS TO REFER, PLEASE CONTACT US SO WITH ALL THESE, THESE ARE PROGRAMS, OUR PROGRAM CANNOT BE SUCCESSFUL WITHOUT THE HARD WORK OF OUR FELLOWS, SUPPORT OF NINR OF COURSE THE FELLOWS ARE HARD WORKING YOU CAN SEE THEY ARE ALL SMILING ALSO OUR COLLABORATORS, INTRAMURALLY, BUT ALSO EXTRAMURALLY, AND I REALLY THANK THEM SO MUCH AND I HAVE LISTED ALL THESE RESOURCES AVAILABLE HERE, THESE ARE ACTUAL RESOURCES FROM DIFFERENT ORGANIZATIONS THAT CAN HELP UNDERSTAND WHAT THE DEFINITION OF FATIGUE IS, WHAT ARE THE SCALES THAT ARE BEING USED OUT THERE THAT ARE RECOMMENDED TO MEASURE FATIGUE ESPECIALLY IN CANCER POPULATION, ALSO CLINICAL RECOMMENDATIONS HOW TO MANAGE FATIGUE SO I’M LOOKING FORWARD TO YOUR QUESTIONS, AFTER THE LAST PANEL PRESENTATION THANK YOU [APPLAUSE] SO AT THIS TIME I WOULD LIKE TO INTRODUCE OUR NEXT PANELIST YOU KNOW, I HAD MY INITIAL FINDINGS ABOUT THE LINK ABOUT INFLAMMATION CYTOKINES AND FATIGUE I HAVE TO REACH OUT TO A LOT OF PEOPLE OF COURSE AS I MENTIONED THERE’S SO MANY EXPERTISE HERE AND ALL THE PEOPLE THAT I’VE APPROACHED SAID IF YOU WANT TO TALK TO A CYTOKINE EXPERT, TALK TO DR JOHN O’SHEA, SENIOR INVESTIGATOR AND SCIENTIFIC DIRECTOR OF THE INTRAMURAL RESEARCH PROGRAM OF THE NATIONAL INSTITUTE OF ARTHRITIS AND MUSCULOSKELETAL AND SKIN DISEASES HE RECEIVED DOCTOR OF MEDICINE FROM UNIVERSITY OF CINCINNATI, RESIDENCY AT UNIVERSITY OF NEW YORK, PIONEERING WORK WITH THE JANICE FAMILY KINASES, ROLE IN CTOKINE SIGNALING, IMMUNODEFICIENCY, IS WIDELY RECOGNIZED, WHICH IN LARGE PART PAVED THE WAY TO A NEW CLASS OF IMMUNOMODULATORY DRUGS CURRENTLY BEING USED IN SEVERAL CLINICAL POPULATIONS HE HAS RECEIVED MULTIPLE PRESTIGIOUS NATIONAL AND INTERNATIONAL AWARDS INCLUDING THE U.S. PUBLIC HEALTH SERVICE PHYSICIAN RESEARCHER OF THE YEAR AWARD, 2016 MILLSTEIN AWARD LADIES AND GENTLEMEN, IT’S AN HONOR TO WELCOME DR. JOHN O’SHEA [APPLAUSE] >> THANKS VERY MUCH, THAT WAS GREAT AND THANKS FOR INVITING ME TO SPEAK IN THIS SYMPOSIUM

SO LET ME ORIENT MYSELF IN MY 13 MINUTES I WANT TO STAY ON TIME HERE, I WANT TO TALK ABOUT CYTOKINES, CYTOKINE SIGNALING AND THEN OPPORTUNITIES FOR THERAPY SO I WAS THINKING THE MISSION OF THE NURSING INSTITUTE, OBVIOUSLY RELATES TO UNDERSTANDING COMPLEX SYMPTOMOLOGY AND ULTIMATELY HAVING A BIOLOGICAL BASIS FOR THAT IN INTERVENING ONE OF THE THINGS WE’VE LEARNED OVER THE PAST 20 YEARS OR SO IS THAT NO MATTER WHAT YOU WORK ON, EVEN IF YOU DON’T KNOW IT, YOU’RE WORK ON INFLAMMATION ALL CELLS ARE IMMUNE CELLS, INFLAMMATION PLAYS A PART YOU HEARD THAT AGAIN THIS MORNING AND AGAIN NOW IN THINKING ABOUT TRYING TO UNDERSTAND WHAT KINDS OF BIOMARKERS WE SHOULD BE MEASURING AND UNDERSTANDING HOW IT’S BIOMARKERS RELATE TO DISEASE, CYTOKINES ARE CENTRAL STAGE FOR THAT, CENTER STAGE I SHOW YOU HERE AN EXAMPLE OF ONE OF OUR DISEASES BUT IT REALLY APPLIES NOT JUST TO OUR DISEASES IN THIS CASE RHEUMATOID ARTHRITIS BUT MANY OTHER DISEASES HAVE YOU RIDICULOUSLY COMPLEX CARTOONS WITH IL-1 AND CRAZY STUFF, AND PROBABLY THOSE WHO DON’T WORK ON THIS EVERY DAY YOU’RE STARTING TO GLAZE OVER AND GET VERY BORED BUT LET ME TRY TO NOT BORE YOU ENTIRELY AND TRY TO PUT SOME CONCEPT AROUND THIS AND SO THERE ARE PROBABLY 200 OR SO THINGS YOU CAN CALL CYTOKINES IN THE HUMAN GENOME AND THE QUESTION FOR THOSE WHO DON’T DO THIS EVERY DAY AND JUST LOVE THIS STUFF IS TO TRY TO KEEP TRACK OF IT AND TRY TO UNDERSTAND, IS THERE ANY LOGIC AND LIKE REALLY WHY SHOULD YOU CARE, RIGHT? THE REASON YOU SHOULD CARE IS ILLUSTRATED ON THE NEXT SLIDE OR THE NEXT POINT HERE THAT THERE ARE THERAPIES NOW, INCREASING THERAPIES I’LL ILLUSTRATE THAT IN A MOMENT SO AGAIN JUST TO ORIENT YOU, THERE ARE SEVEN CLASSES, SEVEN MAJOR CLASSES OF CYTOKINES THIS IS THE CLASS THAT I’LL BE TALKING ABOUT A LOT, BUT LEO TALKED BEFORE ABOUT TNF RECEPTOR FAMILY OF WHICH TRAIL IS A MEMBER YOU PROBABLY HEARD OF THE IL-1 FAMILY THERE ARE OTHER CYTOKINES AS WELL SOME CYTOKINES BIND TO RECEPTORS THAT YOU THINK OF IN OTHER CONTEXT, INSULINS RECEPTOR, TYROSINE KINASES, SOME CYTOKINES BIND TO THIS FAMILY, TGF-BETA IS A LARGE FAMILY AND CHEMOKINES BIND TO SEVEN TRANSMEMBRANE RECEPTORS THE IMPORTANT THING IS WITH THE EXPLOSION OF CYTOKINE BIOLOGY WITH THE MOLECULAR BIOLOGY REFERENCE REVOLUTION, WE’VE HAD A VAST NUMBER OF THERAPIES TARGETING ALL CLASSES OF CYTOKINE RECEPTORS, TARGETING TNF WITH TNF RECEPTORS OR ANTIBODIES OR COMMON TNF RECEPTORS, ET CETERA, ET CETERA BUT WE AS LEO REFERRED TO HAVE BEEN INTERESTED IN HOW DO CYTOKINES SIGNAL AND CAN WE DEVELOP NEW THERAPIES TO DEAL WITH DISEASES THAT ARE DRIVEN BY THESE CYTOKINES AGAIN, I’M REALLY ONLY GOING TO BE FOCUSED ON THIS CLASS OF RECEPTORS SHOWN HERE AND THE WAY THESE CYTOKINES WORK IS ASTONISHINGLY SIMPLE THOSE OF YOU REMEMBER FROM YOUR TRAINING SIGNAL TRANSDUCTION WHERE HAVE YOU KINASE, KINASE, KINASE, KINASE, KINASE, AN INFINITE NUMBER OF STEPS TO GET FROM OUTSIDE THE CELL TO GENE EXPRESSION IN THE NUCLEUS THIS IS AN EXTRAORDINARILY SIMPLE PATHWAY THAT’S CONSERVED BETWEEN US MINIMALLY AND INSECTS AND ORGANISMS NOT QUITE SURE WHETHER THEY ARE SINGLE OR MULTI-CELLULAR ORGANISMS BUT THE PATHWAY LOOKS LIKE THIS, A CYTOKINE OUTSIDE THE CELL, YOU HAVE CYTOKINE RECEPTORS THAT ARE BOUND TO THIS DEDICATED CLASS OF KINASES, JANICE KINASE SHOWN HERE WHEN CYTOKINES BIND JANICES KINASE GET ACTIVATED, PHOSPHORYLATE THEMSELVES AND THE RECEPTOR FORMING DOCKING SITES FOR TRANSCRIPTION FACTORS THAT BINDS THE RECEPTOR, THEN THE STATS THEMSELVES GET PHOSPHORYLATED AND THEY GO TO THE DNA AND THEY DRIVE GENE EXPRESSION NOW, THEY ARE CALLED STATS JIM DARNELL WHO DISCOVERED THIS, HIS WIFE NAMED THEM THIS BECAUSE

THEY ARE FAST THAT’S WHAT SHE WAS THINKING HE FIGURED IT WAS RETROSPECTIVE I CALLED THEM SIGNAL TRANSDUCER AND ACTIVATOR, DESCRIBING TO HIS WIFE SHE SAID THAT’S AMAZINGLY FAST AND THEY CAME UP WITH THE IDEA OF STAT, REPRESENTING AN EXAMPLE WHERE THERE’S A VERY DIRECT LINK BETWEEN A PERTURBATION OUTSIDE THE CELL AND SENSING OF ENVIRONMENT BY THE CELL AND REGULATION OF GENE TRANSCRIPTION SO WE’VE BEEN, AS LEO REFERRED TO BEFORE, WE’VE BEEN — WHEN WE UNEARTHED THIS, IT BECAME CLEAR IF YOU HAD DRUGS THAT TARGETED JANICE KINASE IT WOULD BE A NEW CLASS OF DRUG, LATE 20th CENTURY I GUESS, EARLY 90s, THAT TURNS OUT TO BE TRUE COLLABORATING IN OUR CASE WITH PFIZER AND OTHER COMPANIES INVOLVED AS WELL, JAK INHIBITORS WERE DEVELOPED FOR A VARIETY OF DISEASES INCLUDING AUTOIMMUNE DISEASES, SHOWN HERE, RUXALITINIB WAS FIRST TOFACITINIB IS APPROVED IN THE U.S. AND RECOMMENDED TO BE APPROVED IN EUROPE FOR RHEUMATOID ARTHRITIS IN PATIENTS WHO FAILED CONVENTIONAL THERAPY IT’S ALSO GOT ONGOING PHASE 3 TRIALS FOR PSORIATRCI BARICITINIB WAS PRESENTED TO THE FDA AND FDA WANTS MORE INFORMATION ON SAFETY FOR BARICITINIB, FOUR PHASE 3 TRIALS SHOWING JAK INHIBITORS IS SUPERIOR TO METHOTREXATE AND THE ADULIMUMAB I CUT OUT SLIDES MAKING THIS SHORT I LEFT OUT ONE THING MOST IMPORTANT THING, THERE’S A FOURTH DRUG HERE, IF YOU’RE A DOG AND YOU ITCH, THERE ARE JAK INHIBITORS FOR YOUR ITCHY DOGS [LAUGHTER] AND THE DRUG IS OKLACITINIB, WE HAVE CLINICAL EXPERIENCE HERE AT THE NIH I OFTEN FIND THAT I GET MORE TALKS, MORE QUESTIONS AFTER MY TALK ON ITCHY DOGS THAN — [LAUGHTER] SO ONE OF THE BIG SHOCKS WHEN OUR BOSS HERE, FRANCIS COLLINS AND HIS COLLEAGUES, COMPLETED THE HUMAN GENOME WAS THE HUMAN GENOME IS MOSTLY NOT GENES THAT WAS DISTURBING AND MAYBE HUMBLING IN A WAY, WHEN WE THOUGHT OF COMPLEXITY OF US VERSUS PUTATIVELY SIMPLER ANIMALS, AND ORGANISMS, THAT HAD ABOUT THE SAME NUMBER OF GENES, NOT VERY FEW GENES, AND WE SHORT OF THINK OF OUR SELVES BEING MORE COMPLICATED 2% OF THE GENOME IS GENES, 98% OF THE GENOME IS NOT GENES AND ARGUED IN EARLY DAYS THIS IS JUNK YOU WOULD IMAGINE THAT WAS PROBABLY NOT THE CASE BUT WHAT WE HAVE LEARNED IN THE INTERIM IS THAT MOST OF THE STUFF OUTSIDE OF GENES IS ACTIVE AND IT’S REGULATED IN DIFFERENT WAYS AND DIFFERENT CELLS WE BECAME INTERESTED IN WHAT THE JUNK TELLS YOU ABOUT THE MOLECULAR BASIS OF CYTOKINE ACTION IN INFLAMMATION AND ALL THESE SORT OF THINGS SO WHAT TURNS OUT IS THAT IN THE GENOME THERE ARE THOUSANDS OF TISSUE-SPECIFIC SWITCHES SO YOU HAVE A LIMITED NUMBER OF GENES BUT MANY SWITCHES AND YOU CAN MEASURE THESE SWITCHES BY NEW TECHNOLOGIES CALLED ChIP-SEQ, WHERE YOU IMMUNOPRECIPITATE WITH MODIFICATIONS OF HISTONE MOLECULES SHOWN HERE FOR POISED, ACTIVE ENHANCERS, ET CETERA YOU CAN DO RNA-SEQ, ENHANCERS TRANSCRIBE THEMSELVES, CAN YOU MEASURE THE ACTIVITY OF SWITCHES IN MANY WAYS THAT EMERGE THE FROM THE MID-2000s SO WE AND OTHERS HAVE DONE THIS AND ONE OF THE THINGS THAT YOU FIND OUT IS THAT THERE ARE PARTS OF THE GENOME THAT HAVE TYPICAL ENHANCERS, AND THEN PARTS OF THE GENOME THAT HAVE THE VERY COMPLEX ENHANCER STRUCTURE, DISCOVERED BY RICK YOUNG AT M.I.T. AND OUR BOSS HERE, FRANCIS COLLINS, AT THE NIH AND WHAT IT TURNS OUT IS THIS IS VERY TISSUE SPECIFIC SO IN ANY GIVEN CELL, YOU HAVE PARTS OF THE GENOME THAT HAVE THIS INTENSE ACTIVITY, AND

DEPOSITION OF ACTIVE ENHANCERS, AND OTHER PARTS OF THE GENOME WHERE REGULATION IS MUCH MORE SIMPLE SO WE WERE VERY INTERESTED IN UNDERSTANDING WHAT THE T CELL SPECIFIC SWITCHES WERE AND I’LL GIVE YOU ONE EXAMPLE IN A MOMENT WE WERE THINKING THIS AGAIN A NON-BIASED WAY OF UNDERSTANDING MOLECULAR BASIS OF CYTOKINE ACTION THE OTHER THING OF COURSE WE ALL WANT TO KNOW HOW IS THIS RELATED TO HUMAN DISEASE AND TO THERAPIES, AND I CAN SAY THAT THERE’S LOTS OF DATA POINTING OUT THAT WHEN YOU LOOK AT THE LINKS WITH HUMAN DISEASE, THAT IN ANY GIVEN CELL WHEN YOU HAVE A GWAS HIT MORE LIKELY THAN NOT YOU’LL HAVE SUPER ENHANCER ARCHITECTURE IN A CELL THAT CORRELATES SOMEHOW WITH FUNCTION BUT WE WERE INTERESTED IN PARTICULAR IN HOW DRUGS THAT WE WERE INTERESTED IN MIGHT IMPACT ENHANCERS VERSUS SUPERENHANCERS AN EXAMPLE OF A SUPERENHANCERS THE INTERFERON GAMMA LOCUS, HERE IS THE GENE HERE, THIS TINY NUBBIN SOUNDING THIS REALLY ESTATE IS THE BROADER REAL ESTATE WITH ALL THIS ACTIVITY IN THIS CASE ChIP-SEQ FOR P 300, IMMUNOPRECIPITATING WITH P 300, PUTS THIS IN TO SEE HOW OFTEN YOU QUEENS — YOU SEQUENCE THIS IN CELLS THAT MAKE INTERFERON GAMMA THERE’S A COMPLEX SORT OF ARCHITECTURE SURROUNDING THE GENE AND THIS IS TISSUE SPECIFIC SO YOU DON’T HAVE IT IN ANOTHER T CELL SO AGAIN THIS SHOWS YOU THE EXTENT, DEGREE OF HOW DIFFERENT SWITCHES ARE BETWEEN DIFFERENT CELLS THIS GIVES YOU ANOTHER — THIS IS RNA-SEQ, AND YOU CAN SEE IN THIS CASE YOU HAVE INTERFERON GAMMA GENE BEING TRANSCRIBED, NOT IN THESE CELLS, BUT ALSO DOWNSTREAM OF THE INTERFERON GAMMA LOCUS YOU SEE TRANSCRIPTION, WE’VE LEARNED THIS IS REFERRED TO AS LONG NON-CODING RNA, THIS IS TRANSCRIBED AS INTERFERON GAMMA GENE ITSELF EVEN THOUGH IT’S NOT A TYPICAL GENE IT DOESN’T MAKE A PROTEIN PRODUCT THIS TOO ALSO HAS SUPER ENHANCER ARCHITECTURE, ONE OF THE THINGS WE AND OTHERS FOUND IN OUR WORK THE QUESTION IS WHAT IF YOU TREAT WITH A DRUG WE KNOW WORKS THIS TURNS NOW TO THE PFIZER DRUG TOFACITINIB YOU SEE REGIONS WITH SUPERENHANCERS ARCHITECTURE ARE AFFECTED MUCH MORE THAN REGIONS OF THE GENOME THAT HAVE TYPICAL ENHANCER ARCHITECTURE SO JUST RETURN TO THE CONCEPT I’VE BEEN PITCHING, SO IN THE EARLY DAYS WE’VE HAD THE ADVANCED BIOLOGICAL THERAPIES, I MENTIONED TNF INHIBITORS, ET CETERA, THAT REVOLUTIONIZED OUR BUSINESS WITH THE ADVENT OF JAK INHIBITORS, IT’S BACK TO THE FUTURE, RHEOSTATS YOU CAN GO TO HOME DEPOT AND BUY ANOTHER WAY OF YOU THINKING ABOUT THIS PROBLEM, REBECCA, I APOLOGIZE, I COULDN’T FIND A PICTURE OF YOUR BAND, BRIAN AND REBECCA THIS IS OUR BAND AND OUR BOSS, FRANCIS COLLINS WE INFLICT OURSELVES ON A LOT OF PEOPLE UNDER MANY CIRCUMSTANCES I CAN SEE ON MY STREAM, YOU CAN’T SEE IT, THIS GUY RIGHT HERE IS THE MOST IMPORTANT PERSON HE’S THE SOUND ENGINEER THAT’S BECAUSE HE’S GOT THIS BOARD HERE HE’S MAKING THIS CACOPHONYOUS RACKET THAT YOU COULD HEAR INTO SOMETHING PASSIVELY ENJOYABLE AND SO THAT’S HOW I’VE BEEN THINKING ABOUT THERAPIES NOW, THAT WE HAVE BIOLOGICS, THAT’S GREAT IT’S AN ONAND ON SWITCH JAK INHIBITORS, DIALING DOWN THE DOSE IN RIGHT CIRCUMSTANCES REALLY WHAT YOU NEED TO THINK ABOUT IS MULTIPLICITY OF SIGNALS THAT ARE AFFECTING MANY, MANY DIFFERENT SWITCHES SO IF WE UNDERSTOOD BETTER THE LOGIC OF THESE SWITCHES AND HOW TO DIAL IN THE SWITCHES AS A SOUND ENGINEER WOULD DO WE’D HAVE A MUCH BETTER SHOT ABOUT TREATING THESE DISEASES, AND I THINK I’LL JUST END RIGHT THERE THANKS VERY MUCH [APPLAUSE] >> THANK YOU, DR. O’SHEA THE NEXT PANELIST IS DR. CARLOS ZARATE JR., SENIOR TENURED CLINICAL INVESTIGATOR AND CHIEF OF EXPERIMENTAL BRANCH, MOOD AND

ANXIETY DISORDERS IN THE NATIONAL INSTITUTES OF MENTAL HEALTH HE IS WIDELY RECOGNIZED AS PIONEER AND AWARD-WINNING EXPECT IN NOVEL MEDICATION FOR TREATMENT RESISTANT DEPRESSION AND BIPOLAR DISORDERS RESEARCH FOCUSES ON NEUROCORRELATES OF RESPONSE AND HAS BEEN IN RECENT NEWS, RECENTLY BECAUSE OF HIS WORK WITH THE RAPID ANTI-DEPRESSANT EFFECT OF KETAMINE, CONSIDERED BY SOME EXPERTS, I QUOTE FROM SCIENCE EXPLORER, IT’S THE MOST SIGNIFICANT ADVANCE IN MENTAL HEALTH IN MORE THAN HALF A CENTURY IT’S MY PLEASURE TO WELCOME DR CARLOS ZARATE JR >> THANK YOU, LEO DELIGHTED TO BE HERE THIS AFTERNOON, THIS MORNING WHAT I’LL DO IS OFFER MORE OF A BROAD PERSPETIVE OF OUR PROGRAM AND INTERFACE WITH LEO’S PROGRAM, HOW WE GO ABOUT COLLABORATIONS AND ITS REALLY — IT REALLY TAKES ALL OF US TO SOLVE THESE PROBLEMS TOGETHER SO THIS IS MY DISCLOSURE I’LL FOCUS OUR — OUR PROGRAM FOCUSES ON DEPRESSION AND BIPOLAR DISORDER IN ADULTS, A COMMON AND CHRONIC PROBLEM, HETEROGENEOUS QUITE HETEROGENEOUS YES YOU CAN SEE INDIVIDUALS HAVE PROBLEMS WITH NEGATIVE MOOD, DISTURBANCE, BEHAVIOR AS WELL THEY MAY PRESENT WITH COGNITIVE SYMPTOMS, PSYCHOTIC SYMPTOMS, IF YOU HAVE NEGATIVE MOOD YOU MAY HAVE DEPRESSION, ANXIETY, IRRITABILITY AND FATIGUE SUICIDE IS ANOTHER PROBLEM IF HAVE YOU BIPOLAR DISORDER IN FACT YOU HAVE THE OPPOSITE, INCREASED ENERGY, RECKLESS, IMPULSEIVE, DON’T NEED TO SLEEP, OR ANY INDIVIDUAL MIGHT HAVE ANY COMBINATION, THAT’S WHY IT’S HETEROGENEOUS AND THERE ARE HUNDREDS OF CRITERIA EACH MIGHT MEET CRITERIA FOR MAJOR DEPRESSIVE EPISODE BUT OVERLAP ON SYMPTOMS WE DON’T HAVE WONDERFUL TARGETS FOR CYTOKINES HERE WE HAVE LITTLE KNOWLEDGE OF RELEVANT TARGETS IN MOOD DISORDERS BEFORE IT’S BEEN BELIEVED TO BE PREDOMINANTLY A PROBLEM WITH YOUR MENTAL STATE, THEN IT WAS — THEN BIOLOGY WAS INSERTED, IT’S A PROBLEM WITH NEUROTRANSMITTERS, EVOLVED MORE THAN THAT WE SAY NOW THAT MOOD DISORDERS ARE DISTURBANCES OF SYNAPSES AND CIRCUITS THAT OF COURSE HAVE UNDERPINNINGS OF ENVIRONMENT AND GENETICS WE HAVE MANY DIFFERENT TREATMENTS FOR DEPRESSION BUT WE CANNOT MATCH OUR TREATMENTS TO A PARTICULAR INDIVIDUAL WE HAVE OVER 20 DIFFERENT ANTI-DEPRESSANTS AND YOU CAN SEE FROM THE 1950s TO 2000, WE HAVE OVER A COUPLE DOZEN ANTI-DEPRESSANTS AND FOR THE MOST PART IT’S FAIR TO SAY THAT NONE OF THE ANTI-DEPRESSANTS ARE SUPERIOR TO EACH OTHER THEY ARE ABOUT COMPARABLE THEY OFFER DIFFERENCE IN SIDE EFFECT PROFILE EARLY ANTI-DEPRESSANTS WERE MORE BROAD IN TERMS OF RECEPTORS AND TARGET THEN THEY BECAME SELECTIVE WE MOVED INTO THE SSRIs, THEY OFFERED BETTER SIDE EFFECT PROFILING, SAFER IN OVERDOSE, AND THERE NOW IS ACKNOWLEDGMENT THAT THEY ARE PROBABLY NOT AS EFFECTIVE AS SOME OF THE OLDER ANTI-DEPRESSANTS, WE’RE MOVE TO DUAL REUPTAKE AND TRIPLE REUPTAKE INHIBITORS AFTER SEVERAL YEARS OF USE THE LARGE STUDY FUNDED BY THE NATIONAL INSTITUTE OF MENTAL HEALTH STUDIED 3,000 OUTPATIENT FOR EFFECT OF TREATMENT IN REAL WORLD, IT HAD BEEN CLINICIANS AND FAMILY MEMBERS, ANTI-DEPRESSANTS WERE NOT HELPING MAN. — MANY YOU SWITCH IF YOU DO NOT RESPOND AFTER ONE YEAR, 1/3 OF PATIENTS DO NOT ACHIEVE REMISSION DESPITE FOUR LEVELS OF CARE MORE IMPORTANTLY, ONLY ABOUT A THIRD OF PATIENTS ACHIEVED SUBSTANTIAL IMPROVEMENT OR REMISSION AND IT TAKES 10 TO 14 WEEKS WITH ONE ANTI-DEPRESSANT, TWO ANTI-DEPRESSANTS FOR HALF THE PEOPLE TO ACHIEVE REMISSION BUT THAT’S SIX MONTHS OF TREATMENT IN THE MEANTIME YOU’RE TELLING YOUR PATIENTS HANG IN THERE, THEY ARE LOSING THEIR JOBS, UNABLE TO HOLD ONTO THEIR

FAMILIES AND THERE’S A CONSIDERABLE RISK OF SUICIDE SO WITH AVAILABLE TREATMENTS THEY DO HELP OUR PATIENTS BUT WE SEE VERY LOW REMISSION RATES THERE’S A DELAY OF WEEKS TO MONTHS THERE’S PERSONAL PROBLEMS, SOCIAL PROBLEMS, LOSS OF JOB, DURING THE TIME THE MEDICATION TAKES TO KICK IN AND THERE’S A RISK MORE IMPORTANTLY OF KILLING YOURSELF SINCE WE DON’T HAVE CLEAR TARGETS, WE TALK ABOUT SEROTONIN, NOR UP NEATH RIN, THERE ARE OTHER ILLNESSES SUCH AS INFECTIOUS DISEASE, RHEUMATOID ARTHRITIS AS HAS BEEN MENTIONED, INFLAMMATION, SO ON AND SO FORTH THEY HAVE MORE IDENTIFIED TARGETS AND SO INDUSTRY HAS BEEN IN THE LAST COUPLE YEARS STEPPING OUT OF PSYCHIATRY ALTOGETHER AND YOU CA SEE HERE IN THE CARTOON PHARMA REMOVED ITSELF FROM THE STUDY OF PSYCHIATRIC DISEASE IT’S HARD TO MODEL OUR ILLNESS IN A DISH WE CANNOT DO THAT BECAUSE THESE ARE COMPLEX ILLsNESSES PEOPLE HAVE BEEN MOVING INTO OTHER AREAS BUT NEVERTHELESS THERE’S SOME EXCITEMENT WITH RECENT FINDINGS IN THE LAST SEVERAL YEARS TO SUMMARIZE THE DEPRESSION, IT’S A HETEROGENEOUS CONDITION THAT’S COMMON, TREATMENT RESISTANT DEPRESSION, TWO OR MORE, 30 TO 40% LOWER REMISSION RATES, QUESTIONABLE EFFICACY IN BIPOLAR DEPRESSION, LAG EVER ONSET OF ANTI-DEPRESSANT EFFECTS IT TAKES 10-14 WEEKS TO GET FULL ANTI-DEPRESSANT EFFECT WITH ZOLOFT, WELLBUTRIN NEXT GENERATION WILL BE IN A FEW HOURS IF HAVE YOU SIX TO NINE MAJOR DEPRESSIVE EPISODES THAT LAST SIX TO NINE MONTHS IMAGINE THE CUMULATIVE MORBIDITY WOULD REDUCE BY INTERVENING VERY EARLY IN A MAJOR DEPRESSIVE EPISODE, THEIR LIFE WOULD BE MUCH BETTER ANOTHER PROBLEM WITH TRYING TO FIND WHAT ARE THE — WHAT THE BIOLOGY OF DISORDERS, IT HAPPENS TO BE NOSOLOGY, DSM, DIAGNOSTIC STATISTICAL MANUAL FOR DESCRIBING PSYCHOPATHOLOGY WE CAN AGREE WHAT A MAJOR DEPRESSIVE EPISODE IS USING THIS TEXT BOOK HOWEVER, THERE’S A SIGNIFICANT OVERLAP IN SYMPTOMS YOU CAN SEE IF YOU HAVE MAJOR DEPRESSIVE EPISODE YOU HAVE ABOUT 40% CHANCE OF HAVING SOME OTHER COMORBID CONDITION, OCD, PTSD, PANIC, SUBSTANCE USE, BIPOLAR DISORDER, PSYCHOSIS IF YOU’RE STUDYING BIOLOGY, ARE YOU STUDYING BIOLOGY OF DEPRESSION OR OF SUBSTANCE USE? OR OF PANIC? AND SO WHAT HAS BEEN PROPOSED AND OF COURSE SYMPTOMS DO NOT OVERLAP WITH PATHOPHYSIOLOGY, WHAT’S BEEN PROPOSED IS RESEARCH DOMAIN CRITERIA, DECONSTRUCT INTO SIMILAR ELEMENTS SUCH AS ANHEDONIA AND THEN STUDY ANHEDONIA, MOTORIC LEVELS, DISTURBANCE OF ACTIVITY LEVELS, YOU COULD ARGUE MAYBE EVEN MORE THAN MOOD SUICIDE IS ANOTHER CONSTRUCT YOU CAN STUDY MORE INTENSITY HOW DO YOU STUDY THIS CONSTRUCT? YOU GO FROM THE BEHAVIOR WHICH IS THE FATIGUE, THE EXAMPLE LEO HAS TALKED ABOUT, GO THROUGH PHYSIOLOGIST CIRCUITS, CELLS, MOLECULES AND GENES THAT’S WHAT WE’RE DOING HERE AT THE INTRAMURAL PROGRAM AND THEN YOU CAN MAP THAT, FOR EXAMPLE, TO BRAIN IMAGING, FUNCTIONAL OR fMRI, GIVING BETTER UNDERSTANDING OF WHAT CAUSES SEPARATE CONSTRUCT YOU NEED TO STUDY WITH THE DISORDERS, IT GOES ACROSS DISORDERS WHAT ABOUT RELATIONSHIP OF AN H EDONIA WITH FATIGUE? GLUTAMATE HAS BEEN MENTIONED AS IMPORTANT SYSTEM WE HAVE THE TRIPARTIDE, GLUTAMATE, PRESYNAPTIC, THE WHITE BUBBLES, SYNTHESIZED RELEASED, GOES TO NNDA RECEPTOR, POST-SYNAPTIC GLUTAMATE RECEPTORS, IMPORTANT IN NORMAL FUNCTION, LEARNING, MEMORY AND PLASTICITY, HOW ONE NEURON TALKS TO ANOTHER WE BELIEVE THESE ARE DISTURBANCE OF CIRCUIT AND SYNAPSE YOU CAN SEE HERE A CIRCUIT, IN THIS NEURON HERE YOU CAN SEE HOW MAYBE THIS IS A CIRCUIT OF ACTIVITY LEVELS OR MAYBE IN THIS CASE THE CIRCUIT OF FATIGUE OR HERE OF SUICIDE SO WHAT YOU SEE IS SHRIVELING OR ATROPHY OF THE CIRCUITS AND

SYNAPSES AND POOR COMMUNICATION BETWEEN NEURONS AND SO NOT ONLY DO WE NEED TO RESTORE NEURO CHEMICALS, GLUTAMATE, SEROTONIN, DOPAMINE, BUT WE NEED TO GIVE PLASTICITY ENHANCERS, RESTORE THOSE CIRCUITS SO THERE’S OPTIMAL FUNCTION THERE ARE A NUMBER OF POTENTIAL TARGETS AND A NUMBER OF DRUGS WHICH OF COURSE I DON’T HAVE TIME TO GET INTO NOW THIS IS ONE OF THE PROTOTYPES THAT’S MENTIONED, KETAMINE, KNOWN AS SPECIAL K, VITAMIN K IT IS BY PRESCRIPTION ONLY, ANESTHETIC, TRANQUILIZER FOR DIAGNOSTIC PROCEDURES IN MOST PARTS OF THE WORLD IT’S PRETTY SAFE HERE IS VIABILITY KETAMINE DOES BIND TO PCP SITE WITHIN THE CHANNEL, IT AFFECTS 9 NORMAL FUNCTION OF THE CHANNEL INVOLVED IN LEARNING AND MEMORY, DISTURBANCE OF LEARNING AND MEMORY WHILE YOU TAKE KETAMINE THIS WAS A STUDY DONE ONE DECADE AGO LOOKING AT PEOPLE WITH TREATMENT RESISTANT DEPRESSION PRODUCING SIDE EFFECTS SUCH AS DISASSOCIATION SO WE STUDIED INDIVIDUALS THAT FAILED ON AVERAGE SIX TO SEVEN ANTI-DEPRESSANTS, 60% FAILED ECT THERAPY, 60% ARE SUICIDE ATTEMPTS, WE STUDIED THEM ON THE 7th FLOOR, MINUTES AND DAYS, ONE INFUSION, TREATMENT RESISTANT DEPRESSION, YOU SEE IMPROVEMENT IN A COUPLE HOURS WHICH TO THE RIGHT USUALLY TAKES ABOUT 6 TO 8 WEEKS WHAT YOU SEE IN A COUPLE WEEKS TAKES 6 TO 8 WEEKS IN NON-RESISTANT DEPRESSANT PATIENTS THIS HAS BEEN REPLICATED LAST SEVERAL DECADES, AT THE DISORDER LEVEL, RAPID ANTI-DEPRESSANT EFFECTS, MAJOR DEPRESSIVE ORDER IN BIPOLAR DEPRESSION, AND AS WE MOVE TO DECONSTRUCT THE ILLNESS WE SEE RAPID IMPROVEMENT IN SUICIDAL THINKING AND PEOPLE WERE ADMITTED TO THE UNIT HAD SUICIDAL THINKING, IT’S GONE WITHIN 40 MINUTES, TO THE RIGHT AND ANHEDONIA, LACK OF DRIVE OR PLEASURE LEO MENTIONED RAPID ANTI-FATIGUE EFFECTS SO TAKING ADVANTAGE OF KETAMINE WHICH IS NOW BEING USED AS A TREATMENT WE CAN USE IT AS A TOOL USING THE MULTIPLE CORE FACILITIES WE HAVE HERE RANGING FROM SLEEP STUDIES, CHEMICALS TO POSITRON EMISSION TOMOGRAPHY, GENE CELLS ALL THE WAY TO FINDING OUT WHAT MAKES KETAMINE SO UNIQUE WE CAN BEGIN TO MAP — THESE ARE FINDING THROUGH GENES TO DIAGNOSIS, HOW THAT MIGHT HELP US UNDERSTAND OUR ILLNESSES ONE FINAL EXAMPLE IS SUICIDE I HAVE A MINUTE OR TWO SELF INJURY, WITH SOME INTENT TO DIE, 800,000 PATIENTS, SUICIDE PER YEAR IN THE WORLD, 44,000 IN THE UNITED STATES ONCE AGAIN YOU RUN INTO THE PROBLEM OF HETEROGENEITY WE DECONSTRUCT, STUDY FROM CIRCUITS, THROUGH GENES AND BEHAVIOR ONE EXAMPLE OF LOOKING AT POSITRON EMISSION TOMOGRAPHY PET IMAGE, GLUCOSE REPRESENTS GLUTAMATE, YOU HAVE HIGHER GLUCOSE ACTIVATION HERE IN THE INFRALIMBIC CORTEX, KETAMINES KNOCKS IT DOWN IN 40 MINUTES YOU ATTACH SYMPTOMS WITH BIOLOGY WE’RE GAINING AT THE TARGET LEVEL, PROOF OF CONCEPT STUDY, OBTAIN BETTER TREATMENT CELLULAR LEVEL STUDIES WITH EXTRAMURAL COLLEAGUES TO TRY TO UNDERSTAND THE MECHANISTIC LEVEL HOW TO BLOCK WHETHER SOME TARGETS ARE RELEVANT OR NOT TO THESE NOVEL AGENTS AT A SECOND LEVEL AT THE CIRCUIT SYSTEMS LEVEL THESE ARE ALL STUDIES DONE BY US SHOWING THAT WE CAN BEGIN TO UNDERSTAND THE USE IN MULTI-MODAL BIOLOGIC MEASURES DISEASE TREATMENT AT THE HUMAN CLINICAL TRIALS EXAMPLES GIVEN BY LEO AND BY MYSELF ON TREATMENTS THAT MIGHT HAVE AN IMMEDIATE IMPACT ON OUR LIFE, FOR EXAMPLE WIPING OUT SUICIDAL THINKING IF YOU SHOW UP WITH IT IN EMERGENCY ROOM I’D LIKE TO ACKNOWLEDGE OUR STAFF THEY HAVE DONE ALL THIS WORK I JUST TALKED TO YOU ABOUT ALL THIS WORK WE HAVE OUR RESEARCH IRTA TODAY STOP BY POSTERS, AND KEVIN YU WILL TALK ABOUT INFLAMMATION, GLUTAMATE AND OTHER OUR WORK

I THANK OUR COLLABORATORS, LEO AND ESPECIALLY TO OUR PATIENTS, AND THEIR FAMILIES SO THANK YOU FOR YOUR ATTENTION [APPLAUSE] >> THANK YOU TO LEO, FOR MODERATING THIS PANEL, AND TO CARLOS AND JOHN FOR SUCH EXCELLENT FANTASTIC PRESENTATIONS AT THIS TIME WE WILL NOW OPEN THE FLOOR FOR QUESTIONS THERE ARE MICROPHONES PLACED IN THE AISLES AND THROUGHOUT THE AUDITORIUM SO THAT WE CAN HEAR FROM AS MANY PEOPLE AS POSSIBLE PLEASE KEEP YOUR QUESTIONS TO ONE QUESTION, AND I WILL TAKE THE FIRST QUESTION DR. DORSEY? >> YES, HI THANK YOU FOR THE GREAT PRESENTATIONS I HAVE A QUESTION FOR DR SALIGAN SO YOUR RESULTS IN DIFFERENTIAL SHOWED YOU HAVE INCREASED GLUTAMATE RECEPTOR EXPRESSION OF VARIOUS RECEPTORS AND YOU’RE LOOKING AT A LINK BETWEEN THAT AND INFLAMMATION, BUT GIVEN YOUR KETAMINE RESULTS HAVE ABOUT BEEN STUDY LOOKING AT CHANGES IN THE CENTRAL NERVOUS SYSTEM THAT MIGHT SUGGEST SYNAPTIC PLASTICITY OR OTHER EVENTS THAT WOULD CONTRIBUTE TO FATIGUE PHENOTYPE AND IN LIGHT OF KETAMINE RESULTS ARE YOU THINKING OF INCORPORATING IMAGING STUDIES IN THAT WORK? >> THANK YOU, DR. DORSEY THAT’S ACTUALLY PART OF THE PROPOSED HYPOTHESIS WHY KETAMINE WORKS FOR FATIGUE, ONE IS PLASTICITY CARLOS MENTIONED THIS IS A FIRST STEP, VERY PROOF OF CONCEPT STUDY, HOPEFULLY WITH COLLABORATION ESPECIALLY WITH NIMH WE CAN INCORPORATE IMAGING LATER ON AND HOPEFULLY ANSWER MOST OF THE QUESTIONS TAGGING, HOPEFULLY TAGGING INFLAMMATORY AND GLUTAMATERGIC MARKERS TO MAKE IT MORE — TO ANSWER THOSE QUESTIONS IN THAT LINK >> DR. ZARATE, AN IMPRESSIVE PRESENTATION WHAT PREVENTED KETAMINE FROM BECOMING ESTABLISHED CLINICAL TREATMENT FOR DEPRESSION? THE NEED IS THERE, THE DRUG ALREADY HAS KNOWN SAFETY PROFILES WHAT HAS PREVENTED ITS CLINICAL USE SO FAR? >> WELL, KETAMINE, ONE, IS AN ANESTHETIC AGENT, AND IT IS — WHEN YOU RECEIVE KETAMINE IT PRODUCES DISASSOCIATIVE SIDE EFFECTS AND CLINICAL CHANGES, INCREASE IN HEART RATE AND BLOOD PRESSURE SO IT’S TYPICALLY USED BY PEOPLE WHO ARE TRAINED TO GIVE KETAMINE, BECAUSE IT’S AN ANESTHETIC AGENT, GIVE TOO MUCH YOU GO UNDER BUT NEVERTHELESS SO IT’S A CONTROLLED SUBSTANCE 3 NEVERTHELESS, IT IS USED IN MOST REMOTE AREAS OF AFRICA BY NURSES THERE WITHOUT ANY MEDICAL SUPPORT, BECAUSE IT DOESN’T PRODUCE SO MUCH CNS DEPRESSION IN THE UNITED STATES ACTUALLY KETAMINE HAS REALLY INCREASED THERE ARE MANY CLINICS PROBABLY DOZENS IN NEW YORK AND RAPIDLY EXPANDING WHAT THE ISSUE NOW IS, YOU KNOW, IN MY OPINION WE SHOULD USE ESTABLISHED TREATMENTS, AND IF KETAMINE IS GOING TO BE USED IT SHOULD BE DONE AFTER RECOMMENDATION OF ECT AND HAVING GONE THROUGH THE DECISION TREES AND BY TREATMENT RESISTANT CLINICS AND PEOPLE WHO ARE TRAINED IN ACLS I THINK IN THE OTHER ISSUE, KETAMINE NOW IS BEING DEVELOPED BY THE FDA AS AN INTRANASAL FORM, MAYBE IT MIGHT BE A COUPLE YEARS TILL IT’S APPROVED, BUT THE OTHER GOAL IS TO DEVELOP MORE USER FRIENDLY KETAMINES AND WE ARE NOW STUDYING THE SON OF KETAMINE, HYDROXY NARKETAMINE, HNK, OR HANK, IT DOESN’T PRODUCE RISK OF ABUSE, ADDICTION, DOESN’T HAVE SIDE EFFECTS OF KETAMINE-PREDICTED MODELS SO HOPEFULLY WE START A TRIAL ON RESEARCH UNIT 7-SOUTHEAST, IN THE FIRST QUARTER OF 2018 >> GO AHEAD >> THANKS FOR YOUR PRESENTATION FIRST OF ALL, WHEN YOU GIVE MENTAL HEALTH THIS TYPE OF (INDISCERNIBLE) SOMETIMES COULD BE VERY (INDISCERNIBLE) AND MAYBE HALF BEHAVIOR FACILITIES, REHAB CENTER, CAN ALL HANDLE THIS TYPE OF THINGS AND I JUST

WONDERED DID YOU LOOK INTO THE DATA, THE TREATMENT IS GOOD OR BAD, WHETHER CAUSE UNNECESSARILY WHETHER YOU LOOK INTO THE JAIL SUICIDE OR SOME KIND OF MORTALITY IN THE CUSTODY OF LAW ENFORCEMENT >> OKAY SO IT’S A VERY — IN TERMS OF — I AGREE THAT WE WOULD DO BETTER IN TERMS OF NOSOLOGY OR DIAGNOSIS, AND IN MY OPINION MANY OF THESE DIAGNOSTIC CRITERIA IS A CHECKLIST, IT’S NOT ATTACHED TO ANY OTHER LIKE BLOOD, FOR DIABETES YOU MEASURE BLOOD SUGAR, HIGH OR LOW, BLOOD PRESSURE, SWEE HAVE — WE HAVE TO DO BETTER YOU SPEND TIME WITH PATIENTS OVER YEARS AND ARE ABLE TO MAKE A MORE ACCURATE DIAGNOSIS WITH THAT INDIVIDUAL AND FAMILY, BRINGING THE FAMILY, PUTTING ALL THE INFORMATION WITH SCHOOLS IF THEY ARE YOUNG, YOU CAN MAKE A CORRECT DIAGNOSIS THEN IF I UNDERSTAND, WITHIN THE PRISON SYSTEM, YES, THERE ARE MANY WHO ARE INSTITUTIONALIZED DO NOT RECEIVE ADEQUATE MENTAL HEALTH CARE IN OUR PRISON SYSTEM THAT’S QUITE UNFORTUNATE SO WE HAVE TO DO A MUCH BETTER JOB AT THAT THERE ARE CERTAIN GRANTS AND PROGRAMS THAT ARE LOOKING ABOUT INCREASING — LOOKING AT DIAGNOSIS IN THE MENTAL HEALTH PRISON SYSTEM AND PROVIDING ADEQUATE CARE EVEN DESPITE THESE TREATMENTS WE HAVE LESS THAN A QUARTER OF OUR PATIENTS GO FOR TREATMENT OR STAY IN TREATMENT AND SO WE HAVE TO DO BETTER YOU KNOW, YOU ALL CAN HELP US GET OUR PATIENTS, OUR LOVED ONES, BRING THEM IN FOR ASSESSMENT AND SEE IF THEY MIGHT BENEFIT FROM THERAPY OR OTHER INTERVENTIONS >> THANK YOU >> ONE LAST QUESTION >> THANK YOU VERY MUCH SO THIS QUESTION RELATES TO DR SALIGAN AND ALSO DR. JOHN O’SHEA ABOUT THE TRAIL INCREASE IN PROSTATE CANCER THROUGH RADIATION THERAPY-INDUCED FATIGUE, SEEMS TO BE AN INTERESTING POTENTIAL BIOMARKER SO ARE YOU CONSIDERING POTENTIAL THERAPY OR IS THERE ANY LIKE ANTAGONST MARKET TO BE AVAILABLE FOR THE TRAIL OR MAYBE THAT WILL CAUSE THE CANCER SOMEHOW BECAUSE THAT’S APOPTOSIS-INDUCING STUFF, SO I WOULD LIKE TO HAVE OPINION FROM BOTH OF YOU THANK YOU >> YEAH, THANK YOU SO MUCH SO YEAH, IT’S A REALLY VERY INTERESTING FINDING, AND AGAIN WE’VE VALIDATED IT WITH ANOTHER COHORT FROM GEORGETOWN, AND IT SHOWS IT’S SPECIFIC CORRELATE TO FATIGUE, NOT TO OTHER SYMPTOMS AND SO HOPEFULLY WITH OUR ANIMAL STUDIES IT CAN HELP US, THE TRAIL COLONY, AND HOPEFULLY WE’RE GOING TO SEE AND OBSERVE THE BEHAVIOR ONCE YOU MANIPULATE THE TRAIL EXPRESSION FROM STARTING WITH THE ANIMAL STUDIES AND HOPEFULLY WE CAN, IF WE CAN IDENTIFY SPECIFIC MARKERS, IT CAN VALIDATE THAT IT’S A SPECIFIC MARKER, WE CAN INTRODUCE SOME TARGETED THERAPEUTICS, AND DR. O’SHEA, DO YOU HAVE — >> SURE IT’S AN INTRIGUING BUT COMPLICAED QUESTION, RIGHT? I MEAN OBVIOUSLY FATIGUE IS NOT A SIMPLE THING TO SORT OF DEFINE AND MEASURE IN ALL THESE SORT OF THINGS, WHETHER PHARMA WILL WANTS TO GET INTO THIS BUSINESS OBVIOUSLY ON ONE LEVEL IT’S AN ENORMOUS MARKET BUT IT’S NOT A SIMPLE MARKET, AT THE SAME TIME WE KNOW THAT THIS CLASS OF MOLECULES IS VERY DRUGGABLE SO IN PRINCIPLE THERE’S AMAZING OPPORTUNITY HOW THIS ABOUT PLAY OUT IS HARD TO SAY BUT SORT OF EARLY DAYS, BUT VERY EXCITING AND PROMISING ON ONE LEVEL >> AND IN ADDITION TO YOUR QUESTION ABOUT, YOU KNOW, RISK FOR TUMORIGENESIS, IT IS, IT IS A QUESTION FOR US, AND THAT’S WHY WE WANTED TO REACH OUT TO EXTRAMURAL COMMUNITY AND REALLY LOOK AT WHETHER FATIGUE IS NOT JUST A SYMPTOM BUT A MARKER FOR POSSIBLE RECURRENCE, BECAUSE OF ALL THESE CORRELATES THAT WE’VE BEEN FINDING AND WE SAW — WE ACTUALLY DID AN IN VITRO MODEL, AND TRAIL HAS BEEN USED AS A TARGET FOR CHEMOTHERAPY AS WELL BUT WE LOOKED AT AND IT SHOWED TRAIL TOXICITY SPECIFIC TO THE

AND TUMOR CELLS IN SPECIFIC BUT NOT OTHER CELLS WE WANTED TO LOOK AT LONG-TERM WHETHER HIGH FATIGUERS, ESPECIALLY WITH HIGH TRAIL, HAVE RECURRENCE AND I DON’T THINK THAT HAS BEEN EXPLORED YET >> THANK YOU VERY MUCH FOR YOUR THOUGHTFUL QUESTIONS I BELIEVE THIS PANEL HAS SPECIFICALLY ADDRESS IT’S — ADDRESSED SOME COMPLEXITIES DOING RESEARCH ON SYMPTOMS I BELIEVE JOHN O’SHEA’S USE OF MIXER AND HOW TO TRY TO THINK OF THIS AS NOT — THERE’S ONE SPOT THAT WILL FIX THINGS, WE ONLY NEED TO STUDY ONE THING AND WE CAN FIGURE IT OUT, OR TO FIX IT, IT’S GOING TO TAKE THAT AND I PARTICULARLY ON CARLOS, I REALLY THOUGHT THAT YOUR PRESENTATION LOOKING AT, YOU KNOW, DO WE ADDRESS CELLS, BEHAVIOR, DO WE ADDRESS ENVIRONMENT, BIOLOGY, DO WE ADDRESS PHYSIOLOGY, AS RESEARCHERS AT THIS DAY AND TIME THOSE ARE THE QUESTIONS THAT ARE CONSUMING A LOT OF WHAT WE DO AND TRYING TO DETERMINE HOW TO BEST STUDY A PHENOMENA THAT IS MADE UP OF SO MANY REASONS WHY IT COULD BE OCCURRING THANK YOU FOR YOUR WONDERFUL PRESENTATIONS AND THE QUESTIONS I’M PLEASED TO INVITE YOU NOW TO THE POSTERS ON DISPLAY TODAY’S POSTERS ARE LOCATED IN THE FAES TERRACE, FOR YOUR CONVENIENCE A LIST OF POSTERS IS AVAILABLE IN YOUR HANDOUT IF NOT, YOU CAN FIND THEM ON THE REGISTRATION DESK PLEASE TAKE TIME TO LOOK AT THIS WHILE YOU ALSO BREAK FOR LUNCH IF YOU PREFER TO STAY — THERE IS SOME INFORMATION ON WHERE LUNCH IS AVAILABLE IF YOU’RE UNFAMILIAR WITH THE CLINICAL CENTER AND THAT IS ACTUALLY ON THE RECEPTION TABLE RIGHT BEFORE YOU WALK INTO MASUR BUT BASICALLY THERE’S A COUPLE OF CAFETERIAS AND A COUPLE COFFEE SHOPS THE POSTER SESSION WILL CONTINUE THROUGH 12:45:00 P.M. WHEN WE MEET BACK HERE TO CONTINUES WITH OUR THIRD AND FINAL PANEL THIS AFTERNOON FOR THOSE WHO ARE WATCHING ON LINE, PLEASE REJOIN US AT 12:45 GOOD AFTERNOON AGAIN I HOPE EVERYONE WAS ABLE TO FIND SOME LUNCH AND COULD TAKE A BREAK AND LOOK AT OUR EXCELLENT POSTERS WE WILL HAVE ONE MORE OPPORTUNITY TO LOOK AT THE POSTERS AT THE END OF THIS NEXT PANEL ONCE AGAIN, I AM DR. ANN CASHION, SCIENTIFIC DIRECTOR OF NINR’S INTRAMURAL RESEARCH PROGRAM I AM HONORED TO BE HERE WITH YOU TODAY TO BE DIRECTOR OF CEREMONIES FOR THIS LAST PANEL IF THOSE OF YOU WHO ARE STILL STANDING WOULD PLEASE TAKE YOUR SEATS, FOR THOSE OF YOU WATCHING I’M PLEASED TO INTRODUCE THE THIRD PANEL’S MODERATOR FOR THIS AFTERNOON DR. JESSICA GILL IS NINR’S BRAIN INJURY UNIT’S CHIEF SHE EARNED HER MASTER’S DEGREE FROM OREGON HEALTH AND SCIENCE UNIVERSITY, IN PSYCHIATRIC NURSING, AND Ph.D. AT JOHNS HOPKINS SHE COMPLETED HER POSTDOCTORAL FELLOWSHIP AT NINR, LATER BECAME A CLINICAL INVESTIGATOR IN THE CENTER FOR NEUROSCIENCES AND REGENERATIVE MEDICINE WHERE SHE EXAMINED THE BIOLOGICAL MECHANISMS OF POSTTRAUMATIC STRESS DISORDER AND TRAUMATIC BRAIN INJURY AND RELATED IMPAIRMENTS IN SERVICE MEMBERS DR. GILL RETURNED TO NINR AS THE LASKER CLINICAL RESEARCH SCHOLAR WHERE HER PROGRAM OF RESEARCH EXAMINES RISK FOR NEUROLOGICAL AND BEHAVIORAL SYMPTOMS FOLLOWING TRAUMATIC BRAIN INJURIES AND CONCUSSIONS THROUGH BLOOD-BASED BIOMARKERS TOGETHER WITH HER PANELISTS, DR GILL WILL BE DISCUSSING THE IDENTIFICATION OF BIOMARKERS TO IMPROVE CLINICAL CARE OF PATIENTS WITH BRAIN INJURY DR. GILL [APPLAUSE] >> THANK YOU FOR THE INTRODUCTION, IT’S AN AMAZING OPPORTUNITY TO BE HERE TO TALK ABOUT A TIMELY AND CRITICAL ISSUE AND TWO WORLD RENOWNED RESEARCHERS ON THE PANEL IS A PRIVILEGE BECAUSE OF THEIR EXPERTISE AND COLLABORATIONS THAT WE’VE STARTED AND DIRECTION THAT WE’RE TAKING THROUGH THESE COLLABORATIVE EFFORTS AND SO WHAT I’LL DO TODAY IS GIVE A BRIEF OVERVIEW OF SOME RESEARCH WE’RE DOING AT NIH AND

HIGHLIGHT SOME COLLABORATIVE WORK I’M DOING WITH DR. STERN AND KAPOGIANNIS AND SAVE THE MAJORITY OF TIME FOR THE TWO PRESENTERS AND SAVE TIME AT THE END TO ADDRESS QUESTIONS THAT YOU MAY HAVE SO THE FOCUS OF MY LAB HERE IS IDENTIFYING BIOMARKERS PRIMARILY IN THE BLOOD TO INFORM THE CARE WE PROVIDE TO INDIVIDUALS WITH TRAUMATIC BRAIN INJURY AND CONCUSSION, COMMON IN THE LIVES OF AMERICANS WITH A THIRD OF US SUSTAINING ONE OR MORE INJURIES IN OUR LIFETIME MOST ARE MILD IN NATURE AND MOST INDIVIDUALS WILL GO ON TO RECOVER WITHIN THE NEXT COUPLE MONTHS THERE’S A SUBSET OF PATIENTS THAT WILL GO ON TO HAVE CHRONIC NEUROLOGICAL SYMPTOMS, AND SO THROUGH THE USE OF BIOMARKERS WE CAN IDENTIFY THESE INDIVIDUALS AND HOPEFULLY PROVIDE PREVENTIVE INTERVENTIONS IN ADDITION TO THIS SOME VULNERABILITY FACTORS WE KNOW OF ARE MULTIPLE CONCUSSIONS AND SUBCONCUSSIVE HEADS WHICH DR STERN WILL TALK ABOUT WE KNOW THERE’S SOME VULNERABILITY FACTORS BUT HOW CAN WE UNDERSTAND DEMOGRAPHIC AND CLINICAL CHARACTERISTICS THAT PLACE SOME INDIVIDUALS AT HIGHER RISK SO WE CAN MODIFY RISK AND IMPROVE SAFETY SO TO DO THIS WE LOOK AT THREE PRIMARY TYPES OF BIOMARKERS, THE FIRST BEING DIAGNOSTIC THEY GIVE US ABILITY TO IDENTIFY INDIVIDUALS WHO HAD A BRAIN INJURY AND DISTINGUISH THOSE INDIVIDUALS FROM INDIVIDUALS WITH SIMILAR INJURY CHARACTERISTICS AND SYMPTOM PRESENTATION, IMPORTANT IN COHORTS OF ATHLETES AND MILITARY PERSONNEL WITH MULTIPLE INJURIES AND OTHER PHYSICAL INJURIES SO WE NEED TO IDENTIFY THOSE INDIVIDUALS WHO WE NEED TO FOLLOW OVER TIME AND MONITOR FOR AGAIN THESE RISKS FOR CHRONIC NEUROLOGICAL SYMPTOMS THIS IS PARTICULARLY IMPORTANT WHEN WE’RE DOING PHENOTYPING ON ATHLETIC FIELDS AS WELL AS DEPLOYMENT STATIONS WHERE WE DON’T HAVE FULL PHENOTYPING CAPACITY AND CLARITY OF NEUROIMAGING TO IDENTIFY AND DETERMINE DEGREE OF NEURONAL INJURY WE’RE IDENTIFYING BIOMARKERS PROGNOSTIC, AND THAT 90% OF PATIENTS WHO HAVE A MILD INJURY WILL GO TO FULLY RECOVER AGAIN IT’S REALLY VULNERABILITY FACTORS THAT ARE INDICATED THROUGH BIOMARKERS THAT WE CAN APPROXIMATE TO IDENTIFY THOSE INDIVIDUALS WHO WE NEED TO FOLLOW AND MONITOR MORE CLOSELY LASTLY IDENTIFYING MECHANISTIC BIOMARKERS THAT GIVE US IDENTIFICATION OF THERAPEUTIC TARGETS BUT WE CAN MODULATE USING PHARMACOLOGICAL AND NON-PHARMACOLOGICAL INTERVENTION TO PROMOTE BETTER RECOVERY IN INDIVIDUALS WITH GREATEST RISK THE QUESTION BECOMES HOW CAN WE IDENTIFY THESE PATIENTS? HOW CAN WE IMPROVE THE CARE WE PROVIDE? CURRENTLY THERE’S NO FDA-APPROVED MEDICATION TO PREVENT ONSET OF NEUROLOGICAL SYMPTOMS AND DEFICITS NOR ANY MEDICATION IF THEY BECOME CHRONIC SO WE HAVE LARGE COHORTS OF INDIVIDUALS SUFFERING MULTIPLE CONCUSSIONS, AS WELL AS MANY CIVILIANS COMING INTO EMERGENCY ROOMS EVERY YEAR THIS IS A HUGE CRITICAL UNMET CLINICAL NEED THAT WE NEED BIOMARKERS TO HELP US ADDRESS IN MY LAB WE LOOK AT GENOMICS AS WELL AS PROTEOMIC ACTIVITIES BUT TODAY WHAT I’LL TALK ABOUT PRIMARILY IS THAT OF TAU, IT LINKS ALL THE PANEL MEMBERS AND IS A FOCUS OF COLLABORATIVE EFFORTS IT’S A MICROTUBULE-ASSOCIATED PROTEIN AND WE INCREASE IN TAU IN BLOOD AND CEREBROSPINAL FLUID FOLLOWING INJURY. THE DEGREE OF THE INCREASE THAT WE SEE IS RELATED INJURY AND PROGNOSTIC VALUE, WHICH WILL DEVELOP INJURIES WE KNOW ON THE PERIPHERAL ACTIVITIES OF TAU, LESS IS KNOWN ABOUT THE CENTRAL ACTIVITIES OF TAU AND HOW IT CAN AGGREGATE IN SOME INDIVIDUALS ALONG WITH AMYLOID BETA, RESULTING IN FORMATION OF NEUROFIBROLARY PLAQUES, HALLMARK OF ENCEPHALOPATHY AND ALZHEIMER’S DISEASE WE SEE THE FORMATION OF PLAQUES IN CONJUNCTION WITH COGNITIVE DEFICITS AND DECLINES BUT IN CTE WE’RE SEEING IN INDIVIDUALS WHO HAVE MULTIPLE CONCUSSIONS AND BRAIN INJURIES OVER THEIR LIFETIME THESE INDIVIDUALS ARE ALSO OFTEN IN THEIR 40s AND 50s, MUCH YOUNGER AGES THAN ALZHEIMER’S DISEASE SO FROM THE COLLABORATIONS ON THIS PANEL WE ASKED THE QUESTION OF THE COMMON MECHANISM UNDERLYING DISEASES AND HOW DOES BRAIN INJURY PLAY INTO VULNERABILITY SO SOME STUDIES HAVE SHOWN TAU IS ELEVATED EVEN YEARS FOLLOWING A BRAIN INJURY, AND MILITARY PERSONALLY HAD A DEPLOYMENT-RELATED BRAIN INJURY WHAT WE SEE IS THAT THE DEGREE OF ELEVATION ALSO RELATES TO CHRONIC NEUROLOGICAL SYMPTOMS SO WE’RE SEEING TAU IS DIAGNOSTIC AND PROGNOSTIC GIVING US INDICATION HOW IT MAY SHAPE RECOVERY FROM BRAIN INJURY IN ADDITION WITH THE WORK WITH

DR. KAPOGIANNIS WHICH HE’S GOING TO DESCRIBE IN GREATER DETAIL WE LOOKED AT PERIPHERAL BLOOD WE ALSO USED MILITARY PERSONNEL WHO DEPLOYED AND HAD TBI DURING DEPLOYMENT AND HAVE CHRONIC NEUROLOGICAL SYMPTOMS TAU IS INCREASED INDICATING CENTRAL PATHOLOGY THAT ALSO COINCIDES WITH PERIPHERAL ALTERATIONS WE’RE SEEING AND AGAIN DR. KAPOGIANNIS WILL TALK ABOUT THIS MORE IN DETAIL IN ADDITION, WE’VE LOOKED AT SPORTS CONCUSSION AND SPORTS RELATED PLAY, IN THE ACUTE AND SUBACUTE TO PAIR WITH WHAT DR STERN IS DOING IN CHRONIC COHORTS WHAT WE SEE IS THERE’S ELEVATIONS IN TOTAL TAU IN PERIPHERAL BLOOD WITHIN 6 HOURS OF CONCUSSION AND THIS ELEVATION RELATES TO GREATER OR PROLONGED RETURN TO PLAY CHANGE FROM BASELINE WITHIN INDIVIDUAL AND OVERALL GROUP DIFFERENCE BETWEEN THOSE PLAYERS WITH AND WITHOUT PROLONGED RETURN TO PLAY GIVES PREDICTION WHICH INDIVIDUALS WILL BE ABLE TO RETURN TO PLAY AT SAFER PERIOD, PARTICULARLY IMPORTANT AS WHAT WE KNOW ABOUT SPORTS CONCUSSION IS THAT THOSE PLAYERS THAT HAVE A CONCUSSION AND DON’T HAVE FULL NEURONAL RESOLUTION AND THEN RETURN TO PLAY AND HAVE A SUBSEQUENT CONCUSSION ARE AT THE GREATEST RISK TO HAVE LONG-TERM CHRONIC NEUROLOGICAL SYMPTOMS SO THROUGH THE USE OF BLOOD-BASED BIOMARKERS WE CAN HELP MAKE DECISIONS SAFER AS CURRENT RETURN TO PLAY IS BASED PRIMARILY ON SUBJECTIVE REPORTING OF SYMPTOMS FROM PLAYERS, COACHES AND TRAINERS AND MANY TIMES THIS CAN BE BIASED BY INCENTIVE OF WANTING TO GO BACK TO PLAY WE ALSO SEE THIS IN MILITARY PERSONNEL WHO WANT TO RETURN TO SERVICE BUT ALSO HAVE HIGH RISK MULTIPLE CONCUSSION AND BRAIN INJURY HOW CAN WE USE BLOOD-BASED BIOMARKERS TO IMPROVE CARE WE PROVIDE TO THESE INDIVIDUALS TO AGAIN PROTECT THEM FROM RISK OF MULTIPLE CONCUSSIONS? SO SOME DIRECTIONS WE’RE GOING AT NIH AS WELL AS THROUGH COLLABORATIONS WITH DR. STERN AND DR. KAPOGIANNIS IS HOW CAN WE UNDERSTAND THE RELATIONSHIP WITH THESE ACUTE BIOMARKERS AND ACUTE SUBACUTE PERIODS HOW IS TAU SHAPING RECOVERY AS WELL AS OTHER BIOMARKERS AND HOW CAN WE UNDERSTAND IMPACT OF SUBCONCUSSIVE HITS AS WELL AS CONCUSSIONS, TO REALLY UNDERSTAND WHAT THE CUMULATIVE DAMAGE OR NATURE COULD BE OF BIOLOGICAL CHANGES THAT RELATE TO THESE COGNITIVE DECLINES THAT WE’RE SEEING IN CTE AND WHAT’S THE COMMONALITY WITH ALZHEIMER’S DISEASE WE’RE ALSO EXTENDING TO MILITARY PERSONNEL WHO ALSO ARE AT HIGH RISK TO HAVE BLAST AND CONTUSION-TYPE INJURIES AND TO HAVE THESE IN CLOSE SUMMATION WHEN DEPLOYED THESE INDIVIDUALS ARE ALSO POSSIBLY AT RISK FOR CTE PATHOLOGY THAT WE’RE JUST NOW BEGINNING TO UNDERSTAND WE’RE ALSO WITH COLLABORATORS IN THE NEUROLOGIC INSTITUTE LOOKING AT THE ROLE OF MENINGEAL INJURY AND BLOOD-BRAIN BARRIER, TO UNDERSTAND HOW THESE ACUTE AND SUBACUTE CHANGES AND BLOOD-BRAIN BARRIER DISRUPTION MAY RELATE TO CTE RISK PATHOLOGY WITH THAT I’LL SAY THANK YOU TO MY NINR TEAM AND COLLABORATORS HERE AT NIH AS WELL AS OTHERS AND WILL INTRODUCE OUR NEXT SPEAKER [APPLAUSE] NEXT I’D LIKE TO INTRODUCE DR DIMITRIOS KAPOGIANNIS WHO I’VE BEEN ABLE TO COLLABORATE WITH ON THE LAST YEAR, AN AMAZING RESEARCHER AND COLLABORATOR WHO EXTENDED THE WORK AT NINR AS WELL AS COLLABORATORS OFF SITE HE IS A TENURE TRACK CLINICAL INVESTIGATOR AT THE LABORATORY OF NEUROSCIENCES IN THE NATIONAL INSTITUTE OF AGING, ALSO AN ASSISTANT PROFESSOR AT JOHNS HOPKINS UNIVERSITY IN DEPARTMENT OF NEUROLOGY HE RECEIVED MEDICAL DEGREE FROM NATIONAL UNIVERSITY OF ATHENS GREECE AND COMPLETED NEUROLOGY RESIDENCY AT HARVARD MEDICAL SCHOOL, CONDUCTS TRANSLATIONAL NEUROIMAG AND BIOMARKER STUDIES, AND ALZHEIMER’S DISEASE AND TBI RESEARCH, DEVELOPED GROUND BREAKING TECHNOLOGY TO LOOK AT NEURONAL DERIVED EXOSOMES USING PERIPHERAL BLOOD TRANSFORMING THIS AREA OF SCIENCE WELCOME, DR. KAPOGIANNIS [APPLAUSE] >> THANK YOU VERY MUCH I WOULD LIKE TO THANK JESSICA FOR THIS KIND INTRODUCTION AND EVEN KINDER INVITATION, IT’S EXCITING TO BE ABLE TO BE HERE WITH YOU AND PRESENT OUR WORK THAT WE DID TOGETHER SO I WOULD LIKE TO FOCUS ON THE TECHNOLOGY ACTUALLY BECAUSE I THINK A NEW TECHNOLOGY OR NEW METHODOLOGY CAN OPEN NEW PATHWAYS FOR DISCOVERY.& SO I REALLY WOULD LIKE TO CONVEY WHAT ARE THE SALIENT

CHARACTERISTICS OF IT I WILL SAY A FEW WORDS FIRST ABOUT EXTRACELLULAR VESICLES AND OUR APPROACH TO ISOLATION SO THERE ARE SEVERAL PATHWAYS THAT LEAD TO FORMATION AND RELEASE OF EXTRACELLULAR VESICLES FROM ALMOST EVERY CELL OF THE BODY SOME OF THEM INVOLVE A CANONICAL PATHWAY THAT INVOLVES EXOSOMES, AND MULTI-VESICULAR BODIES RELEASED AS EXOSOMES, SLIGHTLY HIGHER, JUST COMING OUT FROM BUDDING OF THE MEMBRANE, AND SO THERE IS IN EVERY BIOLOGICAL FLUID, A ZOO, IF I CAN USE THAT TERM, OF VESICLES WITH A CONTINUUM OF SIZES AND CONTENT SO A TYPICAL EXTRACELLULAR VESICLE/EXOSOME HAS A MEMBRANE, SEVERAL PROTEINS ON THE SURFACE AND THEN A CONTENT INSIDE INTERESTINGLY MOST OF THE PATHOGENIC PROTEINS INVOLVED WITH NEURODEGENERATIVE DISEASE SUCH AS TAU, A BETA AND ALPHA SYNUCLEIN HAVE BEEN DEVELOPED ON THE SURFACE ARE MOLECULES COMMON TO EXOSOMES SUCH AS TETRASPANNNENINS, SOME REFLECT ORIGIN OF THESE CELLS OBVIOUSLY THE SPECIFICITY OF WHAT I DESCRIBE FURTHER DOWN DEPENDS ON SPECIFICITY OF SURFACE MOLECULES SO THE MORE SPECIFIC TO HAVE CERTAIN ORIGINS SUCH AS NEURONAL ORIGIN, A SURFACE MOLECULE IS, THE MORE SPECIFIC IT IS GOING TO BE THE ISOLATION THAT I WILL DESCRIBE WE FOCUS ON L1 COM, A NEURONAL CELL ADHESION MOLECULE EARLY EXPERIMENTS IN NEURONAL CULTURE SHOWED NEURONS PRODUCE EXOSOMES THAT EXPRESS THIS MOLECULE ABUNDANTLY ON SURFACE PLUS THERE HAVE BEEN GOOD ANTI- BODIES AGAINST IT WE EMPLOY A TWO-STEP METHODOLOGY, STARTING FROM PLASMA, WE CHOOSE A VERY HIGH YIELD, HIGH EFFICIENCY TECHNIQUE TO PRECIPITATE TOTAL EXOSOMES THAT THEY PRECIPITATE AS PELLET, SUSPEND TOTAL EXOSOMES AND TARGET WITH ANTIBODIES AND A EXPRESS L1CAM AND PRECIPITATE IT WHAT WE GENERATE IS A FAIRLY HOMOGENOUS POPULATION OF VESICLES OF DIFFERENT SIZES THAT EXPRESS AT LEAST ONE AND THEN SEVERAL MORE L1CAM MOLECULES THIS IS AN IMAGE WHERE ANTIBODIES WITH L1CAM HAVE BEEN LINKED TO GOLD PARTICLES, YOU CAN VISUALIZE THEM HERE SO THE NEXT STEP IS WE COUNT THESE VESICLES IN EVERY PREPARATION AND WE DETERMINE THEIR SIZE DISTRIBUTION, THE METHODOLOGY TO DO THAT IS NANOPARTICLE TRACKING ANALYSIS AND I HOPE THIS WILL SHOW THIS IS A LASER SHINING ON THESE VESICLES IN SUSPENSION AND DEPENDING ON THESE SIZE, MOTION IS DEPENDENT ON SIZE, AND THAT WAY WE CAN COME UP WITH A CURVE THAT REFLECTS THEIR CONCENTRATIONS VERSUS SIZE SUCH AS THIS SO WE’VE BEEN, FOR LONG, WE’VE BEEN ASKED TO PROVIDE SOME MEASURES OF DEGREE OF ENRICHMENT OF NEURONAL IMAGES WE HAVE EXPERIMENTS IN METHODS PAPER CURRENTLY IN PRESS AND WE THOUGHT THAT TO DEMONSTRATE ENRICHMENT FOR NEURONAL ORIGIN IN THESE EXOSOME PREPARATIONS WE NEED A GOOD CONTROL WHAT WE DECIDED TO DO IS HAVE THE SAME SET OF SAMPLES, SPLIT IN TWO, ONE HALF PRECIPITATE WITH L1 CAM AND AS CONTROL WE WANTED A POPULATION OF VESICLES THAT WOULD GO THROUGH THE EXACT SAME STEPS IN THE METHODOLOGY

BUT IT WOULD BE PRESUMABLY FROM EVERY CELL OF ORIGIN, AND FOR THAT WE TARGETED CD8 1 SO IF WE COMPARE L1 WITH CD8 VESICLES WE PERFORM ASSAYS, WESTERN BLOTS AND ELISA, AND THAT PRETTY MUCH RUN TO THE SAME CONCLUSION HERE I HAVE A NUMBER OF SAMPLES, PRECIPITATED FOR L1CAM, CD81, WE SHOW WE’RE ACTUALLY HAVING AN ENRICHED POPULATION FOR THE TARGET MOLECULE NEURON SPECIFIC ANYLASE, BDNF AND SEVERAL OTHER NEURONAL MARKERS, SYNAPTIC PROTEINS PRETTY MUCH WHAT WE FIND FROM ALL THESE EXPERIMENTS IS THAT SOMEWHERE BETWEEN FOUR-FOLD TO 2 1/2-FOLD ENRICHMENT DEPENDING ON MARKER WE LOOK AT COMPARED TO THE CONTROL POPULATION NOW THE CONTROL POPULATION IS ACTUALLY ALLOWED TO HAVE SOME OF THESE MARKERS BECAUSE THESE MARKERS, THE CONTROL POPULATION DOES HAVE A NEURONAL EXOSOME IN IT ALSO WHAT WE — THIS 2 1/2 TO 4 TIMES-FOLD ENRICHMENT FOR NEURONAL MARKERS, WHAT DOES IT MATTER, ONE MAY ASK? IT MATTERS, IT MATTERS GREATLY HERE THERE ARE TWO MOLECULES OF GREAT INTEREST, IF YOU TAKE PLASMA AND RAN AN ESSAY, SENSITIVITY OF ELECTRO CHEMICAL LUMINESCE ASSAY, YOU SEE YOU GET SIMILAR TO BLUNT BASICALLY IT’S NON-DETECTABLE IF YOU MEASURE PLASMA, THE TOTAL PLASMA, YOU HAVE A SIGNAL, BUT IF YOU DO OUR TWO-STEP PRECIPITATION AND ENRICHMENT PROCESS THAT I DESCRIBED, NOW WE HAVE HIGH MEASURABLE VALUES OF P TAU WAY ABOVE THE LOWER LIMIT OF QUANTIFICATION AND CAN GENERATE ACCURATE MEASUREMENTS THESE MEASUREMENTS WE HAVE AN AMAZING REPRODUCIBILITY BETWEEN SAMPLES IN THE RANGE OF .8, .9 PER CENT, IF WE DO THE WHOLE THING AGAIN FROM THE BEGINNING SO BASED ON THIS METHODOLOGY WE PUBLISHED NOW A NUMBER OF PAPERS IN ALZHEIMER’S DISEASE, THE VERY FIRST WE FOCUSED ON PATHOGENIC PROTEINS A BETA AND TAU AND TURNED OUR SEVERAL TO SEVERAL INTRACELLULAR PATHWAYS THAT ARE NORMAL IN ALZHEIMER’S DISEASE, INSULIN RESISTANCE, SOME SURVIVAL, CELLULAR SURVIVAL FACTORS SUCH AS REST, LYSOSOMAL DYSFUNCTION, I’M NOT GOING TO GET SYNAPTIC MARKERS, NOT GOING TO GET TO THAT IN DETAIL, BECAUSE IT PERTAINS TO THE TRAUMATIC BRAIN INJURY STORY, WE’LL JUST FOCUS ON PATHOGENIC PROTEINS THAT WE MEASURED IN THE FIRST PAPER, TOTAL TAU, 2,000 AND A BETA WE COMPARED ALZHEIMER’S PATIENTS WITH AGE MATCHED CONTROLS AS WELL AS FROM THE TEMPORAL DEMENTIA PATIENTS AND CONTROLS FOR THESE PATIENTS AS NEURODEGENERATIVE CONTROL, SO TO SPEAK, PATIENTS WITH ALZHEIMER’S DISEASE HAVE MUCH HIGHER LEVELS OF THE PHOSPHO-TAU SPECIES, INTERESTINGLY NOT HIGHER LEVELS OF TOTAL TAU SPECIES AND THIS IS RELEVANT BECAUSE P TAU IS THE ONE THAT IT IS MOST CLOSELY REFLECTING ALZHEIMER’S-SPECIFIC PATHOLOGY RATHER THAN JUST GENERAL NEURONAL INJURY SO WE WERE VERY EXCITED THROUGH A COMMON COLLABORATOR FORMED THIS COLLABORATOR WITH JESSICA BECAUSE WE WERE ABLE TO LOOK AT ANOTHER VERY EXCITING DISEASE WHERE THESE PROTEINS PLAY PATHOGENIC ROLE, THIS IS TBI JESSICA PROVIDED SOME VERY METICULOUSLY CHARACTERIZED AND GREATLY ASSEMBLED COHORTS WHERE WE HAD PATIENTS WITHOUT TBI, CONTROLS WITHOUT TBI, PATIENTS WITH TBI THAT WENT ON TO DEVELOP CHRONIC NEUROLOGIC SYMPTOMS, NON-SPECIFIC, SUCH AS CHRONIC HEADACHES, FATIGUE, INATTENTION,

AND SO FORTH, AS WELL AS PATIENTS WITHOUT THESE CHRONIC SYMPTOMS SO WE HAD PEOPLE THAT HAD TBI AND RECOVERED FROM IT, PEOPLE THAT HAD TBI AND THEY WERE JUST DEBILITATED BY THAT SO WHAT WE FOUND IS THAT THERE WERE OVERALL DIFFERENCES IN ALL OUR GROUPS PATIENTS WITH TBI HAD HIGHER LEVELS OF BOTH TAU AND A BETA, SUGGESTING COMMON MECHANISM BETWEEN OUR TBI PATHOLOGY THAT LEADS TO CHRONIC NEUROLOGIC SYMPTOMS AND ALZHEIMER’S DISEASE AND THEN WE ASKED THE QUESTION HOW DO THESE MARKERS HELP US IN DIAGNOSTIC CLASSIFICATION? THERE ARE TWO WAYS OF LOOKING AT IT ONE IS HOW CAN WE SEPARATE PATIENTS WITH TBI VERSUS WITHOUT TBI? AND FOR THAT DISTINCTION WE SAW THAT BOTH A BETA 42 AND TAU WERE IMPORTANT CLASSIFIERS, CLASSIFYING PERCENT, CLASSIFYING GENERATING A CURVE OF .8, CLASSIFYING CORRECTLY ABOUT 8% OF THE SUBJECTS BUT PARTICULARLY WELL THE CONTROLS SO IF YOU HAVE WITH OUR MARKERS WE CAN ESSENTIALLY RULE OUT SOMEONE WHO HASN’T HAD TBI, WE CAN RULE OUT TBI THE OTHER MORE INTERESTING QUESTION IS LIKE CAN WE SEPARATE THOSE THAT HAVE TBI AND RECOVER WELL FROM THOSE THAT HAVE TBI, AND DON’T RECOVER? AND THE SINGLE — THIS IS VERY INTERESTING THE SINGLE MARKER THAT WAS ABLE TO DO THAT DISTINCTION ACCURATELY WAS A BETA 42 SO IF YOU HAD TBI AND YOU HAD HIGH A BETA, THEN YOU WERE MORE LIKELY TO DEVELOP CHRONIC NEUROLOGIC SYMPTOMS AND OUR BIOMARKER, AGAIN, FOR SOME REASON, IT WAS BETTER IN CLASSIFYING THOSE WITHOUT TBI, WITHOUT CHRONIC SYMPTOMS, ESSENTIALLY IT WAS PARTICULARLY ACCURATELY RULING OUT CHRONIC SYMPTOMS AFTER TBI SO WITH THIS IN MIND, SOME GENERAL COMMENTS, I THINK THAT THIS ISOLATING NEURONAL ORIGIN FROM PLASMA IS A GREAT PLATFORM FOR DIAGNOSTIC PROGNOSTIC AND MECHANISTIC BIOMARKERS FOR NEUROLOGICAL DISEASE, ALZHEIMER’S, TBI AND BEYOND I THINK THE TERM THAT IS OUT THERE IS LIQUID BIOPSY THIS IS KIND OF NOT WHERE WE ARE NOW I THINK BUT THE ULTIMATE GOAL IS TO HAVE BIOMARKERS THAT ARE AS SUCCESSFUL AS IF WE WERE ABLE TO TAKE A CHUNK OF TISSUE AND ANALYZE IT UNDER THE MICROSCOPE THAT IS THE GOAL AND I THINK THAT IT WILL PROVE TO BE PARTICULARLY USEFUL FOR DEMONSTRATING TARGET ENGAGEMENT AND FOLLOWING RESPONSE TO EXPERIMENTAL TREATMENT THAT IN MIND, I WOULD LIKE TO THANK OUR AMAZING TEAM OF POSTDOCS AND POSTBACS AT THE NIA THAT DO THIS WORK I TAKE THEM CAKE FOR THEIR BIRTHDAYS SO THEY WORK BETTER THAT’S MY USE I WOULD LIKE TO THANK OUR GREAT COLLABORATOR, JESSICA GILL, AND FOR THIS INVITATION THANK YOU [APPLAUSE] >> GREAT THANKS, THAT WAS AN AMAZING PRESENTATION AND REALLY SHOWS HOW WE CAN USE PERIPHERAL BIOMARKERS THAT CHALLENGE AND REALLY HOW WE CAN GET MORE SENSITIVE AND UNDERSTANDING CENTRAL MECHANISMS RELATED TO BRAIN INJURY, SO THIS IS REALLY A TRANSLATIONAL MODIFICATION OF HOW WE’RE DOING THAT SO IT’S GREAT TO HAVE DIMITRIOS HERE TODAY NEXT I’D LIKE TO INTRODUCE DR ROBERT STERN, AND ROBERT STERN IS COMING TO US FROM BOSTON UNIVERSITY HE’S AN AMAZING COLLABORATOR AND RESEARCHER WHO CHALLENGE THE THE PARADIGM OF BRAIN INJURY AND UNDERSTANDING COHORTS OF ATHLETES WITH MULTIPLE BRAIN INJURIES AND SUBCONCUSSIVE HEADS A PROFESSOR OF NEUROLGY, NEUROSURGERY AND ANATOMY AND BOSTON UNIVERSITY SCHOOL OF MEDICINE, DIRECTOR OF CLINICAL CORE OF ALZHEIMER’S DISEASE AND CTE CENTER THERE MAJOR FOCUS IS LONG-TERM EFFECTS OF CHRONIC REPETITIVE HEAD INJURIES IN ATHLETES AND SPECIFICALLY LOOKING AT COHORTS OF ATHLETES WHO HAVE BEEN ENGAGED IN LONG EXPOSURES DURING THEIR LIFETIME TO THESE SUBCONCUSSIVE HITS, CTE, RECENTLY AWARDEDs A $16 MILLION GRANT TO DO A MULTI-CENTER STUDY TO BETTER UNDERSTAND CTE IN LIVING PARTICIPANTS AND IN DEPTH PHENOTYPING AND BUY MARKER COLLECTION, FUNDED IN OTHER

AREAS OF RESEARCH INCLUDING ASSESSMENT AND TREATMENT OF ALZHEIMER’S DISEASE AND COGNITIVE EFFECT OF CHEMOTHERAPY IN THE ELDERLY WELCOME, DR. STERN [APPLAUSE] >> THANK YOU VERY MUCH IT IS REALLY AN HONOR TO BE HERE, ESPECIALLY AN HONOR TO BE ABLE TO SHARE A PANEL WITH THE TWO OF YOU IT’S REALLY FANTASTIC I’LL BRING MY GUY UP HERE LET ME START WITH SOME DISCLOSURES, JUST TO LET YOU KNOW THAT I HAVE SOME INVOLVEMENT WITH INDUSTRY LET ME ALSO THEN JUST GO TO THIS (LOUD MUSIC) , OVER THE LAST SEVERAL YEARS THERE HAVE BEEN GREAT STRIDES IN CONCUSSION PREVENTION, AWARENESS, DETECTION AND MANAGEMENT HERE IS MY FAVORITE WAY FROM A BOSTONNIAN SHOWING THE BEST TYPE OF BIOMARKER TO DETERMINE A CONCUSSION YOU ALSO HAVE PEOPLE LIKE DR GILL WHO HAS BEEN DOING SENSATIONAL WORK ON THE DEVELOPMENT OF BIOMARKERS LIKE PLASMA TAU TO DETECT WHAT’S GOING ON THAT’S IMPORTANT BECAUSE CONCUSSIONS RIGHT NOW ARE ONLY DIAGNOSED THROUGH SYMPTOMS A LOT OF PEOPLE DON’T WANT TO COMPLAIN ABOUT THOSE SYMPTOMS SO HAVING SOME OBJECTIVE MEASURE IS ABSOLUTELY CRITICAL HERE IS ANOTHER VERY IMPORTANT DISCLOSURE I ACTUALLY KNOW VERY LITTLE ABOUT CONCUSSIONS I REALLY HAVE MORE EXPERTISE IN NEURODEGENERATIVE DISEASE I’M ALSO NOT VERY CONCERNED ABOUT CONCUSSIONS WHEN IT COMES TO LATER LIFE PROBLEMS AND THAT NEURODEGENERATIVE DISEASE YOU’LL ALSO MORE WHAT I’M TALKING ABOUT IN A FEW MINUTES WHAT I’M REALLY CONCERNED ABOUT IS WHAT WE REFER TO AS REPETITIVE HEAD IMPACT, OVERALL AMOUNT OF HITS TO THE HEAD OR BODY THAT MAKE THAT BRAIN MOVE AROUND AND RESULT IN SOME KIND OF INJURY SO WE USE THAT WONDERFUL CLICH� OF THE TIP OF THE ICEBERG, THE TIP BEING MODERATE TO SEVERE BRAIN INJURY, THE REAL BIG INJURY WHAT WE HEAR PEOPLE TALKING ABOUT ALL THE TIME ARE THESE CONCUSSIONS OR ALSO REFERRED TO AS MILD TRAUMATIC BRAIN INJURIES, THAT’S JUST AT THE SURFACE A WHOLE LOT OF FOCUS HAS BEEN ON IT REALLY IMPORTANT TO DO THAT THEY NEED TO BE TREATED THEY NEED TO HAVE APPROPRIATE RECOVERY I’M MORE CONCERNED ABOUT WHAT WE DON’T NECESSARILY SEE, REFERRED TOE AS SUBCONCUSSIVE TRAUMA I WANT YOU TO THINK ABOUT THESE GUYS LINEMEN IN FOOTBALL, EVERY PLAY OF EVERY GAME, EVERY PRACTICE, WHAT DO THEY DO? THEY HIT THEIR HEADS AGAINST EACH OTHER PERHAPS TENS OF THOUSANDS OF TIMES THROUGH A CAREER WHAT ARE THESE SUBCONCUSSIVE IMPACTS? IMPACTS TO THE BRAIN WITH ADEQUATE FORCE TO HAVE AN EFFECT ON NEURONAL FUNCTIONING, POSSIBLY INCLUDING NEUROMETABOLIC CASCADE WE THINK ABOUT IN CONCUSSION, PERHAPS HAVING NEUROIMMUNE RESPONSE, PERHAPS BREAKING DOWN THE BLOOD BRAIN RATHERRER, PERHAPS RELEASE OF PROTEIN LIKE TAU AMYLOID SOME SPORTS, SOME POSITIONS ARE PRONE PRO LINEMEN MAY HAVE A THOUSAND TO 1500 OF THESE PER SEASON, AT 20 TO 30G IN FORCE EACH REMIND YOU OF YOUR PHYSIC CLASS? FORCE EQUALS MASS TIMES AC CELEBRATION IT’S NOT A JOKE ATHLETES ARE BIGGER, STRONGER, FASTER THIS IS MY FAVORITE — THERE WE ARE HE’S 325 POUNDS AND HE CAN RUN FASTER THAN ANYONE IN THIS ROOM, I CAN GUARANTEE YOU PUT TWO OF THOSE, 325 POUNDS, RUNNING ACROSS THE LINE OF SCRIMMAGE, THEY HIT THEIR HEADS AGAINST EACH OTHER THAT’S FORCE SO HOW DO WE COUNT THESE THINGS? WELL, THERE’S BEEN THE USE OF HELMET ACCELEROMETER, GIZMOS PUT IN HELMETS TO MEASURE THE AMOUNT OF FORCE THAT EACH PLAYER MIGHT GET DURING PRACTICE, DURING A GAME, AND EVEN IN HIGH SCHOOL FOOTBALL PLAYERS ONE STUDY SHOWED THAT A HIGH SCHOOL POSSIBLE PLAYER ON AVERAGE RECEIVES 652 HITS ABOVE 15G IN FORCE, ONE KID ON THE TEAM RECEIVED OVER 2,000 OF THESE IN JUST ONE SEASON COLLEGE STUDIES, USING ACCELEROMETERS, SHOW EVEN MORE

COMMON SUBCONCUSSIVE HITS EVEN AFTER ONE THESE THERE’S EVIDENCE THERE CAN BE COGNITIVE, PHYSIOLOGICAL AND STRUCTURAL CHANGES TO THE BRAIN THERE’S A VERY POWERFUL PAPER THAT CAME OUT THE END OF LAST YEAR BY FOLKS AT WAKE FOREST WHERE THEY PUT ACCELEROMETERS IN YOUTH FOOTBALL PLAYERS, WE’RE TALKING ABOUT KIDS 8-12 YEARS OLD AND GAVE THE KIDS MRIs BEFORE THE SEASON AND DID DIFFUSION TENSOR IMAGING TO LOOK AT WHITE MATTER INTEGRITY BEFORE THE SEASON AND COUNTED HITS DURING THE SEASON THEY REMOVED ANYONE WHO HAD A SYMPTOMATIC CONCUSSION AND THERE WAS THIS STRIKING DRAMATIC RELATIONSHIP BETWEEN THE TOTAL NUMBER OF HITS IN ONE SEASON IN THESE KIDS AND CHANGE IN THEIR MRI FINDINGS OF THE WHITE MATTER INTEGRITY THAT’S PRETTY SCARY THERE’S ONLY ONE PROBLEM WITH THESE SUBCONCUSSIVE HITS RIGHT NOW WE HAVE NO CLEAR UNDERSTANDING OF THE MEANINGFUL IMPACT WE NEED TO DO MUCH MORE RESEARCH LIKE WHAT DR. GILL IS DOING TO UNDERSTAND THE BASIC SCIENCE OF WHAT’S GOING ON AT THE TIME OF THESE HITS ALL KINDS OF POTENTIAL THINGS MIGHT BE HAPPENING, AND DEVELOPING APPROPRIATE BIOMARKERS TO DETECT THEM IS THE KEY AND THEN FOLLOW PEOPLE LONGITUDINALLY TO BE ABLE TO UNDERSTAND THE CLINICAL OUTCOMES SO WHAT I’VE BEEN FOCUSING ON IS THIS QUESTION DO CONCUSSIONS AND SUBCONCUSSIVE TRAUMA LEAD TO NEURODEGENERATION? (LOUD MUSIC) >> THE GOAL IS TO INDUCE BRAIN DAMAGE EVERYONE KNOW WHO IS THE GUY ON THE LEFT IS, RIGHT? ANYONE KNOW? WHO IS IT? YOU DON’T KNOW THE GUY ON THE LEFT? HOW ABOUT THE GUY ON THE RIGHT? EVERYONE KNOWS, RIGHT? IT’S CASSIUS CLAY, NOT MOHAMMED ALI, RIGHT BEFORE HE CHANGED HIS NAME NOW WE HAVE AN UNDERSTANDING OF THAT INABILITY TO GET WORDS OUT THAT KIND OF LACK OF CLARITY — NO, THAT’S BUSH [LAUGHTER] I WASN’T SURE IF I WAS ALLOWED TO SAY THAT HERE AT NIH [LAUGHTER] I DID SAY THAT JOKE IN TEXAS ONCE IT WASN’T GOOD SO WHAT’S INTERESTING IS THAT WE HAVE KNOWN ABOUT THE LONG-TERM CONSEQUENCES OF GETTING YOUR BOXING FOR A LONG TIME BACK IN 1928 IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, A PAPER CALLED PUNCH DRUNK DESCRIBED THE FORMER BOCKERS LATER IN LIFE BEING WONDERFUL SCIENTIFIC TERMS GOOFY AND SLUG-NUTTY, DESCRIBED LATER ON THEY REQUIRED INSTITUTIONALIZATION IN AN ASYLUM BECAUSE OF DEMENTIA SOON AFTER THE TERM DEMENTIA PUGILISTICA WAS DESCRIBED IT WASN’T UNTIL THE EARLY 2000s THAT PEOPLE START IT’S PAYING ATTENTION TO THIS DISEASE WHY? BECAUSE ONE OF OUR BELOVED AMERICAN FOOTBALL PLAYERS WAS FOUND TO HAVE IT MIKE WEBSTER, A WONDERFUL, TALENTED PITTSBURGH STEELER, TRAGICALLY DIED IN MIDDLE AGE AFTER HIS LIFE FALLING APART AND DR. BENNETT OMALU WAS ABLE TO EXAMINE HIS BRAIN AND DISCOVERED HAD HE CHRONIC TRAUMATIC ENCEPHALOPATHY, A NEURODEGENERAL ACTIVE DISEASE SIMILAR IN MANY WAYS TO ALZHEIMER’S DISEASE, UNIQUE NEUROPATHOLOGICALLY AND IN SOME WAYS UNIQUE CLINICALLY IT’S ASSOCIATED WITH HAVING A HISTORY OF THESE REPETITIVE HEAD IMPACTS, INCLUDING THE SYMPTOMATIC CONCUSSIONS BUT ALSO SUBCONCUSSIVE TRAUMA REPETITIVE TRAUMA SEEMS TO SETS IN MOTION CASCADE OF EVENTS THAT EVENTUALLY LEADS TO PROGRESSIVE NEURODEGENERATION IT IS NOT PROLONGED POST CONCUSSION SYNDROME, NOT LIKE YOU GET A HIT AND GET BETTER IT’S NOT CUMULATIVE EFFECT OF CONCUSSION, AND INJURY, SYMPTOMS, AN INJURY, GETS WORSE, MORE SYMPTOMS AND KEEPS ADDING IT’S NOT A BRAIN INJURY PER SE IT’S A NEURODEGENERATIVE DISEASE, IT’S A DISEASE THAT APPEARS TO BEGIN EARLIER IN LIFE BUT THE SYMPTOMS OFTEN BEGIN YEARS OR DECADES AFTER THE PERSON STOPS GETTING THEIR HEAD HIT AD THEN TYPICALLY THEY WORSEN AND THERE’S IN BEEN MANY CASES

OF INDIVIDUALS WITH NEUROPATHOLOGICALLY CONFIRED CTE WITH NO HISTORY OF SYMPTOMATIC CONCUSSIONS BUT WITH EXTENSIVE HISTORY OF SUBCONCUSSIVE EXPOSURE SO LIKE ALZHEIMER’S DISEASE AND OTHER NEURODEGENERATIVE DISEASES EVEN RIGHT NOW IN 2017 IT CAN’T BE DIAGNOSED DURING LIFE FOR SURE SO MY COLLEAGUE AT BOSTON UNIVERSITY, DR. ANN McKEE, HAS EXAMINED MORE BRAINS WITH A HISTORY OF CTE THAN ANY OTHER NEUROPATHOLOGIST, OVER 300 OR MORE WHAT CTE IS NEUROPATHOLOGICALLY IS INTERESTING, CHARACTERIZED BY A UNIQUE ABUNDANCE OF THIS ABNORMAL MISFOLDED HYPER PHOSPHORYLATED TAU PROTEIN, P TAU, NEURO FIBRIRARY TANGLES, IT SHARES WITH ALZHEIMER’S DISEASE PHOSPHORYLATED TAU ACCUMULATES IN THE DISEASE THAT MAKES IT UNIQUE THE PATHOPNEUMONIC FINDING IS DEPOSITION OF P TAU SURROUNDING SMALL BLOOD VESSELS AT THE DEPTHS OF CORTICAL SULCI WHAT YOU SEE ON THE LEFT IS THE WHITE HOLEA SMALL BLOOD VESSEL, EVERYBODY BROWN AROUND IT IS STAINED WITH AT8 STAIN SO YOU’RE SEEING BIGGER THINGS, THE TANGLES, ASTROCYTIC TANGLES, TAU THREADS ON THE RIGHT WHAT YOU SEE IS THE DEPOSITION OF THE P-TAU AT THE DEPTHS OF SULCUS, YOU CAN SEE THE RIBBON IN THE DEPTH OF THE SULCUS STARTING AT THE SUPERIOR FRONTAL LOBES, PERHAPS PARIETAL AS WELL I’LL SKIP A COUPLE THINGS, TAU PROTEIN IS CRITICAL FOR EVERY NEURON, BUT IN SOME INSTANCES LIKE ALZHEIMER’S DISEASE, IN THIS CASE IN INDIVIDUALS WITH THIS TYPE OF REPETITIVE HEAD IMPACT, PROTEIN GOES AWRY AND STOPS GOING WHAT IT’S SUPPOSED TO DO AND EVENTUALLY LEADS TO NEURONAL INJURY AND HAS MORE AND MORE CURVES, MORE SYMPTOMS DR. McKEE WITH NIH HELD A CONSENSUS PANEL OF NEUROPATHOLOGIST WORKSHOP A COUPLE YEARS AGO WHERE THEY WENT THROUGH THIS VERY LONG PROCESS OF SLIDES AND DETERMINED AS OF CONSENSUS CTE INDEED IS A UNIQUE DISEASE, UNIQUE FROM TAUOPATHY, ONLY THINK IN THOSE WITH THIS HISTORY CLINICAL FEATURES, RIGHT NOW WE ONLY KNOW IT FROM INTERVIEWING NEXT OF KIN TO GET AN IDEA WHAT THE PERSON WAS LIKE DURING LIFE IT SEEMS THAT THERE ARE CHANGES IN MOOD INCLUDING SADNESS, DEPRESSION, ALSO APATHY, THE LACK OF INTEREST IN THINGS ANXIETY, AGITATION, PERHAPS RAGE, VERY OFTEN CHANGES IN BEHAVIOR, SOMEONE HAVING A SHORT FUSE, NOT ABLE TO PUT A LID ON IT, POOR IMPULSE CONTROL AND AGGRESSIVE BEHAVIOR THERE’S CHANGES IN COGNITIVE BEHAVIOR SIMILAR TO ALZHEIMER’S DISEASE WITH RAPID FORGETTING OF INFORMATION, REPEATING STORIES, EXECUTIVE DYSFUNCTION INCLUDING PROBLEMS WITH JUDGMENT AND DECISION MAKING, POOR MULTI-TASKING, ORGANIZATION AND PLANNING DIFFICULTY EVENTUALLY IF BAD ENOUGH LEADS TO DEMENTIA WHAT WE SEE OVER AND OVER AGAIN IS A CASE SITUATION, THE COURSE OF THE DISEASE WHERE SOMEONE LOOKS JUST LIKE AN INDIVIDUAL WITH ALZHEIMER’S DISEASE/DEMENTIA, BUT WITH THAT HISTORY OF GETTING THEIR HEADS HIT OVER AND OVER AGAIN, IN FACT THEY DON’T HAVE ALZHEIMER’S, WHAT THEY HAVE IS CTE ONE CASE EXAMPLE, JOHN GRIMSLEY WHO DIED AT AGE 45, HE WAS A PRO BOWL LINEBACKER, BELOVED GUY, WHO SPENT HIS POST NFL CAREER AS A HUNTING AND FISHING GUIDE AND KNEW HIS WAY AROUND FIVE ARMS FIVE YEARS PRIOR TO DEATH, FROM 40 TO 45 STARTEDs HAVING PROGRESSIVE AWFUL MEMORY IMPAIRMENT STARTED HAVING A SHORT FUSE HAVING JUST KIND OF A DIFFERENT GUY, PEOPLE WOULD DESCRIBE HIM AS SADLY ONE NIGHT HE WAS HOME ALONE, CLEANING HIS GUNS LIKE HE

WOULD NORMALLY DO, AND EITHER FORGOT TO TAKE OUT THE AMMUNITION OR DID THINGS IN THE WRONG ORDER AND HE ACCIDENTALLY SHOT HIMSELF IN THE CHEST HIS WIFE VIRGINIA VERY BEAUTIFULLY DONATED HIS BRAIN TISSUE TO OUR CENTER AND THIS IS DR. McKEE’S WORK ON THE TOP, JUST A SLICE OF A BRAIN TISSUE SHOWING THE ABNORMAL TAU DEPOSITION, ON THE BOTTOM MICROSCOPICALLY ENHANCED, YOU CAN SEE TAU DEPOSIT THIS IS THE BRAIN OF A HEALTHY 45-YEAR-OLD, WHAT THE BRAIN IS SUPPOSED TO LOOK LIKE, NONE OF THIS ABNORMAL TAU ANOTHER PERSPECTIVE, THE BRAIN OF A 73-YEAR-OLD BOXER WITH DEMENTIA FOR MANY YEARS INSTITUTIONALIZED IN THE NURSING FACILITY, DIAGNOSED LIVING WITH DEMENTIA PUGILISTICA LOOK AT THE COMPARISON, THE 45-YEAR-OLD GUY WHO PLAYED FOOTBALL AND 73-YEAR-OLD BOXER SINCE THEN THERE’S BEEN MANY, MANY INDIVIDUALS WHO PLAYED PROFESSIONAL FOOTBALL AND WHOSE BRAINS WERE EXAMINED AFTER DEATH AND THEY WERE FOUND TO HAVE CHRONIC TRAUMATIC ENCEPHALOPATHY, MANY WITH VERY TRAGIC STORIES IN THEIR LIFE IT’S NOT JUST FOOTBALL THE BRAIN DOESN’T KNOW WHAT’S HITTING IT YES, WE’VE SEEN CTE NEUROPATHOLOGICALLY IN BOXERS, WRESTLER, PRO RUGBY AND HOCKEY PLAYERS, ENFORCERS, BOXERS ON ICE, MORE RECENT EVIDENCE ON SOCCER PLAYERS IN THE UNITED KINGDOM FOUND CTE IN FORMER PROFESSIONAL SOCCER PLAYERS THERE IT’S NOT JUST PROS WE’VE SEEN CTE WHO PLAYED FOOTBALL THROUGH COLLEGE OR HIGH SCHOOL EVEN, YES IN PEOPLE WHO SERVED IN THE MILITARY WE’VE SEEN ANYTIME PEOPLE WHO DIED AS YOUNG AS 17 AND THROUGH THEIR 80s AND 90s ALL THE PICTURES OF NEUROPATHOLOGY PAINT A THOUSAND WORDS IN THAT NEUROLOGY PATHOLOGICAL FINDING OF CTE IN ATHLETES HAD A TREMENDOUS IMPACT ON PUBLIC POLICY AND AWARENESS BUT I THINK THE PUBLIC FEELS THAT WE KNOW A LOT MORE THAN WE ACTUALLY DO OVER THE LAST EIGHT YEARS OR SO THERE’S BEEN THIS DRAMATIC INCREASE IN AWARENESS IN ATTENTION AND CULTURE CHANGE SO PEOPLE CAN EVEN PRONOUNCE CHRONIC TRAUMATIC ENCEPHALOPATHY ON TV SHOWS OR WATER COOLERS I GOT TO BE ON “60 MINUTES.” THAT WAS COOL THE REALITY THOUGH IS THAT SCIENCE MOVES AT THIS PACE EVEN IN THE BEST OF CIRCUMSTANCES I USED TO SAY THERE WE’RE AT THE INFANCY OF KNOWLEDGE IN. CT BUT WE’RE GETTING SOMEWHERE, WE’RE IN TODDLERHOOD WE NEED TO KNOW BASIC THINGS IS IT COMMON? WE DON’T KNOW WE NEED LONGITUDINAL STUDIES, EPIDEMIOLOGICALLY SOUND STUDIES WE NEED TO FIGURE OUT WHY SOME PEOPLE GET IT AND SOME PEOPLE DO NOT WE KNOW NOW ALL CASE OF NEUROPATHOLOGICALLY CONFIRMED CASES OF CTE HAD ONE THING IN COMMON, HISTORY OF REPETITIVE HITS TO THE HEAD, A NECESSARY VARIABLE, OBVIOUSLY NOT SUFFICIENT, NOT EVERYONE WHO HITS THEIR HEAD A BUNCH IS GOING TO GET A NEURODEGENERATIVE DISEASE WE HAVE TO FIGURE OUT WHAT THE RISK FACTORS ARE, GENETICS THAT INCREASE OR DECREASE SUSCEPTIBILITY ApoE E4 MAY INCREASE SUSCEPTIBILITY BUT WAY MORE ISED NEWED TO BE DONE WHAT ABOUT ACTUAL EXPOSURE TO THESE HITS? THERE’S BEEN STUDIES SO FAR LINKING THE OVERALL DURATION, THE YEARS OF PLAYING FOOTBALL, WITH NEUROPATHOLOGICAL STAGE OF CTE WE’VE DONE WORK ON THE TOTAL NUMBER OF HITS ESTIMATING HOW MANY HITS THROUGH LIFE SOMEONE HAS GOTTEN AND LATER LIFE COGNITIVE MOOD AND BEHAVIORAL PROBLEMS, A DOSE-RESPONSE RELATIONSHIP WE’VE LOOKED AT THE AGE SOMEONE FIRST STARTS GETTING HIT AND FOUND THAT GUYS WHO START PLAYING FOOTBALL BEFORE AGE 12 COMPARED TO THOSE WHO START AT 12 OR OLDER SEEM TO BE AT INCREASED RISK FOR LATER LIFE COGNITIVE IMPAIRMENT, MEMORY IMPAIRMENT, AS WELL AS ALTERATIONS OF WHITE MATTER INTEGRITY ONE QUESTION IS DO ALL PEOPLE WITH THAT EARLY STAGE NEUROPATHOLOGIC FINDING IN DEPTHS OF CORTICAL FOCUS, FOCAL AREAS, DO THEY ALL GO ON TO DEVELOP SYMPTOMS? WE JUST DON’T KNOW HOW DOES IT SPREAD?

HOW DOES IT START IN THESE LITTLE AREAS AND THEN SPREAD TO THE REST OF THE BRAIN WREAKING HAVOC, DESTROYING BRAIN TISSUE? THERE’S BEEN SOME WORK TO SUGGEST THAT SIMILAR MECHANISM TO ALZHEIMER’S DISEASE, WHERE IT’S KIND OF A PRION SPREAD OF THE CON TOXIC EFFECTS OF TAU, AND BY EXOSOMES, NOT AS A BIOMARKER, BUT TAU SEEMS TO LEAVE CELLS AND TRAVEL IN EXOSOMES, ENGULFED IN FAR-AWAY CELLS AND STARTS THE DESTRUCTION AGAIN WHAT DO WE NEED TO KNOW? FIGURE OUT WHAT CLINICAL FEATURES ARE RELATED TO P-TAU NEUROPATHOLOGY, I’M NOT SURE EVERYTHING WE HEAR ABOUT MOOD AND BEHAVIOR CHANGES AND COGNITIVE THINGS, I’M NOT SURE WHAT’S DUE TO THIS PHOSPHORYLATED TAU PATHOLOGY OR MAYBE THERE’S OTHER THINGS GOING ON IN SOME PEOPLE IN PARALLEL, LIKE INFLAMMATORY RESPONSES, WHITE MATTER DAMAGE AND AXONOPATHY OR OTHER CONCURRENT NEURODEGENERATIVE DISEASES AND SO FOR ME, THE BIG CRITICAL NEXT STEP IS TO BE ABLE TO DIAGNOSE IT DURING LIFE IF WE CAN, WE’LL BE ABLE TO DO ALL OF THOSE THINGS I WAS JUST SAYING WE NEED ANSWERS TO DIFFERENTIATE CTE FROM OTHER CAUSES OF THESE SAME TYPES OF CLINICAL FEATURES, UNDERSTAND TRUE INCIDENCE AND PREVALENCE, DETERMINE RISK FACTORS FOR REAL INCLUDING GENETICS AND EXPOSURE VARIABLES AND MOST IMPORTANTLY WE COULD ACTUALLY DO SOMETHING ABOUT IT, IF WE COULD DETECT IT EARLY WE COULD BEGIN CLINICAL TRIALS FOR TREATMENTS AND PREVENTION SO THE STEPS REQUIRED TO DIAGNOSE THIS NEURODEGENERATIVE DISEASE DURING LIFE, ONE, IS TO START UNDERSTANDING THE CLINICAL FEATURES WHICH WE STARTED TO DO, AND THEN DEVELOP AND BEGIN TO REFINE DIAGNOSTIC CRITERIA SO WE PUBLISHED SOME PRELIMINARY DIAGNOSTIC CRITERIA THAT WE NOW NEED TO REFINE AND VALIDATE THROUGH THE YEARS BUT MOST IMPORTANTLY TO BE ABLE TO KNOW THAT THIS IS CTE, CAUSED BY THE PATHOPHYSIOLOGICAL CHANGES WE SEE POSTMORTEM WE NEED TO DEVELOP BIO, — BIOMARKERS THERE’S NO LAUGHTER THAT’S LEFT SIMILAR TO ALZHEIMER’S DISEASE THOUGH, ANOTHER NEURODEGENERATIVE DISEASE, IF THE COMBINATION OF BIOMARKERS AND A GOOD CLINICAL EVALUATION THAT’S GOING TO LEAD TO AN ACCURATE DIAGNOSIS OF CTE DURING LIFE SO STEP ONE EVERYONE WHO IS DOING BIOMARKER WORK HERE KNOWS AND EVERYONE WHO WANTS TO DO IT IN THE FUTURE KNOWS CRITICAL FIRST STEP IS TO DEVELOP IS A GREAT ACRONYM [LAUGHTER] I’M GOING TO WIN THE NOBEL PRIZE FOR ACRONYM DEVELOPMENT BASED JUST ON THIS ONE ALONE ISN’T THAT GOOD? THAT WAS THE ACRONYM NAME FOR A COOL STUDY WE DID, WE GOT FUNDING FROM THEY OF YOUR INSTITUTES HERE THANK YOU TO HAVE A MORE BORING NAME OF A STUDY, CHRONIC TRAUMATIC ENCEPHALOPATHY, CLINICAL BIOMARKERS, WE’RE PUBLISHED, LOOKING AT DATA, 100 FORMER NFL PLAYERS, 40-69, SYMPTOMATIC BEFORE THEY CAME IN, WE HAD CONTROLS, PEOPLE SAME AGE WHO NEVER HIT HEADS IN ORGANIZED FASHION, DIDN’T PLAY CONTACT SPORTS, NO HISTORY OF BRAIN INJURY, TWO TO THREE DAYS OF EVERYTHING POSSIBLE TO BE ABLE TO UNDERSTAND WHAT’S GOING ON ALL KINDS OF IMAGING AND LUMBAR PUNCTURES AND EEGs AND GOT BLOOD, CLINICAL EXAMINATION WHEN WE STARTED THERE WERE NO MEASURES ON THE HORIZON FOR& MEASURING TAU IN THE BLOOD OR DETECTING TAU IN THE BRAIN WHILE SOMEONE IS ALIVE SO FORTUNATELY NEAR THE END OF THE STUDY WE WERE ABLE TO DO SOME ADDITIONAL ADD-ON STUDIES, AFTER WE LOOKED AT ALL THE NEUROIMAGING, THOSE DIDN’T LOOK AT TAU WE COULD SEE IN THE BRAIN THIS IS A PRELIMINARY FINDING OF A STUDY THAT WE’RE JUST COMPLETING NOW, 20 FORMER NFL PLAYERS, 10 CONTROLS, WITH A PET SCAN WITH A TRACER THAT IS ABLE TO DETECT ABNORMAL PAIRED HELICAL FILAMENT TO TAU, PHOSPHORYLATED TAU WE SEE IN ALZHEIMER’S DISEASE AND WE THINK IN CTE, VERY PRELIMINARY FINDING YOU AN EXAMPLE

THIS IS IS A CORONAL SLICE OF SCAN WITH BRIGHT SPOTS ARE TAU UPTAKE IT’S INTERESTING, IF YOU PUT THIS PATHOLOGY SLIDE NEXT TO IT, YOU CAN SEE MAYBE INDEED WHAT WE’RE ACTUALLY SEEING IS THE DEPOSITION OF TAU IN THE DEPTHS OF CORTICAL CELL SIDE LIKE WE WOULD EXPECT WHAT ABOUT A BLOOD TEST? WELL, WE DID A STUDY WITH EXOSOMAL TAU THE PROBLEM IS I’M GOING TO TELL YOU ABOUT THIS IN FRONT OF THE EXPERT WITH TREMENDOUS APOLOGIES AND HUMILIATION BY SUMMARIZING, WE DID INDEED DO A PRELIMINARY STUDY IN OUR DETECT STUDY PARTICIPANTS WE EVEN GOT IT PUBLISHED I HAVE NO IDEA WHY BECAUSE IF YOU LOOK AT THAT, WHAT WE DID COMPARED TO THE REAL STUFF, THIS IS A STUDY, 78 FORMER NFL PLAYERS, 16 CONTROLS, AND WE DIDN’T DO IT THE RIGHT WAY I WON’T TELL YOU DETAILS WE THOUGHT WE WERE LOOKING AT EXTRACELLULAR VESICLES, LOOKED LIKE EXOSOMES, WE THOUGHT THEY WERE THE RIGHT SIZE, LOOKED AT TAU EXPRESSED IN EXOSOMES WHAT WE DID FIND WAS THAT THE FORMER NFL GROUP HAD SIGNIFICANTLY HIGHER EXOSOMAL TAU, AND IT WAS DIRECTLY ASSOCIATED WITH COGNITION THIS WAS THE STRIKING PART FINALLY, I’M GOING TO GET TO ONE MORE THING BECAUSE THE BOSS IS COMING UP TO LOOK AT THE SAME KIND OF MEASURE THAT DR. GILL HAS LOOKED AT, THE TOTAL TAU IN PLASMA, SAME TYPE OF APPROACH LO AND BEHOLD A STRIKING RELATIONSHIP BETWEEN TOTAL HEAD IMPACT EXPOSURE AND HIGHER LEVELS OF TAU NEXT STEP IS DEVELOP ANOTHER ACRONYM THAT’S HOW I’M GOING TO LEAVE IT WE DID GET THIS $15 MILLION GRANT WITH 50 COLLABORATORS, 10 INSTITUTIONS, I HAVE THE BEST FOLKS TO SERVE AS CO-PRINCIPAL INVESTIGATORS, SO STAY TUNED WE’VE STARTED THE PROJECT WE ARE GOING TO BE COLLECTING A WHOLE LOT OF DATA FOLLOWING PEOPLE WITH A THREE-YEAR FOLLOW-UP AND HOPEFULLY WE’LL COME UP WITH SOME ANSWERS WITH THAT, THANK YOU [APPLAUSE] >> THANK YOU VERY MUCH WONDERFUL PRESENTATION YOU HAVE SO MUCH, EACH OF YOU HAVE SO MUCH TO PROVIDE, SO MUCH INFORMATION TO SHARE BUT I WOULD LIKE TO THANK JESSICA FOR MODERATING THIS EXCITING AND INNOVATIVE PANEL, PARTICULARLY FOCUSED ON BIOMARKERS, AND TO DIMITRIUS AND BOB FOR REPRESENTING YOUR INTERESTING AND NOVEL FINDINGS WE WILL NOW OPEN THE FLOOR FOR QUESTIONS PLEASE USE ONE OF THE MICROPHONES IN THE AISLES, AND WE REQUEST YOUR QUESTIONS BE BRIEF DR. DORSEY? >> GREAT PRESENTATIONS THANK YOU FOR DR. STERN, AS THE NUMBER OF SPORTS-RELATED INJURIES EXPANDS BEYOND FOOTBALL, ARE YOU THINKING THERE WILL BE SEX DIFFERENCE IN CTE AND IF SO INSIGHT, PREDICTING WHO WILL GET CTE WITH SUBCONCUSSIVE INJURIES? >> WONDERFUL QUESTION CAN YOU HEAR ME? >> NO >> THERE WE ARE THAT’S A GREAT QUESTION IT’S A CRITICAL QUESTION WE NEED TO BE ABLE TO UNDERSTAND, NUMBER ONE, DO WE SEE CTE IN WOMEN? THERE’S ONLY BEEN A COUPLE CASES OF WOMEN WITH NEUROLOGICAL CONFIRMED CTE ONE SADLY WAS THE VICTIM OF DOMESTIC ABUSE BUT AS WE NOW MOVE FORWARD, I THINK THERE’S GOING TO BE MORE AND MORE LIKELIHOOD THAT WE’LL SEE THIS DISEASE IN WOMEN WHO HAVE GREATER EXPOSURE TO THESE TYPES OF REPETITIVE HEAD IMPACTS, PEOPLE WHO STARTED TO HIT THEIR HEADS EARLIER IN LIFE AND DID A LOT OF IT, AND PERHAPS WITH SEX-RELATED DIFFERENCES IN ANATOMY AND IN STRENGTH AND IN HORMONES, WHATEVER IT MIGHT BE, WE WILL BE ABLE TO DETECT THOSE THINGS AS THIS COHORT OF WOMEN ARE GETTING OLDER TO BE ABLE TO SHOW THIS DISEASE >> AS A FOLLOW-UP HAVE THERE BEEN PRE-CLINICAL RODENT MODELS OF CTE DEVELOPED? IS THAT ANOTHER PLACE YOU COULD BEGIN TO SEE THAT APART? >> YEAH, THERE’S MANY DIFFERENT PRE-CLINICAL MODELS BEING DONE WITH RODENTS, WITH PIGS, OTHER ANIMAL MODELS THAT ARE REALLY NOW STARTING TO REAP SOME FRUIT

I’M NOT SURE WE’RE GOING TO BE ABLE TO DECIPHER THE SEX DIFFERENCES AS MUCH WITH THESE MODELS IT’S STILL IN THE EARLY STAGES BUT IT DOES LOOK LIKE THAT TYPE OF MODEL WILL BE ABLE TO ALLOW US TO UNDERSTAND WHAT MIGHT BE GOING ON IN THE MECHANISTIC FASHION SO WE CAN THEN DEVELOP TOOLS TO INTERVENE >> GREAT THANKS >> NEXT >> THANK YOU FOR MY PRESENTATION I WANT TO ASK SOME SIMPLE QUESTION THE SCIENCE HAS ADVANCED SO MUCH IT’S AMAZING BUT I JUST WONDER, IF OUR HEALTH FACILITIES, HOSPITALS AND THINGS LIKE THAT, �DEAL WITH THIS, SIMPLE STROKE OR CONCUSSION AND LEAN, DO THEY HAVE TO SAY FIRST MINUTE TO TREAT THE PATIENT OR IGNORE THEM AND WAIT UNTIL POSSIBLY DIE OR AFTER A FUNERAL SERVICE >> I THINK I CAN ADDRESS THAT SO A LOT OF STUDIES WE HAVE ARE ACUTE SITES, EMERGENCY ROOMS WHERE WE’VE GOT UP TO THREE MILLION EACH YEAR, WE PHENOTYPE AND CAN GIVE INFORMATION ABOUT DIAGNOSTICS BUT WE’RE STILL LIMITED IN CARE WE MONITOR OVER TIME IF THEY DEVELOP CHRONIC SYMPTOMS AND CAN ACTUALLY PROVIDE TREATMENT TO THEM BUT IT’S SPECIFICALLY ADDRESSED TO SYMPTOMS WITH BRAIN INJURIES THERE’S A GREAT VARIETY OF TYPES OF SYMPTOMS, SOME INDIVIDUALS MAY GET SLEEP DIFFERENCES, DISTURBANCE OVER TIME, OTHERS WILL GET HEADACHES AND SO WHAT WE’RE DOING WITH BIOMARKERS IS UNDERSTANDING MECHANISTIC PATHWAYS TO UNDERSTAND WHICH TYPES OF SYMPTOMS WE NEED TO LOOK FOR IN THOSE INDIVIDUALS BUT THEY DON’T NEED TO PASS AWAY THERE ARE INTERVENTIONS, ONE IS ON THE HORIZON, TO TREAT THESE EARLY >> AND OUR LAST QUESTION >> SO WHAT ARE THE SIZES OF THE TAU-CONTAINING VESICLES CIRCULATING IN BLOOD, HOW MANY MICROMETERS? >> SO THE VESICLES THAT CIRCULATE IN BLOOD THAT ARE CATEGORIZED AS, EXOSOMES, 30 MILLIMETERS TO A 100, OTHERS CIRCULATING IN BLOOD UP TO A THOUSAND NANOMETERS IN OUR DISTRIBUTION OF SIZE I SHOWED YOU, WE ALWAYS SEE THAT THERE IS A RANGE OF VESICLES AND THE MEDIUM IS A LITTLE OVER A HUNDRED, USUALLY, SO WE THINK THAT THAT’S WHERE OUR SIGNAL IS COMING FROM, BUT FROM HUMAN STUDIES ALONE YOU CAN’T BE EXACTLY SURE THAT THAT’S EXACTLY THE SOURCE OF YOUR SIGNAL >> BUT IN GENERAL MOST OF THE MICRO PARTICLES IN THE BLOOD ARE REMOVED BY THE ENDOTHELIA SYSTEM OF LIVER, SPLEEN, SO MOST OF THE VESICLES UNTIL THERE IS SEQUESTRATION FROM THEM IN THE RES, SO WHAT DOES IT IMPLY? >> WHAT I THINK IS HAPPENING, THE CONTINUOUS TURNOVER AND WHAT YOU END UP SEEING IN BLOOD IS A KIND OF STEADY STATE FROM CONTINUOUS RELEASE BY DIFFERENCE CELLS, CONTINUOUS UPTAKE BY SAME TYPE OF CELLS AND DIFFERENT TYPES OF CELLS LIKE THE SPLEEN AND OTHER SITES THAT YOU MENTIONED SO IT IS A CONSTANT TURNOVER >> BUT THE QUESTION IS STILL IN TERMS OF THE PRODUCTION, IS THERE ANY FOLLOW-UP, DOES THE VESICLE INCREASE RIGHT AFTER THE IMPACT OR IT TAKES QUITE A WHILE FOR INITIATING THIS TYPE OF CIRCULATING VESICLES, IN THE REVERSE — IN PICK TIME FOR VESICLES IN THE VESICLE >> THEY ARE PRODUCED NATURALLY IN FACT WE DID NOT SEE A DIFFERENCE IN THE NUMBER OR SIZE OF VESICLES THAT ARE RELEASED IN PATIENTS WITH TRAUMA OR WITHOUT, AND IN FACT WE DON’T SEE A DIFFERENCE IN SIZE AND NUMBER OF VESICLES RELEASED IN ALZHEIMER’S DISEASE OR NOT ALZHEIMER’S DISEASE, THE CONTENT OF THESE VESICLES MAY BE DIFFERENT IN DIFFERENT CONDITIONS NOW, HOW DO THESE VESICLES FROM THE BRAIN GET TO THE PERIPHERY IS ANOTHER INTERESTING QUESTION THAT YOU’RE HINTING TO AND THERE ARE AREAS OF NORMAL BLOOD-BRAIN BARRIER BREAKDOWN, THAT THEY MAY BE ESCAPING THERE ARE ALSO — I’VE SEEN IN IMAGES A COLLABORATOR HAS PRODUCED, MODELS OF — IN VITRO

MODELS OF BLOOD-BRAIN BARRIER AND YOU CAN SEE VESICLES BEING PRODUCED IN ONE SITE, UPTAKEN BY ENDOTHELIAL CELLS AND RELEASED IN LUMINAL SITE SO RESULTS PROOF-OF-CONCEPT AT LEAST THAT VESICLES CAN CROSS THROUGH THE BLOOD-BRAIN BARRIER >> THANK YOU GOOD LUCK IN COMPLETING THE WORK >> THANK YOU >> A WONDERFUL WAY TO END, ALSO I THINK THE SESSION LIKE EVERY PANEL SESSION TODAY IS A WONDERFUL DEMONSTRATION OF COLLABORATION AMONG MULTIPLE DISCIPLINES AND MULTIPLE INVESTIGATORS, ALL WORKING IN IT’S AREA OF CLINICAL RESEARCH, HOPING TO FIND TREATMENTS AND INTERVENTIONS THAT WILL ACTUALLY IMPROVE PATIENT CARE AND PATIENT OUTCOMES, SO I THINK Y’ALL HAVE BEEN AN EXCELLENT REMINDER OF THE THEME THAT HAS RUN THROUGHOUT THE DAY SO THAT CONCLUDES OUR SYMPOSIUM TODAY PLEASE GIVE A FINAL ROUND OF APPLAUSE FOR ALL OF TODAY’S PANELISTS [APPLAUSE] THANK YOU ALL FOR JOINING US, WHETHER YOU WERE HERE IN PERSON, OR FOLLOWING ALONG ONLINE WE APPRECIATE YOUR PARTICIPATION AND LOOK FORWARD TO SHARING MORE SCIENCE WITH YOU IN THE FUTURE JUST A REMINDER THAT THE POSTER SESSION IS ON THE FAES TERRACE UNTIL 2:30 WE HOPE YOU HAVE AN OPPORTUNITY TO VIEW THE POSTERS ON DISPLAY ALSO FOR ANY OF YOU WHO ARE INTERESTED IN BECOMING AN ASTRONAUT, IN THE NEXT PHASE OF YOUR LIFE, WE WILL HAVE THE MOST RECENT FEMALE ASTRONAUT WILL BE HERE AT 3:00, AND WILL GIVE A PRESENTATION AND BE INTERVIEWED BY DR. COLLINS AS WELL SO WE DO HAVE FURTHER EXCITEMENT TO COME HERE IN THIS ROOM BUT THAT’S ALSO ONE OF THE REASONS WE HAVE TO ACTUALLY LEAVE THE ROOM, RATHER QUICKLY, TODAY SO THAT THEY CAN SET IT UP FOR THE NEXT PRESENTATION THANK YOU VERY MUCH [APPLAUSE]