 Good afternoon everybody. Thank you for coming here and it's so nice to see so many of you here. Before Helen introduced the speakers, I would like to make a few announcements. This event is being sponsored by the Biospecimen Interest Group, and it's supported by the Office of Disease Research, and the Office of Biospecimens and Biorepositories Research at the NCI. If you would like to get involved in this group, please contact us or log on to our website. I would like to mention also that our next presentation will be in January, and we are soliciting names for future speakers, so if you have any suggestions, please let us know. Also, I would like to let you know that we are lucky to be the first one to be using the new state-of-the-art equipment that was installed in this auditorium. Today we have the privilege and the honor to have three outstanding speakers presenting an extraordinary program on the hand-diagnosed disease program, which Helen is going to introduce to you. Alright, thanks. I add my thanks to your coming today, and I just want to take a moment and thank Yaffa for organizing this. I'm only an accessory here. Today she has done all the work to make this happen today. And so we're not going to read lengthy bios this afternoon, but just tell you that the speakers today are first Steve Groff, the Director of the Office of Rare Disease Research at the NIH, John Gallin, Director of the NIH Clinical Center, and William Gall, Clinical Director of the NHGRI and Director for the Undiagnosed Disease Program. So Dr. Groff will start us off. Thank you, Helen and Yaffa, for this opportunity to present the program that has started maybe a little bit over a year ago. But before I begin, I do want to first thank the staff here at the Clinical Center. I think maybe sometimes you don't hear the comments that come in from the people, especially in the rare diseases community, but I really can say without any question that the first question I get when I go and I meet with the patient advocacy groups and their scientific and medical advisors is, how do we get a study started at NIH? How do we get into the NIH system? So I think you can see the esteem that so many people in the rare disease community really hold for you and the programs that you represent and the research that you conduct here at the NIH. And it really is a tremendous testimony to the dedication to all the rare diseases that you have become known for. And we certainly appreciate the efforts of so many of the individuals who have helped with the program as we've initiated here at the Clinical Center. And so I'll just really give you a little bit of the background and then we'll turn it over to the more experienced clinicians and activities that we've been involved with. But I do want to thank the Biospecimens Interest Group that invited us and have participated in developing the whole program. So Yaffa and Helen, thank you again. It's a privilege and honor to express this program to the NIH community because it has been one of a tremendous amount of public interest and I think Bill will tell you the level of interest that we've faced and that they've faced within the program of screening patients and physicians who have patients who would like to come here. Just some background information. First, as far as getting the diagnosis or the diagnostic odyssey that we talk about particularly for the rare diseases where so many times the symptoms do not manifest themselves at one time, they're going to carry over a number of years maybe several decades until we really get the full picture of a disease. But back in 1989 when there was a National Commission on Orphan Disease and then this study was replicated in 2002 by the National Organization for Rare Disorders, we did some patient surveys and you can see there are the numbers that time to diagnosis and it's that greater than five years that had us really concerned as far as taking that long to actually obtain the diagnosis. And I think all of us can understand the frustrations and the anxieties that go with not having a diagnosis not knowing what we have, what are the outcomes that we can even think about. So when you start applying this to a pretty large population you see that there are a good number of people who spend many, many years trying to obtain the diagnosis. We have what we call the genetic and rare disease information center that we cosponsor our office, the Office of Rare Diseases Research with the National Human Genome Research Institute. And after about 10,000 inquiries we went back over a three-year period looking at the inquiries that we received at the information center and approximately 6% of the request for information related to undiagnosed diseases. So you can see that is a very, very large problem that we're looking at it's just we don't hear about it very often. In 2000, the NIH and our office published a report of a special emphasis panel on the coordination of rare diseases research and in that we talked about forming specialized centers of research and diagnosis. Unfortunately, when we were looking at this when we implemented our rare disease clinical research network we didn't focus on the diagnosis, we really focused on research, natural history studies, training of the next generation of physicians and then the active role of patient advocacy groups as well as doing clinical trials of the rare diseases. So we never really got into developing the specialized centers and we thought what we'd like to do is really get a little bit of experience here at the NIH. And so what we're really working towards is a better characterization and establishing diagnostic criteria for the rare diseases. And one of the ways that we do within our office and we try to extend this to all of the institutes and many of the intramural research program and investigators here in the clinical center have taken advantage of the program to put together scientific conferences on specific rare diseases or a group of rare disorders. So if you have an interest and you haven't heard about our scientific conference program please contact the office to send a quick note and we'll start talking to you about a conference and everything that you can do and how it all works. So we're happy to help with this. We've seen in recent years this expansion of newborn screening programs here in the United States and we think that this is going to continue to grow. I believe there are about 29 disorders now that are screened in the States here in the United States and we think that number is going to grow. Our program is also focused on the development of genetic diagnostic tests that should be accompanied by appropriate counseling and information to go back to the patient and families as well as to the practitioner. But we have a pilot project that actually started here in the clinical center with Bill Gaul and other investigators that we try to figure out a way to develop genetic tests and to move them out of the research laboratory into a CLIA-certified laboratory. So we've had a nice program and again we do make resources available. If you're in the gene discovery mode and you think that there is some clinical significance of what we're looking at as far as the diagnosis and other information that should be made available to the patients and the families, we'll help put together a genetic test and develop the information that will accompany that test. So again please just contact the office and we'll work together on that. But what we're dealing with really, with a program such as this, there's a tremendous amount of interest in this program. I think we're developing truly a global approach to rare diseases as more and more nations are coming on board with a focus on rare diseases. For so many years it seemed like the United States was the only country working in the rare disease area. Then in 1999 the European Union passed their legislation and so we've had a tremendous amount of effort. There should be a good number of collaborations with the European Union investigators in individual countries, so it's growing. The program itself, we would like to see it grow into more, and maybe Bill will talk about this or John about expanding into more the intramural research program. Most of the patients are being seen by a small number of investigators, but I think we'd like to see how this could be extended into other protocols and new protocols and the clinics here at the clinical center. At some point if additional resources were ever made available, and that's really money, we'd like to expand this into the extramural research program and use the clinical center here as a hub of activities that we could perhaps extend this out to a lot of the extramural research community. We have a very large clinical and translational science awards program, general clinical research centers that are a very, very fertile ground for introducing a program like this and our rare disease clinical research network is also another area that we think we could extend this and expand the initiative, so it's something we'd like to look at. Again, as I mentioned, there's a tremendous interest in the program throughout the world, and again, when I do go and speak with partners throughout the world, this is probably the number one area of interest how's the undiagnosed diseases program? How's it working? Is it really functioning? Are you seeing patients and what are the results? And so the partnerships are available. I think it's just a matter of us figuring out some way how we can really link up with them. There's been some proposed legislation that would develop a national undiagnosed diseases registry, and that has some complications. That's still in the hopper, but we're not sure where it's going, but it is certainly an area of interest as we continue to watch it to see exactly what they're going to ask us to produce. And throughout all of this, we have seen the increase, and many of you probably have observed the continued involvement of patient advocacy groups as research partners, and two new groups have started up. One is INOD in need of diagnosis, and the other is SWAN, the Symptoms Without a Name. And again, as I mentioned, these are people who've lived for many years without a diagnosis and named to their disease. They know most of them are not really good diseases. They're not doing well, but they've devoted their energy to try to bring an emphasis to obtaining diagnosis for a lot more patients. So with that, I will end, and I'm going to turn it over to Dr. John Gallin, who is the director of the Clinical Center. I'll see if I can get the slides. We may need some help finding John's slides. Okay. Okay. Are you getting it from back there? Here we go. Thank you very much, and John, we'll turn it over to you and then to Bill. Is that you? Okay, thank you very much. It's a pleasure to be here, and I want to thank first the Office of Rare Diseases for sponsoring the whole program of the Undiagnosed Disease Program, and specifically I want to thank the Special Interest Group for hosting this session today. I'm just going to spend a few minutes reminding you what kind of facility we have here and why this makes a special home, and then we'll turn it over to Dr. Gall, who's going to really provide the excitement for today. So what is the vision of the Clinical Center? In case you don't know, it's very simple. As America's research hospital, we will lead the global effort in training today's investigators in discovering tomorrow's cures. Now, we spent a lot of time writing this sentence, believe it or not, and things like America's is a key word, and our hope is that as time evolves, the facility will transform from not only a national hospital for patients, but also an institution that serves investigators both here at the Clinical Center and across the nation more so than it has even in the past, and that particularly relates to the comments Dr. Groff just made. So we opened, you know, in 1953, and since then we've seen more than 350,000 patients, and about half of them have been patients with rare diseases. Our new hospital opened in 2005. Currently we have 234 beds open. There are about 1,850 people who work for the Clinical Center, and I should add that it's about 4,000 people who work for the 17 different institutes that use the Clinical Center. So in these walls there's about 6,000 people working, and my hope is that they all work well together in my senses that they do. Of those people there's about 1,220 credentialed physicians, which is a rather remarkable number for 234 beds. I don't think you'll find that anywhere in the world. The engine that drives this place are the clinical protocols, and there are 1,450 active clinical protocols, and the budget for this year is $362.3 million. So our nurses say there's no other hospital like it. So what makes this place different? Well, as you all know, every patient is enrolled on a protocol. Care is free. Our nurses are very highly educated. Every one of them is a registered nurse. About 15% have a master's degree and about 5% have PhDs. The hospital is embedded in an environment with research labs surrounding it with some of the world's greatest investigators. Our theme is often first in human and clinical trials. We can do long-term high intellectual and economic risk studies. Because we don't write grants, we can respond rapidly to public health emergencies as we have done in the past, for example, in AIDS and in the SARS epidemic. And we have these unique cohorts of patients with rare diseases. So we've had a long tradition of studying rare diseases and patients with unknown diagnosis. So what's new with this undiagnosed disease program? Well, from my perspective, there are two major things that are new. First of all, there's a call for undiagnosed diseases with no phenotype restrictions. So we're inviting anybody who has an unexplained problem to make an inquiry. The second is that really, for the first time, at least since I've been here, a multidisciplinary approach is given to every patient. And this is shown by this list of consultants, which you're not supposed to read, but be impressed by the number. And so although Dr. Groff said there's relatively few people who are involved in this program, I think it's a very large, robust group representing almost all the different components of the NIH. But indeed, it could be bigger, and we hope it gets bigger over time. So what does the clinical center do? Well, we have an office of patient recruitment and public liaison, which Triage's patient calls. And since May of 2008, there's been about 1,700 inquiries, and every patient receives a preliminary screening. All the clinical center departments are primed to be helpful, and I think most of them have been key collaborators, but particularly our general medicine and pediatrics consult services, among others. We have a very large amount of outside inquiries about this program. You've read about it in nature. You've read about it in the New York Times, and you'll be hearing and reading about it more. And the communications staff from both the clinical center and predominantly the Human Genome Institute, as well as the NIH in general, have been very engaged in trying to help the public understand better what we do. The clinical center obviously provides a certain amount of space and supplies and special resources, and it's really the special resources that I think make this such a marvelous facility, and these resources have evolved because of our long tradition of phenotyping patients. So let me just, in one slide, showed you what I think are some highlights. We have a brand new GMP facility that's going to open in a few weeks here on the first floor for making candidate drugs. This is a fabulous resource that can help once the diagnosis is made, and new therapeutic strategies are contemplated when industry is not capable of interest or interested in helping making a candidate drug. We have a phenomenal amount of imaging equipment in this facility working closely with the NMR Center. There are over 27 MRI machines, for example, in this hospital, some of which serve animals, but the NMR Center is a facility to make new machines. A new 7 Tesla machine is about to be unveiled for clinical use, and we have multimodality, minimally invasive procedural suites, rather unique for the country. We have a biomechanics lab and the rehab medicine movement for testing and assessing movement, which late in chance group runs. Our blood bank is phenomenal in terms of helping prepare special kinds of cells for research purposes, both in the lab and in the clinic. We're now priming up to be able to do stem cell therapy when the investigators want to do that. And the phenotyping capability includes the metabolic suite for originally designed to assess obesity, but is available for testing. Wasting syndromes or any syndrome where you want to characterize the metabolic state of the patient with great precision. We also have some IT tools, and one I want to mention, and I'm going to end my comments with, is the Biomedical Translational Research Information System, or BETRAS, which Jim Semino has been building. And what is BETRAS? Well, it's a data and tissue repository, and in view of the interest of this interest group, I wanted to show you in one slide what it does. So from the clinical center, there's input into this system from the laboratory, the pharmacy, the imaging facilities, the CRIS system, the old-miss system, and from all the different institutes, they will be depositing whatever they want to deposit into this system that relates to patients. In the future, the CTSA network we hope will also contribute to this system, and we will be taking all the biospecimens and tissue information that's available at NIH, and I am told there's over 30 million specimens out there in freezers and things all over the place. Our goal is to eventually have all that information linked into this system. And so what we hope in the future is that additional institute research data and images will be added every year. The addition of the stored sample data, which comes from these patients with rare diseases, will allow investigators to search samples along with related clinical research data. So you'll have tissue information, you'll have clinical information, you'll have phenotyping information, genetic information, et cetera, all available in one place, and hopefully this will be a valuable resource to the community. And finally, as we begin to partner with the extramural community, our dream is that this kind of a system will become a national resource containing a vast amount of information that will enable hypothesis generation, hypothesis testing, before even going and doing experiments. So if you're interested in Beatrice and it's just been unveiled and become activated, you can learn more about it at this site. So those are my comments, and now I'd like to introduce Dr. Golf who's going to tell you about what's happening in this clinic. Well, thanks very much. I want to thank the Special Interest Group for the last specimens for their invitation, and John and Steve, especially my institute, but most of all, all of you who have contributed to this program so much. And if there's one message I want to send out to all of you, it's that we have cases up here that have not been fully explored, and if any of you are interested, I would like you to come up to us and tell us your interests, your specialty area, and if you want to pursue any of these disorders, please do because they still remain mysteries and we can use all the help we can get. So, I guess it's this one. Let me do it. All right, I'll use the bottom one. I'm fine. Yeah, that's what I was hitting. So this started with the Office of Rare Disease, getting all sorts of inquiries that really couldn't be answered, and Steve mentioned that already. But in addition, there was a retreat in 2007 in which the directors of the ICs thought of ways in which to sort of enhance or rejuvenate the clinical center. One of those ways was to recreate the fascinoma clinics of the 60s and 70s. You'll probably recall that most of the leadership of the NIH is now in the members of the second half century club, so they remember back to the 60s and 70s when they did this themselves, and I think they remembered that fondly, so they wanted to do that. And so we have the goals of the program to assist patients come to a diagnosis, but also discover new diseases that will reveal something to us about biochemistry, about pathways, about cell biology. And I'd like to show you today about how we're moving towards some of those goals. The way this program works is that we receive medical records and also a summary letter from the physician. Actually, sometimes we don't receive that, and we have to ask for it, but we're supposed to get it. And then we triage the submitted records and send them out to specialists in the area that they cover letter and their records indicate. They get back to us and make a decision about whether to accept or decline the patient and then tell the patients and the physicians. And then for the accepted patients, they come back to us for about a week admission, and we have a delay time now for admissions probably about two to three months for both pediatrics and adults. So this got a lot of press and actually Dr. Zerhouni was part of the announcement almost a year and a half ago now. And you can just sort of read all the people who are interested in this. This struck a chord with people. I think it's because many of them had trouble reaching, let's say, a team that would look at everything comprehensively and sort of universally. Instead, they'd have to go to one specialist, a specialist, and then another specialist, et cetera. So there was a significant amount of press. That's fine. So this is what happened. Basically, we're inundated and couldn't really handle it. And in fact, another way of looking at it is sort of loosey without the candy. So out of desperation, we sought more support and actually received support from the leadership of the NIH and from individual institutes and especially from individual investigators, many of you of whom are in the audience. The number of inquiries we've had since May of 2008 is really 2,300. The number of medical records is clearly over 900. I don't even actually know. We do have a database, however. Most of the patients we've been able to reject and many of them are eminently rejectable. Any of us would reject. Some of them are a little more questionable and I'm sure that occasionally we make some mistakes. But we have accepted about 190 individuals on many on my service and many on other services throughout the NIH to existing protocols. We have about 150 charts that are currently active and under evaluation. And 13 of the patients that we have either seen or were about to see have died before they got here or shortly after they got here. Which really speaks to the severity and criticality of the patients that apply to this as well as the number of patients who don't have that criticality. Most of the cases are actually neurological cases and many of the cases are pediatric cases that are very complicated. We now have expanded our personnel hired by the UDP to these numbers here or so. So we have a really reasonable contingent of individuals. And these are the personnel who are currently with us as paid personnel acquiring more sort of as we speak just working on a couple of other contracts. And the consultants here again a significant list of individuals from all the disciplines of the NIH. We have planning meetings in which we triage some of these charts and update the database and often we have to ask for specific further information in the form of slides or images and we get it. People really do not resist this. They get free medical care here. Of course there may be some other reasons too. And the pediatrics group now is headed by Dr. Cynthia Tift who's in the second row here. She just came on board as the deputy clinical director in NHGRI and she's conducting the pediatric portion of this now. Then we have open meetings once a month which is basically to sort of show off many of the interesting cases that we have with images and slides and a lot of contributing individuals here many of whom spend a considerable amount of time preparing for these meetings and then I sort of conduct the meeting and we learn about new cases that are of interest. So I wanted to tell you about some genetic aspects of this pursuit and then give you some cases. The genetic analysis in addition to using targeted diagnostics that are clear certified and molecular and are send out tests that we pay for, besides that we do some unbiased screening with SNP analysis. And these SNPs are done by Dr. Tom Markello through the NHGRI genomics core which we have access to and there's some significant software that's involved that was really developed in part by Tom and in part was able to be purchased. We're able to determine two things. One is copy number variance. In other words, supposed to have two copies. Do you have only one? Do you have none? In other words, are there deletions or do you have a duplication and have three copies? And runs of homozygosity where heterozygosity is no longer exists in this individual patient. And that can speak towards autosomal recessive disease or genes in the region of that's an inappropriate homozygosity that would be candidates. So the way that this works is a single nucleotide polymorphism is an area within the genome that has a natural variation in many of us. And it isn't a 1% to 99% ratio. It's really a 30, 70, 60, 40, 50, 50 or so. So these are common variants and they're defined by a single nucleotide but surrounded by other bases so that one can determine if the person has, for example, the A or the T in the first case or the C or the G in the second case. And so these SNPs are selected by Illumina in this case across the board and they're selected approximately every 3,000 bases so that one can determine to basically use these as signals or as markers for the absence of a region of sequence. And that absence can be on one allele or on two alleles or it can be a duplication and we can determine that and I'll sort of show you how in this. And so if you have, for example, 10 SNPs in a row that are missing, you know you've got roughly 30 kilobases missing and it may be a portion of a gene that's missing. Things of that sort are what we can do. And it turns out by convention that the less frequent allele is called the B allele and so everybody of us who is diploid is A, A, B, B or A, B. And this is a picture of the distribution of some of these individuals so that would be B, B, A, A and A and B and these are essentially intensity plots of the signal that comes out of a SNP analysis through the genomics core. So here, for example, is a listing of a number of SNPs with their R ratios and an R ratio is the ratio of the A to B, or actually B to A and if the ratio is one, in other words your heterozygous, you're logged to the base two of R is going to be zero. So for example, this means that the person is heterozygous because that reads 0.0084 which is close enough to zero. So the way that one uses this is to determine the intensity and if you have an intensity that's logs below the 0 to 1 or negative 1 to positive 1 range, namely here, if the intensity is that low it means it's deleted and then you can line this up with a human genome database to determine what genes are in that region, what genes could be deleted and what genes to be looked at for the causative gene. And in this case, when you expand the previous slide where there were only a couple of SNPs visible, here you have really all of these SNPs that have very low intensity, indicating a deletion. That deletion is 32 SNPs, 60 kilobases involved and in fact it corresponds to the particular deletion that I study which is cystinosis, a very common 57,257 base pair deletion which accounts for half of the North American and European individuals who have cystinosis. So this is sort of proof of principle that we can pick these things out. The other issue is you can measure heterozygosity versus homozygosity. And this illustrates that. So this now is the B allele frequency plotted on the ordinate and over here are the AAs. Their B allele frequency is zero. Here's the BBs. Their B allele frequency is one and the B allele frequency is 0.5 for heterozygos. So you can see that these are homozygos, these are homozygos SNPs and these are heterozygos SNPs. And this is a centromere for which there are no SNPs. So if you were to expand this on the next slide, you're only going to see the middle line. Only you're going to see the middle line for all sorts of different chromosomes. And here, for example, is a loss of heterozygosity or an absence of heterozygosity. So if you thought that this was an autosomal recessive disorder, you could look in this region, see what genes are there and they could be candidates. Now in general, this type of analysis will give you more candidates than you can possibly use so that really this is a first step towards pursuing a genetic diagnosis. So here's another area that you may have seen. And here's an individual whom we saw very early in the course of this program who gave no history of consanguinity, but if you look at all these spots, does have consanguinity all over the place and has approximately a three to four percent of all this person's genome is homozygous, which could correspond to roughly a second cousin relationship among the parents. Because remember, people who are first cousins share one-eighth of their genes. First cousins once removed one-sixteenth and second cousins one-thirty-second, which would be about three percent or so. So one can discover this type of issue. So let me tell you now about some of the cases that we've seen here. And remember, what I'm going to show you now is really a distillate of a huge number of charts that people have gone through and discarded with cause the majority of them. And so perhaps every decent case that we've seen here represents fifty to a hundred cases that have been looked through and called. We don't know what's going on with this next group of patients. And in fact, we haven't even seen yet. But she's fascinating in a way, because this is a before and this is the way she is now. And she feels that the room is so hot. I'm sorry. I think I can do this like this. The room feels so hot, but only on her face, not on the rest of her body. So she keeps the temperature in the room at fifty-eight degrees and has a fan blowing on her face. And her face is painful. And then nobody knows exactly why she has this autonomic symptomatology, but only in a segmental area. We haven't seen this patient yet. We have seen these kids, and they have short stature, dysarthria, bowel, bladder dysfunction, some dysmorphisms. And again, we've seen these individuals, but we don't know what they have. And so we're interested in having bone experts look into this. Here's a little girl who has cranioectodermal dysplasia. And you can see the dysmorphisms in her face. In fact, she has a sister, and her sister is under psychiatric care, because her sister doesn't understand why people make fun of her sister. Her problem is that she has no roots to her teeth. Her sweat glands are missing. So she has many signs of actodermal dysplasia, but this doesn't really fit any particular of the 150 different types. And in sort of summary here, her main problem is that she has thickening of the skull, and this bony overgrowth is impinging on the optic nerve canal so that she has some papillodema as well. And that may need to be released at some point. Again, we don't know what's going on. Nor do we know what's happening with this girl with microcephaly and seizures and developmental delay. And believe me, there are many, many of these individual cases. Or this five-year-old girl who has liver disease and pancreatitis, and also some neurological delays. But the interesting thing from a metabolic standpoint is that within her liver, she has areas of beginning fibrosis, she has some inflammatory cells here, and she has copper accumulation. But the copper accumulation in her liver is not associated with Wilson disease or any typical pattern of that copper distribution, which is always in zone one. Instead, she has it in zone three, which is the furthest away from the vasculature. And our pathologists have said they've never seen this and neither have other liver pathologists. So this is particularly a different type of copper accumulation. She also has a biliary canaliculus here, and you can see the lumen. This is apparently abnormal. In other words, this should be a virtual space, not a real space that you can see. And this reflects the fact that the columnar cells are swollen and are surrounding that lumen. Again, we don't know what we're doing in this case, nor do we know what we're doing with these individuals who have all these different disorders, including one who has a major accomplishment and probably could increase that number. Now I want to tell you about some interesting cases that we actually have a lead on and that some people are working on. And here's a 21-year-old woman who has lung nodules, which you can see here. You know, these things do not belong there. And she has acides, and her ureter has been kinked, so she had hydronephrosis. All these things are thought to be related to her main defect, which again we don't know about. But on biopsy of the cheek overgrowth, she has this type of a pattern, which is both fibrous and inflammatory. And she has some plasma cells there, eosinophils, and she has some of the hematopoietic derived stem cell markers within that biopsy of her cheek and lung. In her liver it shows essentially the same thing, some fibrosis, but a lot of inflammatory material as well. And Dr. Kleiner has made the diagnosis of angiolymphoid hyperplasia with eosinophilia and a fibronflammatory disease, a descriptive diagnosis. And Dr. Axantinovich has discovered that there's increased IL-8 and IL-1R inner circulation. So these are clues towards the type of inflammatory reaction that might be occurring. And now we have a lot of other tissue by virtue of really a biopsy that Dr. Carter Van Weis did on her in a four-hour operation here at the NIH to collect material to try to find out what types of cytokines are being emitted and what type of therapeutic efforts we may make directed towards those inflammatory molecules. Here's a 46-year-old woman who has in her kidneys thrombotic microangiopathy, but she also has granulomas on her skin and interestingly increased circulating the vasculinothelial growth factor. This is her kidney biopsy, and you can see that there's thickening around the vascular wall and that the mesangium is increased within her glomerulus. She also has blunted podocytes, and this really is reminiscent of preeclampsia, which you know is due to the production by placenta of an inhibitor of VEGF so that there's no longer enough trophism by VEGF of the kidney cells, and therefore the patients get renal disease, hypertension, and the treatment is essentially removal of that antibody by delivery. In other words, get rid of the placenta, get rid of the antibody. So here's a woman who shows some findings of preeclampsia, but due to a different cause besides the placenta. In other words, it's probably a genetic defect either in the VEGF itself or possibly in a VEGF receptor. So that's currently under investigation along with a collaborator at Beth Israel. And this is the woman who was in the New York Times article who has some of the similar findings. She also has a thrombotic microangiopathy in her kidney. She also has problems with her venous lakes within her skull, and she lost her right eye because of retinal vascular problems, and you can see she has really systemic disease. She has actually died by stopping therapy because her therapy was so significant. She was losing a lot of blood through her gut and decided not to continue with the transfusions, and three days later she died. But she sent us her body, and we have performed an autopsy on it and have that tissue to study now. This is a 39-year-old man who had slowly progressive neurological problems, and you can see that there's some diffuse leukoencephalopathy which progressed at this time relatively slowly, but since then, I'll just show you a couple of areas where there's some abnormalities here, but since then you can see the extent of brain volume loss that this person has had over the last three years or so. And we brought him in on two occasions and probably bring him in again under Dr. Toro's service, and essentially excluded the diagnosis of leukoencephalopathy and made the diagnosis of progressive multiple, primary progressive multiple sclerosis based upon a number of oligoclonal bands, increased protein, increased IgG within the CSF. But Camillo also measured the BV antibody titers and found them to be elevated, and also the PCR was increased. So this wasn't just the presence of antibiotics, also the presence of the virus itself, and now Drs. Bilikova of NINDS and Jacobson of NINDS and Dr. Cohen, Jeffrey Cohen and Toro are investigating this EBV infection as a possible cause of primary progressive multiple sclerosis, which is essentially hypothesized within the literature, and this may be an index or a sentinel case that might be able to demonstrate that. Now, I just want to tell you about two success stories and then I'll sort of be finished. One is a 52-year-old woman who, without taking steroids and without essentially working out, well, she might have worked out a little bit, but she didn't work out like this, and it did not have any of the standard endocrinological abnormalities that might cause this. It had the development of increased musculature to an incredible extent, and this was becoming painful for her. She had strains in her muscles. Of course, she didn't like her appearance either, but in addition, she had real pain and it was becoming problematic. You can see on the CT scan here how big her perispinal muscles are. Now, some of us in the audience, perhaps half of us, might not mind this real much, but this is not a good thing to have, and these are her rib muscles, so she has incredible increase in the size of her muscles, and when we did CTs of her head, even the muscles that are essentially not used very often that we can't hypertrophy were hypertrophied. For example, the rectus muscles of her eye were huge, like three, four times as big as our neuroradiologists had ever seen. So, she has this for some reason. The EMG was myopathic, but a muscle biopsy was read as normal. We brought the patient in because this was fascinating. The referring physician from Duke said, in my 38 years, I've never seen... Okay. So, it turns out that we did a second biopsy. Even though the last biopsy was done only a year ago, and Dr. Kwan had it sent to AFIP and our pathologists here, and together made the diagnosis of amyloid myopathy. In other words, the amyloid was seen in the thickened walls of the vessels and stained on Congo red, and protein aggregates were there on EM. This led us to consider, I'm sorry, the possibility of amyloidosis, and in fact, one of the most common causes of that would be multiple myeloma. So, we looked for plasma cells in a bone marrow that we did here, as well, and found 10% plasma cells, which is sufficient to make the diagnosis and hadn't been seen before. And the follow-up is that Dr. Minoli referred her to the Mayo Clinic. Now, she was becoming short of breath and fatigued. She had involvement, a little bit of controversy, but it was considered she had involvement of her atria. And if she would get involvement of her ventricles, that's considered to be very bad and could easily lead to death within months. But at the Mayo Clinic, she underwent a stem cell transplant, had some post-transplant complications, but then recovered, is feeling very well now and is no longer having all of the muscle pain. And I'm told feels better day by day. We do expect a full recovery. And in the very, very rare cases in the literature, the muscle mass is said to go down to normal. So we feel very good that we've caught this. And I just would draw one sort of lesson from this, and that is that this is a woman who on two occasions requested to be seen at the Mayo Clinic and was turned down by the specialty clinics there. And frankly, probably would have been turned down by a specialty clinic here as well. So her access to medical care for this particular disorder was because a broad net was cast for people like her. And the irony of it is that when she finally was diagnosed, she was welcomed with open arms by Mayo Clinic. Oops. So then the last case is this Sib ship that we saw with calcification of the large vessels and also the joints. So can anybody tell if there's an abnormality here? So this is, of course, the bone and the kneecap. But this vessel here is without contrast. So this is a plane film showing the outline of her vessels. And here it is on a pelvic film. You can see all that. This hurts the patients because there's poor circulation and they can't, if they walk for a block, they have to stop and it hurts them a lot. And here you see it as well. Also all the way down to the foot. And then in the hands, there's calcification in the joints here, right here, here, here. It's all over. I didn't want to put arrows all over the place. So this is the pedigree. It turns out there are five children, they're adults. They're in their 50s and they have this all. And Dr. Bohm's lab with Cynthia St. Hilaire worked on this and got fibroblasts from a biopsy we did. And this shows the control and this shows the affected woman. And this is the acquisition of calcium over the course of three weeks. And in the control, there is none. After three weeks, this is all the stain for calcium micro crystals by an assay that they performed. And this is critically important to point out to us that the problem was not with circulating calcium or phosphate abnormalities, but really it was intrinsic to the cells. So that was the first step. At the same time, Dr. Markella was doing a SNP analysis and found a region of homozygosity here that was shared by all five affected individuals, but not by the parents. So this spoke to a recessive disorder and spoke to this region here, which could be affected. That region involved 22 megabases in which there are almost 8,000 SNPs. So this is a large region. And again, that's the issue here. This is a large region. There are 22 genes. None sort of were pointed out. None struck themselves to us as real helpful. But on the other hand, we had Dr. Saint-Hilaire and Dr. Bohm involved, so they suggested one. And they have now identified the gene in concert with us. And this is going to be, I think, important for learning things about the mechanism of calcification of vessels in general. And all this required a collection of specimens, all sorts of different specimens, which we continue to do. So it really is an important issue for us in our handling and distribution of specimens. So the good parts of this are that virtually every patient is pleased with the attention and the hope that we provide to them. And occasionally we solve a case. And you can see some of the cases could be new diseases. I think I've noticed that around the bedside, around the tables of discussion, this has brought specialists closer together over cases. It sort of reminds me of when I was a resident as opposed to a bench researcher. It bolsters our protocols, we think. And there may be new protocols that come from this. Not so good is the fact that our triage of necessity is a difficult process for us. And the patients who are rejected are not really happy. In fact, some of the patients who are rejected send me notes. I get a lot of notes. One of the notes says you are a jerk. And I think that that's something, maybe a topic of future discussion, maybe a whole conference could be held on that. But I would say that nobody has ever stood up and said you lie. So this is your chance. If everyone would like to stand up. Anybody? Okay. So we'll let that go. One of the other problems is that we have gotten congressional inquiries. And most of the congressional inquiries are from patients, from representatives or senators, whose constituents have not applied to the program. So they decided that they were going to go to their senator or representative first before actually applying. Of course, this makes the response very easy. But it's really not the appropriate thing to do. Okay. So we're a little bit late sometimes with getting back to patients. And part of that is because we're overwhelmed. And part of it is because our consultants don't get back to us in a timely fashion. And as I said, the patients we see are a distillate. And again, many of the patients really don't have the objective findings that correspond to their complaints. In the future, we need to expand our basic research investigations into some of these distilled cases. Because they're really good cases. And we worked hard on phenotyping them. We'd like to use this program as a model for how we use genetics in the future for investigating rare diseases. And we'd like to post the cases to this community here and ask you for your input. So if any of you have expertise in the disorders that may be related to the ones we have up here, please let us know. Because we're reasonably anxious to offload some of these cases. We'd like to consult international experts via the web and create UDP clinics throughout the United States, if possible. That is to say, if there's support on the behalf of the extramural people or the leadership here. So we found that in order to fulfill the mission of the UDP, we have to admit patients to our service and then consult other services. And that's one of the wonderful things about the NIH is that people are generous about their consultatory services. Again, many of the patients would not come here if they had to come to a particular specialty. And this is a program that really doesn't fit into the natural paradigm of professional advancement. In other words, a young investigator, I would not recommend getting involved as the major part of his or her pursuit in this program because it's so high risk. But the benefits can be enormous as well if you strike gold. Triage is difficult, failure is common, and patients are desperate. And I'll just give you the final example of how desperate patients are. Here's a 46-year-old man who began to have neurological disease, both cerebellar and cerebral. And this is what he writes. And this is the letter that his daughter sent to us over this. And I'm not going to read this and let you read this. I guess it's obvious that a program like ours can't be influenced by anything of this sort, but we will be seeing this patient in a week or so. So I think Hemingway said it best about the patients that we see and the difficulties in life. The world breaks everyone and afterwards some are stronger in the broken places. And I think that Throw also said the massive men live lives of quiet desperation. And this is a program that lets us see really the juxtaposition of science and sadness in the world and lets us as investigators see the human condition in the person of all the patients who apply and whom we see for a week here at the clinical center. Thank you for your attention. So I suppose I know, I think people should leave. But if anyone wants to ask any questions, I will stay here and answer them for the stragglers.