 So, we had a very good group that went around the world in 80 days, I'm sorry, 80 minutes. We had folks from eight different countries, very diverse expertise, everything from informatics and metabolomics all the way through to clinical application. One of the things that came out of the discussion was, first of all, that there's a lot of different priorities for pharmacogenomics depending on where you sit in the continuum. And so, there were some themes that did arise. One of them is around the area of medications, including cheap medications that really are associated with either treatment failure or extreme adverse drug reactions. And so, we were able to hear from the, for example, Parthamajambara in India talking about how cheap and cheerful metformin is useful in some and useless in many in terms of the treatment of diabetes, but yet we don't have a clue why or at least not as many clues. I think Alan Sholder knows the answer, but the rest of us are still learning. And so, there's work to be done in there. The folks in Thailand talked about how they focused in on adverse reactions, acutaneous adverse reactions. It wasn't because either of them were dermatologists or intensivists in terms of the burn unit where these patients often end up, but rather, there was a pharmacovigilance being performed identifying that these cutaneous reactions were a major cause of morbidity and mortality in their country. And they used this evidence-based approach to go after the mechanistic causes of these and then implement those mechanistic markers in the public health setting. And so, there were some very nice lessons learned from the systematic approach that they took. So, we put together a couple of items. We just tried to put it all on one slide partly because I was doing the typing and I did it in the five minutes before everything started, or actually the five minutes after everything started. One is we wanted to really endorse the desire for quality of an evidence-based for pharmacogenomics implementation. And we knew that the evidence-based group was going to say stuff along that line, but the people talk about pharmacogenomics as being the low-hanging fruit. And there are times when low-hanging fruit is not only easy to access, but is sweet and nutritious. And other times when it's easy to access and it's extremely sour and even poisonous. And so, we need to have quality evidence to go after this low-hanging fruit cliche that we always use to make sure that there is time and ability to get to the high-hanging fruit or whatever the opposite of low-hanging is. And so, if we do it wrong with pharmacogenomics and some of these other supposedly ready areas, we will not have a chance to do it with the rest. And so, I don't want to belabor that point. The emphasis on cheap drugs that have treatment failure extreme, adverse drug reactions also includes vaccine failure. And vaccines are not incredibly expensive but have tremendous public health impact. And there are examples where the vaccines are very, very useful. And others where there's a high degree of treatment of prevention failure. And so, that point was brought out. And, you know, the diversity really was reflected in those points because we talked about cholera, we talked about cancer and everything in between. So, there's a lot of different areas where this could go. The next point I want to make was making sure that there is a drug or a pharmacogenomic component in the different federal, in the U.S. NIH efforts for stem cell research or IPS cells in particular. And the reason this was brought up is that there was a lack of basic science in pharmacogenomics, truly basic science in pharmacogenomics to drive a lot of the decisions that are being made. And, you know, there's laboratory science going on but a lot of it is not fundamental mechanistic basic science. And the point was brought up that in the neurology area there is now going to be a more systematic initiative around generating IPS cells. Cardiology has done the same. So, can we make sure that the drug aspects are baked into the thought process from the start so that they can be useful as these collections are built and drive some of these? So, for example, is it the same genes that mediate drug-induced nerve toxicity to versus drug-induced, some Excel, I'm blanking on the word, clonocyte toxicity after the same chemotherapy agent? I mean, many drugs have mucositis and prolnoropathy as toxicity. We just assume it must be all the price of doing business. There's probably some things that could be learned but we just don't have the tools. The second to the last thing I want to mention is that there's a need for global efforts around the development of value proposition for next generation sequencing in cancer. This is something that's happening in many parts of the world. It was the key point brought up by our colleagues from Korea when asked to see what their priorities are as well as our colleagues at the NCI and other parts of the US. It's something that people are doing. But often what's happening is when people talk again about cancer as being the other, you know, pharmacogenomics in general, cancer in particular are the answer. That's where it is. Well, if you see how next generation sequencing is being applied in the clinical setting currently, it's patients that are treated with first line therapy from randomized trials, second line therapy using data generated from randomized trials, and then, oh, crap, we don't want to do, and I really like this lady, let's sequence her tumor and hope that we can find some concoction to put together to treat it. Now, I'm exaggerating a little bit, but not a lot, because it's the modern version of best guess. Because we're using next generation sequencing, therefore it must be true. Now, the reason why this is a big deal is not only because of the potential harm and benefit to the patients, but it's an expensive test, relatively speaking, that generates the use of a very expensive set of drugs. So one example that was brought forward was the finding of an ALC amplification in gastrointestinal cancer, where the $5,000 test led to an $80,000 drug, neither of which would have been normally used in that clinical setting. And so there are some work. And the problem is global, so could there be a global initiative to try to tackle this? Also, the sample size needed to tackle this is going to be large. And so there could be some efforts there. And then the last thing I want to mention from our group as an output priority item. And you'll notice that these are relatively vague, except when you get down to the last two. But the last one was really riffing on what the folks from East Asia had developed. In terms of the strong data that the Thai colleagues had presented, plus the confirmation from Singapore, from Korea, we know what the Taiwanese have done from their papers. And that is that in many parts of the world, all of the cases, or nearly all of the cases, of Stevens-Johnson syndrome and the related syndrome 10 can be predicted preemptively by genetics. Some of the rest of the world can be predicted as well, based on the data from Liverpool and others from what we saw in New England Journal about a year ago. So prediction of drug-induced or carbamazepine in particular-induced Stevens-Johnson syndrome is there. And so Alan claimed the term global eradication of Stevens-Johnson syndrome, which is obviously a very emotive way of saying, can we just force this issue? When he said that term, there was this natural reflex of getting behind it and trying to do something. And the concept of pharmacogenomics globally eradicating anything is kind of cool. And so it certainly was an interesting idea to think about, can we use this in that sort of way? And so I took an hour and a half or hour or 45 minutes to get concentrated into one slide and a few minutes of talking. But I want to thank my group and ask them if anybody in the group wants to add anything before Mark? All right, over to you. I just think, imagine the headline from this meeting. International Group Convened by NHGRI agrees to eradicate Stevens-Johnson syndrome. I think that's awesome. I think it's a spectacular idea. The reason that I really like this is because it's one of the few instances where we don't have to deal with all the other messy stuff like efficacy and the balance between adverse events. And it's a very pure prevention phenotype. I think that's a really spectacularly great idea. One of my first graduate students was named Steven Johnson and he hates any idea to do with this. But I think the rest of the world, the rest of the world will love this. Other questions, comments, additions? Let me just ask, sort of so I also agree with your global eradication notion as being really compelling. But would there be something that you would... I like the also idea of the whole Pharmacogenomics card, which may not eradicate anything, but it may provide some opportunities. And I'm just wondering if you had a chance to think about other ways that that kind of concept could also be deployed. Yeah, thank you for bringing it. I meant to mention that as part of it. So one thing I would suggest to any of you that are organizing workout groups in the future is get Heidi to be one of the co-leaders because then she helps you get everything organized ahead of time, including this two-page handout that we had. And then she got seconded to lead another group, as you just heard, and another group. So basically, I showed up, I had a two-page handout already and everything like that. All thanks to Heidi. So that's one point. One of the things that Heidi and I put together was on the second page here was a list of all our favorite pharmacogenomics examples, germline examples, somatic examples, infectious examples, whether they had a CPIC guidelines or whether the FDA label had been changed, all that kind of stuff. And we brought up the idea, should we spam this group with a survey monkey or one of those things to say which of these are being used in your country, rarely, commonly, that sort of thing? There wasn't a high degree of enthusiasm about that around the table. There's a few of us that were excited about it, but not universal excitement about it. So it didn't make the list. But the idea was to take that data, to use it to help, for example, drive which CPIC guidelines get prioritized because they're of global importance, but also to use that as a way of building up some content that could allow each country to make their own version of the Thailand top 10 pharmacogenetic things for your patient card, hopefully with a little more clever name than that. Because certainly what was put together by the group in Thailand was fantastic, but would not necessarily resonate in my practice. And there'd be another set that would be more. So that definitely was on the radar. And actually the folks in Thailand I talked as we were leaving the room that there was enough interest, the minority interest, that we'll wait until people are less tired and then ping them again and see if we can do that. Because I think it would be an easy output that could really help some people. Very descriptive, but still easy. Can I ask for priorities? Well, I think we, okay. We think, is there any doubt that the eradication of Stephen Johnson syndrome is the highest priority? Well, I think it's certainly a very high priority and certainly achievable in some parts of the world. There were some folks in the room, I don't think anybody was against it. There were some folks that because of their own practice area or interest had some other, I wouldn't necessarily resonate. I think another one that came up and was around the vaccine example, I don't know how one eradicates vaccine failure. It's certainly a bigger issue, but there are concepts there. And basically vaccine pharmacogenomics has been pretty neglected. I mean, Parth has a few things, a few others, you've done some stuff, but not much. Well, we're trying to also be as focused as we can on clinical implementation of things that look like they're validated versus discovering new things. Not that that's not important. Right. I was just gonna make one quick point on the global eradication. The fact that... There are microphones there. Oh, this doesn't work, okay. Oh, okay. I was trying to see if everyone... This one works? Okay. And that is that in the other parts of the world where we don't quite have a handle on all the variants, that this same project can have a discovery aim to it and that it's very rare, but across the globe, we can amass enough subjects to actually figure it out. And for example, George Petrinus has left for the airport, but I know he worked with Michael Lee, who's now at Reakin, from Taipei, to develop a kind of Eastern Europe version of collecting Stephen Johnson tins. And so there's a little things out there that could be used independent to the European Union-funded efforts that are also there. I want to also mention that our colleague Guthrie from Malta has not only been following this by... He wasn't able to travel because of some commitments over in Malta, but has been following this and got on by Skype. So we actually had members on via Skype in terms of our breakout group. So I wanted to thank him for that since he's been an invisible part of the meeting. The one other thing I just want to add about the Stephen Johnson thing is it would give us a chance to test out on a very delimited environment, defining nomenclature standards for reporting and sharing data because there are in fact some defined codes. And so it would allow us to dip a tone to the water to some of these other thorny problems that when we think about in the big picture are difficult to approach, but this may give us some ideas of can we in fact work together to come up with solutions for each of the different pieces that would be necessary to implement a program of that type. Marie did mention that doing a quick Google search of Stephen's Johnson syndrome for images, for a talk he was going to give, brought up not only some very emotive images of blistering and children that needed a lot of help, but also lawyers that were willing to sue that you're a prescriber on behalf of their firm. And so whether that's a good or a bad thing was part of the discussion. Fodd looks like. How strong is the evidence that you can predict? Yeah, so Fodd's question was the strength of the evidence around that. So for that particular example, there has been prospective study. There was a set of papers in New England Journal, I believe it was last year, maybe the year before. No, I don't care about what impact factor. Yeah, there is prospective evidence say that you will, it's in Taipei, they eliminated the problem. According to the data from Thailand, it'll account for about 90% of the cases. I mean, it's something that, It's strong. Yeah, certainly it's not as good as the polio vaccine, but better than the flu vaccine. I do agree with all the problems with Steven Johnson. I don't think it should be the headline or the one liner about this meeting, because then it would look like if we're desperately looking for something in favor of a clinical utility of pharmacogenomics. And that would be weird. I don't think this should be the one liner. We've all too often we've told the public that we can do anything in genomics and we shouldn't fail this time. We've failed with gene therapy 15 years ago, we shouldn't fail again. And this looks like we're desperately looking for something where we can help and this is not true. I think we're deluding ourselves to think there will be a headline from the meeting in terms of outside people outside this room, but I get your point. Earlier in the day, isn't that right? I think he's been burned. I think we shouldn't underestimate the power of the public. Angelina Jolie has done more to breast cancer prevention than any other program. We've seen doubling of our number of requests. And then the primary care physicians don't know how to answer the question of the patients that come in because they know about Angelina Jolie. So that's an answer to Bruce's thing that yes, we need a tree of them. So don't underestimate the public. Last breakout report will be from Laura Rodriguez.