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NIH Clinical Center

Meeting with Congressman Flores

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Representative Flores Visit
I enjoyed spending time with Congressman Bill Flores of Texas (left) during his tour of NIH on September 17, 2019. Here, we talk in the lobby of the NIH Clinical Center with Jim Gilman (right), chief executive officer of the NIH Clinical Center. Credit: NIH.

In Memory of Andrew Lee

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Andrew Lee Composite
Caption: Clockwise from left, Andrew Lee with his Nissan GT-R; Andrew Lee and me; Isaac Barchus with his parents, Steve and Kathe Barchus, and Andrew’s father Bruce Lee. Credits: Driven to Cure, Foundation for the NIH, The Children’s Inn at NIH

A lot of young people are driven—driven to get a good education, land a great job, find true love, or see the world. But, today, I want to honor the life of a young man who was driven by something even bigger. Andrew Lee was driven to cure kidney cancer—not only for himself, but for others as well.

I knew and loved Andrew. And so did the legion of doctors, nurses, researchers, and other team members who had the privilege of fighting cancer with him over four very challenging years. Andrew was 19, just finishing his freshman year of college, when he received a devastating diagnosis: stage 4 kidney cancer, a rare type called Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC). There is no known cure for HLRCC, and doctors estimated his survival at about a year at best.

Still, Andrew and his family weren’t about to go hide somewhere and wait for the end. They began a journey that led him to take part in at least seven clinical trials, including ones at Yale University, New Haven, CT; Georgetown University, Washington, DC; and the NIH Clinical Center, Bethesda, MD. Experimental treatments slowed down the cancer, but sometimes made him terribly sick. Yet, Andrew always remained optimistic and cheerful. If a trial didn’t help him, maybe it would help someone else.

Andrew’s generosity didn’t stop there. Inspired by his father’s gift of a totally awesome 2015 Liberty Walk Nissan GT-R, he founded the Driven To Cure (DTC) nonprofit and traveled the country in his orange sports car to raise funds for kidney cancer research. According to the National Cancer Institute, nearly 63,000 Americans are diagnosed with kidney and renal pelvis cancers each year.

Andrew figured out how to put the “fun” in fundraising, drawing crowds at car shows and raising more than $500,000 in donations in just three years. His efforts were recognized by the Foundation for the NIH’s Charlie Sanders Award, which I had the privilege of presenting to him last fall.

But I think it was Andrew’s humanity that touched us the most. He always had time to share his story, to encourage another child or adult struggling with a frightening diagnosis. He’d give thrills to kids at The Children’s Inn at NIH when he rumbled into the parking lot with his 700 horsepower GT-R. At car shows, throngs of people were drawn in by the turbocharged ride and then captivated by the young man with the bright smile and compelling story. Andrew wrote: “I realized that the vehicle of my dreams was also the vehicle which gave me the opportunity to make a difference; to do something bigger than myself.”

Still, on the personal level, kidney cancer proved relentless. Options for treatment eventually ran out. As the disease progressed, Andrew and his family had to make another difficult transition—choosing to celebrate life, even in the face of its approaching end. He needed a wheelchair, so family and friends came up with one, keeping in mind one of Andrew’s last wishes. When Andrew needed 24-hour care and pain control, he was admitted to the NIH Clinical Center Hospice Unit, where comfort could be provided and his loved ones could gather around. That even included getting government permission for a visit from his dog Milo! Surrounded by friends and family, he died peacefully on April 21.

Andrew made friends with everyone—especially kids at The Children’s Inn. One special buddy was Isaac Barchus, who has a rare autoinflammatory disease called CANDLE Syndrome. When he was back home in Omaha, NE, Isaac enjoyed challenging Andrew to long-distance video games, especially FIFA Soccer.

Although Isaac can walk, it can be very painful, so he sometimes turned to an old, beat-up wheelchair to cover long distances. But not anymore. When Isaac turned 15 on June 7, Andrew’s father Bruce Lee fulfilled his son’s wish for the future of his wheelchair. He presented Isaac with Andrew’s wheelchair, which had now been painted the same orange color as Andrew’s GT-R and emblazoned with the feisty slogan on Andrew’s personalized license plate—F CANCR. What a cool birthday gift!

During his final weeks and days, Andrew and his dad often listened to the Andy Grammer song, “Don’t Give Up on Me.” Andrew’s family never gave up on him, and he never gave up on them either. In fact, Andrew never gave up caring, loving, and believing. He wouldn’t want us to either, as his favorite song reminds us: “I will fight, I will fight for you; I always do until my heart is black and blue.”

Yes, Andrew, our hearts are black and blue from losing you. But we won’t give up on all you stood for in your short but inspiring life. Race In Peace, dear Andrew.

Links:

Remembering Andrew Lee (Foundation for the National Institutes of Health)

NIH Cancer Patient Receives Humanitarian Award (The NIH Record)

The Children’s Inn at NIH

Driven To Cure (Silver Spring, MD)

Video: Fighting Cancer With a 700-hp Nissan GT-R (The Drive)

Video: Andy Grammer—”Don’t Give Up On Me” [Official Lyric Video] from the film Five Feet Apart

Hereditary Leiomyomatosis and Renal Cell Cancer (National Library of Medicine/NIH)

Kidney (Renal Cell) Cancer (National Cancer Institute/NIH)

CANDLE Syndrome (Genetic and Rare Diseases Information Center/NIH)

Treating CANDLE Syndrome (National Institute of Allergy and Infectious Diseases/NIH)


Ultra-Processed Diet Leads to Extra Calories, Weight Gain

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Dietary Weight Gain and Loss
Credit: Hall et al., Cell Metabolism, 2019

If you’ve ever tried to lose a few pounds or just stay at a healthy weight, you’ve likely encountered a dizzying array of diets, each with passionate proponents: low carb, low fat, keto, paleo, vegan, Mediterranean, and so on. Yet most nutrition experts agree on one thing: it’s best to steer clear of ultra-processed foods. Now, there’s some solid scientific evidence to back up that advice.

In the first randomized, controlled study to compare the effects of ultra-processed with unprocessed foods, NIH researchers found healthy adults gained about a pound per week when they were given a daily diet high in ultra-processed foods, which often contain ingredients such as hydrogenated fats, high fructose corn syrup, flavoring agents, emulsifiers, and preservatives. In contrast, when those same people ate unprocessed whole foods, they lost weight.

Intriguingly, the weight differences on the two diets occurred even though both kinds of foods had been carefully matched from a nutritional standpoint, including calorie density, fiber, fat, sugar, and salt. For example, breakfast for the ultra-processed group might consist of a bagel with cream cheese and turkey bacon, while the unprocessed group might be offered oatmeal with bananas, walnuts, and skim milk.

The explanation for the differences appears to lie in the fact that study participants were free to eat as little or as much food as they wished at mealtimes and to snack between meals. It turns out that when folks were on the ultra-processed diet they ate significantly more—about 500 extra calories per day on average—than when they were on the unprocessed diet. And, as you probably know, more calories without more exercise usually leads to more weight!

This might not seem new to you. After all, it has been tempting for some time to suggest a connection between the rise of packaged, ultra-processed foods and America’s growing waistlines. But as plausible as it might seem that such foods may encourage overeating, perhaps because of their high salt, sugar, and fat content, correlation is not causation and controlled studies of what people actually eat are tough to do. As a result, definitive evidence directly tying ultra-processed foods to weight gain has been lacking.

To explore the possible connection in the study now reported in Cell Metabolism, researchers at NIH’s National Institute of Diabetes and Digestive and Kidney Diseases took advantage of the Metabolic Clinical Research Unit at the NIH Clinical Center, Bethesda, MD. The unit is specially equipped to study issues involving diet and metabolism.

The researchers asked 20 healthy men and women of stable weight to stay at the center for 28 days. Each volunteer was randomly assigned to eat either an ultra-processed or unprocessed diet for two consecutive weeks. At that point, they switched to the other diet for another two weeks.

Both diets consisted of three daily meals, and volunteers were given permission to eat as much food as they liked. Importantly, a team of dieticians had carefully designed the ultra-processed and unprocessed meals such that they were well matched for total calories, calorie density, macronutrients, fiber, sugars, and salt.

At lunch, for example, one of the study’s processed meals consisted of quesadillas, refried beans, and diet lemonade. An unprocessed lunch consisted of a spinach salad with chicken breast, apple slices, bulgur, and sunflower seeds with a side of grapes.

The main difference between each diet was the proportion of calories derived from ultra-processed versus unprocessed foods as defined by the NOVA diet classification system. This system categorizes food based on the nature, extent, and purpose of food processing, rather than its nutrient content.

Each week, researchers measured the energy expenditure, weight, and changes in body composition of all volunteers. After two weeks on the ultra-processed diet, volunteers gained about two pounds on average. That’s compared to a loss of about two pounds for those on the unprocessed diet.

Metabolic testing showed that people expended more energy on the ultra-processed diet. However, that wasn’t enough to offset the increased consumption of calories. As a result, participants gained pounds and body fat. The study does have some limitations, such as slight differences in the protein content of the two diets. and the researchers plan to address such issues in their future work.

During this relatively brief study, the researchers did not observe other telltale changes associated with poor metabolic health, such as a rise in blood glucose levels or fat in the liver. While a couple of pounds might not sound like much, the extra calories and weight associated with an ultra-processed diet would, over time, add up.

So, it appears that a good place to start in reaching or maintaining a healthy weight is to follow the advice shared by all those otherwise conflicting diet plans: work to eliminate or at least reduce ultra-processed foods in your diet in favor of a balanced variety of unprocessed, nutrient-packed foods.

Reference:

[1] Ultra-processed diets cause excess calorie intake and weight gain: An inpatient randomized controlled trial of ad libitum food intake. Hall KD et al. Cell Metab. 2019 May 16.

Links:

Obesity (National Institute of Diabetes and Digestive and Kidney Diseases/NIH)

Healthy Eating Plan (National Heart, Lung, and Blood Institute/NIH)

Body Weight Planner (NIDDK/NIH)

Kevin D. Hall (NIDDK/NIH)

Metabolic Clinical Research Unit (NIDDK/NIH)

NIH Support: National Institute of Diabetes and Digestive and Kidney Diseases


A CRISPR Approach to Treating Sickle Cell

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Unedited and edited sickle cells
Caption: Red blood cells from patient with sickle cell disease. The cells were differentiated from bone marrow with unedited and edited hematopoietic stem cells, and the red arrows show the sickled cells. Credit: Wu et al. Nature Medicine. March 25, 2019

Recently, CBS’s “60 Minutes” highlighted the story of Jennelle Stephenson, a brave young woman with sickle cell disease (SCD). Jennelle now appears potentially cured of this devastating condition, thanks to an experimental gene therapy being tested at the NIH Clinical Center in Bethesda, MD. As groundbreaking as this research may be, it’s among a variety of innovative strategies now being tried to cure SCD and other genetic diseases that have long seemed out of reach.

One particularly exciting approach involves using gene editing to increase levels of fetal hemoglobin (HbF) in the red blood cells of people with SCD. Shortly after birth, babies usually stop producing HbF, and switch over to the adult form of hemoglobin. But rare individuals continue to make high levels of HbF throughout their lives. This is referred to as hereditary persistence of fetal hemoglobin (HPFH). (My own postdoctoral research in the early 1980s discovered some of the naturally occurring DNA mutations that lead to this condition.)

Individuals with HPFH are entirely healthy. Strikingly, rare individuals with SCD who also have HPFH have an extremely mild version of sickle cell disease—essentially the presence of significant quantities of HbF provides protection against sickling. So, researchers have been exploring ways to boost HbF in everyone with SCD—and gene editing may provide an effective, long-lasting way to do this.

Clinical trials of this approach are already underway. And new findings reported in Nature Medicine show it may be possible to make the desired edits even more efficiently, raising the possibility that a single infusion of gene-edited cells might be able to cure SCD [1].

Sickle cell disease is caused by a specific point mutation in a gene that codes for the beta chain of hemoglobin. People with just one copy of this mutation have sickle cell trait and are generally healthy. But those who inherit two mutant copies of this gene suffer lifelong consequences of the presence of this abnormal protein. Their red blood cells—normally flexible and donut-shaped—assume the sickled shape that gives SCD its name. The sickled cells clump together and stick in small blood vessels, resulting in severe pain, anemia, stroke, pulmonary hypertension, organ failure, and far too often, early death.

Eleven years ago, a team led by Vijay Sankaran and Stuart Orkin at Boston Children’s Hospital and the Dana-Farber Cancer Institute discovered that a protein called BCL11A seemed to determine HbF levels [2]. Subsequent work showed the protein actually works as a master mediator of the switch from fetal to adult hemoglobin, which normally occurs shortly after birth.

Five years ago, Orkin and Daniel Bauer identified a specific enhancer of BCL11A expression that could be an attractive target for gene editing [3]. They could knock out the enhancer in the bone marrow, and BCL11A would not be produced, allowing HbF to stay switched on.

Because the BCL11A protein is required to turn off production of HbF in red cells. the researchers had another idea. They thought it might be possible to keep HbF on permanently by disrupting BCL11A in blood-forming hematopoietic stem cells (HSCs). The hope was that such a treatment might offer people with SCD a permanent supply of healthy red blood cells.

Fast-forward to the present, and researchers are now testing the ability of gene editing tools to cure the disease. A favorite editing system is CRISPR, which I’ve highlighted on my blog.

CRISPR is a highly precise gene-editing tool that relies on guide RNA molecules to direct a scissor-like Cas9 enzyme to just the right spot in the genome to correct the misspelling. The gene-editing treatment involves removing bone marrow from a patient, modifying the HSCs outside the body using CRISPR gene-editing tools, and then returning them back to the patient. Preclinical studies had shown that CRISPR can be effective in editing BCL11A to boost HbF production.

But questions lingered about the editing efficiency in HSCs versus more common, shorter-lived progenitor cells found in bone marrow samples. The efficiency greatly influences how long the edited cells might benefit patients. Bauer’s team saw room for improvement and, as the new study shows, they were right.

To produce lasting HbF production, it’s important to edit as many HSCs as possible. But it turns out that HSCs are more resistant to editing than other types of cells in bone marrow. With a series of adjustments to the gene-editing protocol, including use of an optimized version of the Cas9 protein, the researchers showed they could push the number of edited genes from about 80 percent to about 95 percent.

Their studies show that the most frequent Cas9 edits in HSCs are tiny insertions of a single DNA “letter.” With that slight edit to the BCL11A gene, HSCs reprogram themselves in a way that ensures long-term HbF production.

As a first test of their CRISPR-edited human HSCs, the researchers carried out the editing on HSCs derived from patients with SCD. Then they transferred the editing cells into immune-compromised mice. Four months later, the mice continued to produce red blood cells that produced high levels of HbF and resisted sickling. Bauer says they’re already taking steps to begin testing cells edited with their optimized protocol in a clinical trial.

What’s truly exciting is that the first U.S. human clinical trials of such a gene-editing approach for SCD are already underway, led by CRISPR Therapeutics/Vertex Pharmaceuticals and Sangamo Therapeutics/Sanofi. In January, CRISPR Therapeutics/Vertex Pharmaceuticals announced that the U.S. Food and Drug Administration (FDA) had granted Fast Track Designation for their CRISPR-based treatment called CTX001 [4].

In that recent “60 Minutes” segment, I dared to suggest that we now have what looks like a cure for SCD. As shown by this new work and the clinical trials underway, we in fact may soon have multiple different strategies to provide cures for this devastating disease. And if this can work for sickle cell, a similar strategy might work for other genetic conditions that currently lack any effective treatment.

References:

[1] Highly efficient therapeutic gene editing of human hematopoietic stem cells. Wu Y, Zeng J, Roscoe BP, Liu P, Yao Q, Lazzarotto CR, Clement K, Cole MA, Luk K, Baricordi C, Shen AH, Ren C, Esrick EB, Manis JP, Dorfman DM, Williams DA, Biffi A, Brugnara C, Biasco L, Brendel C, Pinello L, Tsai SQ, Wolfe SA, Bauer DE. Nat Med. 2019 Mar 25.

[2] Human fetal hemoglobin expression is regulated by the developmental stage-specific repressor BCL11A. Sankaran VG, Menne TF, Xu J, Akie TE, Lettre G, Van Handel B, Mikkola HK, Hirschhorn JN, Cantor AB, Orkin SH.Science. 2008 Dec 19;322(5909):1839-1842.

[3] An erythroid enhancer of BCL11A subject to genetic variation determines fetal hemoglobin level. Bauer DE, Kamran SC, Lessard S, Xu J, Fujiwara Y, Lin C, Shao Z, Canver MC, Smith EC, Pinello L, Sabo PJ, Vierstra J, Voit RA, Yuan GC, Porteus MH, Stamatoyannopoulos JA, Lettre G, Orkin SH. Science. 2013 Oct 11;342(6155):253-257.

[4] CRISPR Therapeutics and Vertex Announce FDA Fast Track Designation for CTX001 for the Treatment of Sickle Cell Disease, CRISPR Therapeutics News Release, Jan. 4, 2019.

Links:

Sickle Cell Disease (National Heart, Lung, and Blood Institute/NIH)

Cure Sickle Cell Initiative (NHLBI)

What are Genome Editing and CRISPR-Cas9? (National Library of Medicine/NIH)

Could Gene Therapy Cure Sickle Cell Anemia? (CBS News)

Daniel Bauer (Dana-Farber Cancer Institute, Boston)

Somatic Cell Genome Editing Program (Common Fund/NIH)

NIH Support: National Heart, Lung, and Blood Institute; National Institute of General Medical Sciences; National Institute of Allergy and Infectious Diseases; National Institute of Diabetes and Digestive and Kidney Diseases


Thoughts from the Front Lines of Rare Disease Research

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Harper Spero and Alexandra Freeman
Harper Spero with physician-researcher Alexandra Freeman, who helps lead the Job’s syndrome research team at the NIH Clinical Center. Courtesy of Harper Spero.

There are nearly 7,000 rare diseases, some of which affect just a few dozen people. Yet, if one considers all these conditions together, about 30 million people in the United States have rare diseases. On this Rare Disease Day, I’d like to challenge each of you to think about how we can raise the visibility of individuals living with rare diseases, as well as the researchers working hard to help them.

I’d like to introduce you to Harper Spero, who is using her rare gift of storytelling to share the experiences of people with a wide variety of conditions that she likes to call “invisible illnesses.” Through her podcast series, called Made Visible, this 34-year-old New York City native is among the many people helping to spread the word that rare diseases are not rare.

Spero knows what it’s like to live with a rare disease. Shortly after she was born, it became clear that she was unusually prone to infections. But doctors had a hard time figuring out what exactly was wrong with this little girl. Finally, at the age of 10, Spero was diagnosed with Hyper-Immunoglobulin E Syndrome (HIES), also known as Job’s syndrome. There currently is no cure for this rare genetic disease, which impairs the immune system and affects multiple parts of the body. But Spero is determined to live a normal life despite her chronic “invisible illness.”

Spero also knows what it’s like to take part in biomedical research. Seven years ago, she came to the NIH Clinical Center here in Bethesda, MD, seeking help for a large cyst in her right lung. It marked the beginning of a positive partnership with a Job’s syndrome research team led by two of NIH’s many dedicated physician-scientists, Alexandra Freeman and Steven Holland. Not only did the NIH researchers work with Spero to figure out the best ways of managing her symptoms, they are using what they’ve learned from her and about 175 other Job’s syndrome patients to develop approaches for earlier diagnosis and interventions. Spero, who visits the Clinical Center annually and communicates with the NIH team on a weekly basis, has been so inspired by the experience that she even chose to feature Dr. Freeman in one of her recent podcasts.

Unlike Spero, I don’t have a podcast—at least not yet. But I do have a blog, and Spero was kind enough to respond to a few of my questions on rare diseases and medical research. So, I’m sharing her thoughts below—I hope you are inspired by them as much as I was!

Why do you feel it is important for people with rare diseases to take part in medical research?

Without research, we can’t make any improvements, changes or find cures. Participating in medical research allows researchers and doctors to learn about the trends (or lack of) between patients, and determine what’s working and what’s not.

What have your own experiences been with the health-care system and medical research?

When I was younger, I really didn’t want to be a specimen. I was going through so much trying to find answers and treatments for myself that it was hard to think about how it would help other patients down the road to be sharing my experiences. I didn’t want to add another doctor’s visit to my schedule. After coming to NIH in 2012, I recognized the importance of being part of the research because it could essentially help me, other patients and for early detection of rare diseases. I recognize that the medical researchers are often much more compassionate than many doctors who simply treat symptoms. Researchers are curious and genuinely care to understand you and your story.

Your podcast is fantastic. How has it affected you to hear and share the stories of so many people affected by rare diseases?

I was definitely aware how many people were living with rare diseases, but I was surprised by how many people were willing to share their stories on my show and how many people wanted to listen to these stories. I hadn’t heard stories being shared in this way around this topic and I wanted to be the one who brought them to life. Many of my guests haven’t publicly (let alone with friends or family) shared their stories so I’m honored that they’re willing to do it with me. They see how important it is to have these conversations and to educate people on what it’s like to have an invisible illness.

What would you tell someone who’s just learned he or she has a rare disease?

You don’t have to do this alone! Find a team of medical professionals you trust to support you. I spent most of my life without a team of doctors that I loved and truly understood me, and now I can’t imagine my life without my team at NIH. Also, talk to your loved ones—let them know what you’re feeling and discuss how they can support you. This is likely new for them too and there’s no right way of navigating and managing a rare disease.

What would you tell a young person who’s considering becoming a rare disease researcher?

Thank you for your interest in doing this! We need more compassionate, curious and passionate people doing this work and investing their time to learn more and help find answers for rare diseases. Please treat us with respect and care.

If you could change one thing in the medical care/research of rare disease, what would it be? And what about in society in general?

There’s a way to do your job without treating patients like guinea pigs. We’re humans too, and we’re humans who have likely been through the wringer in the medical world. Be kind to us. Treat us the way you’d like to be treated. Compassion seems to be a word I’m using a lot. I think society can be more compassionate towards one another especially around rare disease. You can never fully understand what someone is going through so ask questions, show you care and treat people with kindness.

What are your hopes for the future?

I’d love there to be more answers and solutions for navigating a rare disease. A lot of the treatments I do are based on trial-and-error. What works for one patient definitely doesn’t always work for me. So, we’re constantly trying to navigate what works best for me. I’d love to see a cure to be found for Hyper IgE/Job’s Syndrome, as well as other rare diseases.

Links:

Podcast Series: Made Visible

NIH Patient Shares Stories of ‘Invisible Illness,The NIH Record, February 8, 2019

Hyper-Immunoglobulin E Syndrome (HIES) (National Institute of Allergy and Infectious Diseases/NIH)

Rare Disease Day at NIH 2019 (National Center for Advancing Translational Sciences/NIH)

Rare Diseases Are Not Rare! Challenge Offers New Tools to Raise Awareness. January 2019 (NCATS)

Video: Rare Disease Patient Profiles (NCATS)

Genetic and Rare Diseases Information Center (NCATS)

Undiagnosed Diseases Network (Common Fund/NIH)

Video: One in a Million (Undiagnosed Diseases Network, University of Utah Health, Salt Lake City)


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