1. Colorado Clinical Proteomics Program 1. Pediatric Lung Disease 2. Hypothesis and Specific Aims 3. Colorado Clinical Proteomics Program - Organization - Setting - Cores - Networks - Special Features

2. Colorado Clinical Proteomics Program Pediatric Lung Disease Protein Biomarkers - Assessment difficult - Non-invasive sampling - Small volume specimens LungDisease MorbidityMortality AdultLungDiseaseChildhood Asthma, Bronchopulmonary Dysplasia, Cystic Fibrosis, Pulmonary Artery Hypertension

3. Colorado Clinical Proteomics Program Pediatric Asthma - 10-35% of all children - Quality of Life, School Attendance School Attendance - Morbidity, Hospitalization 4/1000 Hospitalization 4/1000 - Mortality - Cost AsthmaReversibleAirwayObstruction (Sennhauser et al, 2005; Engelsvold, Omyar, 2003; Myers, 2000)

4. Colorado Clinical Proteomics Program Bronchopulmonary Dysplasia (BPD) - 0.2% to 1% newborns (10,000-40,000/yr) (10,000-40,000/yr) - 60% Readmission rate - Increasing rate of premature births premature births - Surfactant - Decreased severity - No change in Incidence Incidence BPD Chronic Lung Disease Chronic Lung Disease Preterm Infants Preterm Infants Mechanical Ventilation Mechanical Ventilation All Lung Components All Lung Components (Wen et al, 2004)

5. Colorado Clinical Proteomics Program Cystic Fibrosis (CF) - 17,000 Children - 20% Hospitalized - Progressive Loss Of Lung function Of Lung function - Median age of Death (25 years) (25 years) - Cost Cystic Fibrosis Genetic Genetic Failure of Failure of Airway Defense Airway Defense (CF Foundation Patient Registry 2003, Bethesda, MD)

6. Colorado Clinical Proteomics Program Pulmonary Arterial Hypertension (PAH) PAH CHD CHD Idiopathic Idiopathic Developmental Developmental Abnormalities Abnormalities Mortality – 10 year 40% Mortality – 10 year 40% Morbidity Morbidity Prolonged hospitalizations Prolonged hospitalizations 240 followed at Colorado 240 followed at Colorado (Yung et al, 2004)

7. Colorado Clinical Proteomics Program Clinical Proteomics Potential Asthma BPD CF PAH Asthma BPD CF PAH Population screening Yes Population screening Yes Susceptibility Susceptibility Staging Staging Rapid progression study study Rapid progression study study Exacerbation Exacerbation - Identification - Identification - Susceptibility study - Susceptibility study Response to tx study study Response to tx study study Toxicity with tx Toxicity with tx Clin Trial stratification Clin Trial stratification Outcome Measures Outcome Measures Clues to Pathogenesis Clues to Pathogenesis Inflammation,Fibrosis Yes(?) Yes Yes Yes Inflammation, Fibrosis Yes(?) Yes Yes Yes

8. Colorado Clinical Proteomics Program Hypothesis and Specific Aims Hypothesis: Development and Validation of Protein Bio- Markers will lead to improved care in Pediatric Lung Disease Aim 1. Establish a Clinical Proteomics Program in Pediatric Lung Disease comprising five cores to develop and validate panels of Protein Biomarkers Aim 2. Address specific issues in Pediatric Lung Disease through panels of protein biomarkers: through panels of protein biomarkers: Asthma – frequent exacerbations, failure to respond to Tx Asthma – frequent exacerbations, failure to respond to Tx CF, BPD – identification of rapid progressors CF, BPD – identification of rapid progressors PAH – failure to respond to Tx PAH – failure to respond to Tx Aim 3. Develop Educational Program in Clinical Proteomics Aim 4. Develop a National Resource for NHLBI investig.

9. Colorado Clinical Proteomics Program Colorado Clinical Proteomics Program – Organization NHLBI Clinical Proteomics Steering Committee NHLBI Clinical Proteomics Steering Committee Colorado Steering Committee - Heads of Core, Colorado Steering Committee - Heads of Core, M. Duncan, Proteomics Consultant. M. Duncan, Proteomics Consultant. - Clinical Core – F. Accurso, MD (PI) - Clinical Core – F. Accurso, MD (PI) - Laboratory Core – R. Harbeck, PhD - Laboratory Core – R. Harbeck, PhD - Data Management/Biostatistics – J. Murphy, PhD - Data Management/Biostatistics – J. Murphy, PhD - Educational Core – R. Deterding, MD; L. Shroyer, PhD - Educational Core – R. Deterding, MD; L. Shroyer, PhD - Administrative Core – F. Accurso, MD - Administrative Core – F. Accurso, MD

10. Colorado Clinical Proteomics Program Colorado Clinical Proteomics Program – Setting Childrens Hospital Clinical, Lab, Admin National Jewish Center Clinical, Lab, DMU/Biostats University of Colorado Veterans Administration Education, Biostats 3 miles 6 blocks

11. Colorado Clinical Proteomics Program Clinical Core Director: F. Accurso, MD Asthma: S. Szefler, MD, National Jewish - CAMP, ICAC BPD: S. Abman, MD; J. Kinsella, MD Children’s Hospital, University - NHLBI funded trial of nitric oxide in prevention of BPD PAH: S. Abman, MD; D. Ivy, MD, Children’s Hospital, Univ. - Local, Multicenter trials CF: F. Accurso, MD, Children’s Hospital, Univ. - CF Foundation Therapeutics Development Network Regulatory Compliance: HIPAA, Institutional Review Board

12. Colorado Clinical Proteomics Program Laboratory Core Director: R. Harbeck, PhD Specimen Collection Sample Processing Storage AnalysisValidation Luminex Platform IL-1-8-10, -12, -13, 15, GM-CSF, IFN, TNF, eotaxin, MCP-1, RANTES, MIP-1, VEG F

13. Colorado Clinical Proteomics Program Data Management/Biostatistics Core Director: J. Murphy, PhD Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Exploratory Clinical Assay Retrospective Prospective Large Scale Exploratory Clinical Assay Retrospective Prospective Large Scale Studies Development/ Longitudinal Longitudinal Application Studies Development/ Longitudinal Longitudinal Application Validation Validation Validation Validation Validation Validation Data Management: Data Management: - Implementation - Regulatory Compliance Biostatistics: J. Murphy; G. Zerbe, PhD. Biostatistics: J. Murphy; G. Zerbe, PhD. - Statistics appropriate for each Phase (Pepe et al, 2001; Srinivas et al, 2002)

14. Colorado Clinical Proteomics Program Education Core Co-Directors: R. Deterding,,MD, L. Shroyer, PhD Clinical Science Program, K30, med school curriculum Clinical Science Program, K30, med school curriculum Local, National and Web Based Goals Local, National and Web Based Goals Curriculum Design, Implementation, Evaluation, Dissemination Curriculum Design, Implementation, Evaluation, Dissemination Trainees: Multidisciplinary backgrounds, all levels Trainees: Multidisciplinary backgrounds, all levels Year 1 Year 2 Year 3Year 4 Curriculum Pilot Local Full Local Evaluate Local Development Start National National (ATS, ACCP) Start Web based Web based Start Web based Web based Evaluate National Evaluate National

15. Colorado Clinical Proteomics Program Clinical Study Timeline: CF ClinicalQuestion Year 1 Year 2 Year 3 Year 4 CFProgression of Disease Phase 4 Local Prospective N=200 Phase 4 Local Prospective N=200 Phase 4 Multicenter Prospective N=400 Begin Phase 5

16. Colorado Clinical Proteomics Program 1. Pediatric Lung Disease 2. Hypothesis and Specific Aims 3. Colorado Clinical Proteomics Program - Organization - Setting - Cores - Networks - Special Features Collaboration with M. Duncan, Proteomics, Randox Laboratories, Protein Arrays

17. Colorado Clinical Proteomics Program Experience with Matrices Other than Plasma or Serum Sputum (Sagel et al. 2001) Sputum (Sagel et al. 2001) BAL (Khan et al. 1995) BAL (Khan et al. 1995) Bronchial Brushing (Wooldridge et al, 2004) Bronchial Brushing (Wooldridge et al, 2004) Breath Condensate Breath Condensate Urine Urine - Proteomic Study of Urinary Biomarkers in CF Exacerbation Exacerbation - Collaboration with M. Duncan and S. Hunsucker

18. Colorado Clinical Proteomics Program Protein Biomarker Timeline: Immunoreactive Trypsinogen (IRT) Colorado Screening Program (n>1,000,000) Colorado Screening Program (n>1,000,000) 1979 1991 1995 2004 Pilot CF Screening (Eliot et al) Validated(Hammond et al) ClinicalBenefit(Farrell We need to do better. CDC, CF Found. Endorse-ment