Effective data sharing is key to accelerating research to improve diagnostic precision, treatment efficacy, and long-term survival in pediatric cancer and other childhood catastrophic diseases. We present St. Jude Cloud (https://www.stjude.cloud), a cloud-based data-sharing ecosystem for accessing, analyzing, and visualizing genomic data from >10,000 pediatric patients with cancer and long-term survivors, and >800 pediatric sickle cell patients. Harmonized genomic data totaling 1.25 petabytes are freely available, including 12,104 whole genomes, 7,697 whole exomes, and 2,202 transcriptomes. The resource is expanding rapidly, with regular data uploads from St. Jude's prospective clinical genomics programs. Three interconnected apps within the ecosystem—Genomics Platform, Pediatric Cancer Knowledgebase, and Visualization Community—enable simultaneously performing advanced data analysis in the cloud and enhancing the Pediatric Cancer knowledgebase. We demonstrate the value of the ecosystem through use cases that classify 135 pediatric cancer subtypes by gene expression profiling and map mutational signatures across 35 pediatric cancer subtypes. Significance: To advance research and treatment of pediatric cancer, we developed St. Jude Cloud, a data-sharing ecosystem for accessing >1.2 petabytes of raw genomic data from >10,000 pediatric patients and survivors, innovative analysis workflows, integrative multiomics visualizations, and a knowledgebase of published data contributed by the global pediatric cancer community. This article is highlighted in the In This Issue feature, p. 995

Effective data sharing is key to accelerating research that will improve the precision of diagnoses, efficacy of treatments and long term survival of pediatric cancer and other childhood catastrophic diseases. We present St. Jude Cloud (https://www.stjude.cloud), a cloud based data sharing ecosystem developed via collaboration between St. Jude Children's Research Hospital, DNAnexus, and Microsoft, for accessing, analyzing and visualizing genomic data from >10,000 pediatric cancer patients, long term survivors of pediatric cancer and >800 pediatric sickle cell patients. Harmonized genomic data totaling 1.25 petabyes on St. Jude Cloud include 12,104 whole genomes, 7,697 whole exomes and 2,202 transcriptomes, which are freely available to researchers worldwide. The resource is expanding rapidly with regular data uploads from St. Jude's prospective clinical genomics programs, providing public access as soon as possible rather than holding data back until publication. Three interconnected apps within the St. Jude Cloud ecosystem Genomics Platform, Pediatric Cancer Knowledgebase (PeCan) and Visualization Community provide a unique experience for simultaneously performing advanced data analysis in the cloud and enhancing the pediatric cancer knowledgebase. We demonstrate the value of the St. Jude Cloud ecosystem through use cases that classify 48 pediatric cancer subtypes by gene expression profiling and map mutational signatures across 35 subtypes of pediatric cancer.

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A 50-year-old man with carcinoma of the trachea presented for debulking. Due to the distal location of the tumor, a tracheostomy was not feasible. We were asked to provide general anesthesia but to maintain spontaneous ventilation. Sedation was provided with dexmedetomidine 0.7 μg/kg per hour. Following induction with ketamine 2 mg/kg, the trachea was sprayed with 5 ml of 4% lidocaine and, with assistance from the surgeon, a Cook™ Airway Exchange catheter was placed with the distal end just beyond the tumor. We then connected the proximal end to a manual jet ventilator to provide oxygen supplementation and, if necessary, positive-pressure ventilation. Subsequently, the surgeons were able to completely debulk the tumor and examine the airway down to the carina. Spontaneous ventilation was maintained throughout the case, with additional boluses of ketamine as necessary. The patient woke up after the procedure and had no delirium, nightmares, or recall. Dexmedetomidine worked synergistically with ketamine by preventing hypertension, hypersecretion, and postoperative delirium that is often seen when using ketamine alone. The successful use of ketamine and dexmedetomidine in this case demonstrates that this method may be applicable to other clinical situations where deep sedation and maintenance of spontaneous ventilation is required.