A Phenome-Wide Association Study of genes associated with COVID-19 severity reveals shared genetics with complex diseases in the Million Veteran Program

The study aims to determine the shared genetic architecture between COVID-19 severity with existing medical conditions using electronic health record (EHR) data. We conducted a Phenome-Wide Association Study (PheWAS) of genetic variants associated with critical illness (n = 35) or hospitalization (n = 42) due to severe COVID-19 using genome-wide association summary data from the Host Genetics Initiative. PheWAS analysis was performed using genotype-phenotype data from the Veterans Affairs Million Veteran Program (MVP). Phenotypes were defined by International Classification of Diseases (ICD) codes mapped to clinically relevant groups using published PheWAS methods. Among 658,582 Veterans, variants associated with severe COVID-19 were tested for association across 1,559 phenotypes. Variants at the ABO locus (rs495828, rs505922) associated with the largest number of phenotypes (nrs495828 = 53 and nrs505922 = 59); strongest association with venous embolism, odds ratio (ORrs495828 1.33 (p = 1.32 x 10-199), and thrombosis ORrs505922 1.33, p = 2.2 x10-265. Among 67 respiratory conditions tested, 11 had significant associations including MUC5B locus (rs35705950) with increased risk of idiopathic fibrosing alveolitis OR 2.83, p = 4.12 × 10-191; CRHR1 (rs61667602) associated with reduced risk of pulmonary fibrosis, OR 0.84, p = 2.26× 10-12. The TYK2 locus (rs11085727) associated with reduced risk for autoimmune conditions, e.g., psoriasis OR 0.88, p = 6.48 x10-23, lupus OR 0.84, p = 3.97 x 10-06. PheWAS stratified by ancestry demonstrated differences in genotype-phenotype associations. LMNA (rs581342) associated with neutropenia OR 1.29 p = 4.1 x 10-13 among Veterans of African and Hispanic ancestry but not European. Overall, we observed a shared genetic architecture between COVID-19 severity and conditions related to underlying risk factors for severe and poor COVID-19 outcomes. Differing associations between genotype-phenotype across ancestries may inform heterogenous outcomes observed with COVID-19. Divergent associations between risk for severe COVID-19 with autoimmune inflammatory conditions both respiratory and non-respiratory highlights the shared pathways and fine balance of immune host response and autoimmunity and caution required when considering treatment targets.

Polygenic Risk Scores in Alzheimer's Disease Genetics: Methodology, Applications, Inclusion, and Diversity

The success of genome-wide association studies (GWAS) completed in the last 15 years has reinforced a key fact: polygenic architecture makes a substantial contribution to variation of susceptibility to complex disease, including Alzheimer's disease. One straight-forward way to capture this architecture and predict which individuals in a population are most at risk is to calculate a polygenic risk score (PRS). This score aggregates the risk conferred across multiple genetic variants, ultimately representing an individual's predicted genetic susceptibility for a disease. PRS have received increasing attention after having been successfully used in complex traits. This has brought with it renewed attention on new methods which improve the accuracy of risk prediction. While these applications are initially informative, their utility is far from equitable: the majority of PRS models use samples heavily if not entirely of individuals of European descent. This basic approach opens concerns of health equity if applied inaccurately to other population groups, or health disparity if we fail to use them at all. In this review we will examine the methods of calculating PRS and some of their previous uses in disease prediction. We also advocate for, with supporting scientific evidence, inclusion of data from diverse populations in these existing and future studies of population risk via PRS.

A Phenome-Wide Association Study of genes associated with COVID-19 severity reveals shared genetics with complex diseases in the Million Veteran Program

The study aims to determine the shared genetic architecture between COVID-19 severity with existing medical conditions using electronic health record (EHR) data. We conducted a Phenome-Wide Association Study (PheWAS) of genetic variants associated with critical illness (n=35) or hospitalization (n=42) due to severe COVID-19 using genome-wide association summary from the Host Genetics Initiative. PheWAS analysis was performed using genotype-phenotype data from the Veterans Affairs Million Veteran Program (MVP). Phenotypes were defined by International Classification of Diseases (ICD) codes mapped to clinically relevant groups using published PheWAS methods. Among 658,582 Veterans, variants associated with severe COVID-19 were tested for association across 1,559 phenotypes. Variants at the ABO locus (rs495828, rs505922) associated with the largest number of phenotypes (n_rs495828=53 and n_rs505922=59); strongest association with venous embolism, odds ratio (ORrs495828 1.33 (p=1.32 × 10^-199), and thrombosis OR_rs505922 1.33, p=2.2 × 10^-265. Among 67 respiratory conditions tested, 11 had significant associations including MUC5B locus (rs35705950) with increased risk of idiopathic fibrosing alveolitis OR 2.83, p=4.12 × 10^-191; CRHR1 (rs61667602) associated with reduced risk of pulmonary fibrosis, OR 0.84, p=2.26 × 10^-12. The TYK2 locus (rs11085727) associated with reduced risk for autoimmune conditions, e.g., psoriasis OR 0.88, p=6.48 × 10^-23, lupus OR 0.84, p=3.97 × 10^-06. PheWAS stratified by genetic ancestry demonstrated differences in genotype-phenotype associations across ancestry. LMNA (rs581342) associated with neutropenia OR 1.29 p=4.1 × 10^-13 among Veterans of African ancestry but not European. Overall, we observed a shared genetic architecture between COVID-19 severity and conditions related to underlying risk factors for severe and poor COVID-19 outcomes. Differing associations between genotype-phenotype across ancestries may inform heterogenous outcomes observed with COVID-19. Divergent associations between risk for severe COVID-19 with autoimmune inflammatory conditions both respiratory and non-respiratory highlights the shared pathways and fine balance of immune host response and autoimmunity and caution required when considering treatment targets.

MON-LB017 Natural Genetic Variation in Humans Determines Basal and PPAR-Inducible Expression of PM20D1, a Putative Thermogenic Gene

Thermogenesis by brown and beige adipocytes is a potential avenue to increased energy expenditure and thus management of obesity and metabolic syndrome. In mice, Pm20d1 has been previously identified as a candidate thermogenic gene, with its mRNA levels cold-induced and enriched in brown and beige versus white adipocytes, and with the potential mechanism of generating a novel uncoupling metabolite. Thiazolidinedione (TZD) antidiabetic drugs, which activate the PPARγ nuclear receptor, are potent stimuli for adipocyte browning, yet they fail to induce Pm20d1 expression mouse adipocytes or adipose tissue. In contrast, we show here that PM20D1 is one of the most strongly TZD-induced transcripts in human adipocytes, though not in samples from all individuals. Two putative PPARγ binding sites were identified near the gene’s transcription start site (TSS) in human but not mouse adipocytes. The ~4kb upstream binding site falls in a segmental duplication of a nearly identical intronic region ~2.5kb downstream of the TSS, and this duplication event occurred in the primate lineage and is absent in other mammals like mice. We demonstrate by chromatin immunoprecipitation and reporter assays that PPARγ binding and gene activation occur via this upstream duplicated site, thus explaining the species difference. Furthermore, this functional upstream PPARγ site has genetic variation in the human population, with one single nucleotide polymorphism (SNP) allele disrupting a PPAR response element. We show that this allele gives less activation by PPARγ and TZDs in reporter assays and reduced TZD activation of PM20D1 in patient-derived cultured adipocytes. In addition to this upstream variant that determines PPARγ regulation of PM20D1 in adipocytes, genotype at a distinct and unlinked variant >40kb downstream of the TSS strongly correlates with overall levels of PM20D1 expression in human fat as well as multiple other tissues. Seven tightly linked downstream SNP alleles correlate with very low PMD201 expression and correspondingly high DNA methylation at the TSS. These low PM20D1 expression variants may have phenotypic consequences, accounting for human genetic associations in this region with metabolic and neurodegenerative diseases. Overall, human PM20D1 expression is genetically variable at two levels, with genotype at downstream SNPs correlating with overall PM20D1 expression across tissues (an “on/off switch”), while the upstream PPARγ site SNP determines PPARγ and TZD regulation in adipose tissue (a “rheostat”). This human genetic variation in PM20D1 expression may ultimately inform precision medicine approaches. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Chapter 1 An overview of the eruption of Soufrière Hills Volcano, Montserrat from 2000 to 2010

The 1995–present eruption of Soufrière Hills Volcano on Montserrat has produced over a cubic kilometre of andesitic magma, creating a series of lava domes that were successively destroyed, with much of their mass deposited in the sea. There have been five phases of lava extrusion to form these lava domes: November 1995–March 1998; November 1999–July 2003; August 2005–April 2007; July 2008–January 2009; and October 2009–February 2010. It has been one of the most intensively studied volcanoes in the world during this time, and there are long instrumental and observational datasets. From these have sprung major new insights concerning: the cyclicity of magma transport; low-frequency earthquakes associated with conduit magma flow; the dynamics of lateral blasts and Vulcanian explosions; the role that basalt–andesite magma mingling in the mid-crust has in powering the eruption; identification using seismic tomography of the uppermost magma reservoir at a depth of 5.5 > 7.5 km; and many others. Parallel to the research effort, there has been a consistent programme of quantitative risk assessment since 1997 that has both pioneered new methods and provided a solid evidential source for the civil authority to use in mitigating the risks to the people of Montserrat.

Touch, and you will gaze: elderly and youngers' use of remote controls in interacting with a healthcare portal

This study extends previous research by exploring the quality of the interaction experienced by a group of elderly participants interacting with a healthcare portal when applying a touch screen remote control. This is compared to a standard remote control with physical buttons.

Breadth, depth and visibility: a design guide for information architectures aimed at elderly users

This study extends previous research by exploring the quality of the interaction experienced by a group of elderly participants interacting with a healthcare portal when applying a touch screen remote control. This is compared to a standard remote control with physical buttons.

Analysis of case-control association studies with known risk variants

MOTIVATION

The question of how to best use information from known associated variants when conducting disease association studies has yet to be answered. Some studies compute a marginal P-value for each Several Nucleotide Polymorphisms independently, ignoring previously discovered variants. Other studies include known variants as covariates in logistic regression, but a weakness of this standard conditioning strategy is that it does not account for disease prevalence and non-random ascertainment, which can induce a correlation structure between candidate variants and known associated variants even if the variants lie on different chromosomes. Here, we propose a new conditioning approach, which is based in part on the classical technique of liability threshold modeling. Roughly, this method estimates model parameters for each known variant while accounting for the published disease prevalence from the epidemiological literature.

RESULTS

We show via simulation and application to empirical datasets that our approach outperforms both the no conditioning strategy and the standard conditioning strategy, with a properly controlled false-positive rate. Furthermore, in multiple data sets involving diseases of low prevalence, standard conditioning produces a severe drop in test statistics whereas our approach generally performs as well or better than no conditioning. Our approach may substantially improve disease gene discovery for diseases with many known risk variants.

AVAILABILITY

LTSOFT software is available online http://www.hsph.harvard.edu/faculty/alkes-price/software/.

Influence of 9p21.3 genetic variants on clinical and angiographic outcomes in early-onset myocardial infarction

OBJECTIVES

The purpose of this study was to test whether the 9p21.3 variant rs1333040 influences the occurrence of new cardiovascular events and coronary atherosclerosis progression after early-onset myocardial infarction.

BACKGROUND

9p21.3 genetic variants are associated with ischemic heart disease, but it is not known whether they influence prognosis after an acute coronary event.

METHODS

Within the Italian Genetic Study of Early-onset Myocardial Infarction, we genotyped rs1333040 in 1,508 patients hospitalized for a first myocardial infarction before the age of 45 years who underwent coronary angiography without index event coronary revascularization. They were followed up for major cardiovascular events and angiographic coronary atherosclerosis progression.

RESULTS

Over 16,599 person-years, there were 683 cardiovascular events and 492 primary endpoints: 77 cardiovascular deaths, 223 reoccurrences of myocardial infarction, and 383 coronary artery revascularizations. The rs1333040 genotype had a significant influence (p = 0.01) on the primary endpoint, with an adjusted hazard ratio of 1.19 (95% confidence interval [CI]: 1.08 to 1.37) for heterozygous carriers and 1.41 (95% CI: 1.06 to 1.87) for homozygous carriers. Analysis of the individual components of the primary endpoints provided no significant evidence that the rs1333040 genotype influenced the hazard of cardiovascular death (p = 0.24) or the reoccurrence of myocardial infarction (p = 0.57), but did provide significant evidence that it influenced on the hazard of coronary revascularization, with adjusted heterozygous and homozygous ratios of 1.38 (95% CI: 1.17 to 1.63) and 1.90 (95% CI: 1.36 to 2.65) (p = 0.00015), respectively. It also significantly influenced the angiographic endpoint of coronary atherosclerosis progression (p = 0.002).

CONCLUSIONS

In early-onset myocardial infarction, the 9p21.3 variant rs1333040 affects the progression of coronary atherosclerosis and the probability of coronary artery revascularization during long-term follow-up.

Magma extrusion dynamics revealed by high-frequency gas monitoring at Soufrière Hills volcano, Montserrat

Andesitic to dacitic dome-building volcanoes often present a problem for eruption forecasting because signs of impending activity can be minimal or ambiguous. Gas monitoring is one of a number of techniques used to assist in eruption forecasting. However, a variety of explanations have been offered for the large variations in gas release that are commonly reported from erupting volcanoes. Difficulties in interpretation can arise because gas-flux measurements are generally acquired at lower sampling rates than other geophysical observations. Here, we report SO2 flux measurements, by correlation spectroscopy, recorded semi-continuously during December 1999 to January 2000 at the Soufrière Hills Volcano, Montserrat. We compare these data to continuously recorded seismic records, and interpret the results in terms of conduit dynamics. We demonstrate two- to six-fold variations in gas flux over a few hours, and show that these variations can be systematic and directly correlated with long-period swarm seismicity. For the period of study, we find that the gas-flux peak lags several tens of minutes behind the peak in seismic energy release. These features are consistent with models of oscillating magma flow, where magma viscosity is dependent on melt volatile content. We propose that seismicity reflects conduit pressurization, and find that gas flux directly reflects magma flow rate. Although other volcanoes might behave differently, our results suggest that it can be possible to use continuous gas measurements to monitor conduit behaviour, perhaps providing short-term warnings of impending eruptions.

Transient dynamics of vulcanian explosions and column collapse

Several analytical and numerical eruption models have provided insight into volcanic eruption behaviour, but most address plinian-type eruptions where vent conditions are quasi-steady. Only a few studies have explored the physics of short-duration vulcanian explosions with unsteady vent conditions and blast events. Here we present a technique that links unsteady vent flux of vulcanian explosions to the resulting dispersal of volcanic ejecta, using a numerical, axisymmetric model with multiple particle sizes. We use observational data from well documented explosions in 1997 at the Soufrière Hills volcano in Montserrat, West Indies, to constrain pre-eruptive subsurface initial conditions and to compare with our simulation results. The resulting simulations duplicate many features of the observed explosions, showing transitional behaviour where mass is divided between a buoyant plume and hazardous radial pyroclastic currents fed by a collapsing fountain. We find that leakage of volcanic gas from the conduit through surrounding rocks over a short period (of the order of 10 hours) or retarded exsolution can dictate the style of explosion. Our simulations also reveal the internal plume dynamics and particle-size segregation mechanisms that may occur in such eruptions.

Generation of a debris avalanche and violent pyroclastic density current on 26 December (Boxing Day) 1997 at Soufrière Hills Volcano, Montserrat

Growth of an andesitic lava dome at Soufriere Hills Volcano, Montserrat, beginning in November 1995, caused instability of a hydrothermally altered flank of the volcano. Catastrophic failure occurred on 26 December 1997, 14 months after the instability was first recognized. Two months before failure a dome lobe had extruded over the unstable area and by 25 December 1997 this had a volume of 113 x 106m3. At 03:01 (local time) the flank rocks and some dome talus failed and generated a debris avalanche (volume 46 x 106 m3). Between 35 and 45 x 106 m3 of the dome then collapsed, generating a violent pyroclastic density current that devastated 10 km2 of southern Montserrat. The failure of the flank and dome formed two adjacent bowl-shaped collapse depressions. The most intense activity lasted about 11.6 minutes. The hummocky debris avalanche deposit is composed of a mixture of domains of heterolithic breccia. The pyroclastic density current had an estimated peak velocity of 80-90 ms-1, and minimum flux of 108 kgs1. The current was largely erosional on land with most deposition out at sea. Destructive effects included removal of houses, trees and large vehicles, and formation of a scoured surface blackened by a thin (3-4 mm) layer of tar. Two discrete depositional units formed from the pyroclastic density current, each with a lower coarse-grained layer and an upper fine-grained stratified layer. These deposits are overlain by an ashfall layer related to buoyant lofting of the current. Flank failure is attributed to loading of hydrothermally weakened rocks by the dome. The generation of the pyroclastic density current is attributed to failure and explosive disintegration of the dome, involving release and violent expansion of gases initially at high pore pressures.

Pyroclastic flow and explosive activity at Soufrière Hills Volcano, Montserrat, during a period of virtually no magma extrusion (March 1998 to November 1999)

Dome growth at Soufrière Hills Volcano halted in early March 1998. After dome growth ceased, seismicity reduced significantly, but activity related to dome disintegration and degassing of magma at depth continued. A sustained episode of pyroclastic flows on 3 July 1998 marked the single largest collapse from March 1998 to November 1999. This led to a remarkable episode of dome collapses, low-energy explosions and ash-venting that resulted in the regular production of ash plumes, commonly reaching 1.5-6 km above sea level (a.s.l), but sometimes up to 11 km a.s.l., and the development of a small block-and-ash cone around the explosion crater. During the period of this residual activity, higher levels of activity occurred approximately every five to six weeks. This periodicity was similar to the cycles observed during active dome growth during 1995 to 1998, and probably had a similar cause. The relatively high level of observed activity caused continued concern regarding volcanic hazards and their potential to impact upon the resident population. Vigorous magma extrusion resumed in November 1999. The activity of the intervening period is attributed to the continued cooling and degassing of the dome, conduit and deep magma body, the impact of rising volcanic gases in the volcanic edifice, and limited magma flow in the conduit.

Episodes of cyclic Vulcanian explosive activity with fountain collapse at Soufrière Hills Volcano, Montserrat

In 1997 Soufriére Hills Volcano on Montserrat produced 88 Vulcanian explosions: 13 between 4 and 12 August and 75 between 22 September and 21 October. Each episode was preceded by a large dome collapse that decompressed the conduit and led to the conditions for explosive fragmentation. The explosions, which occurred at intervals of 2.5 to 63 hours, with a mean of 10 hours, were transient events, with an initial high-intensity phase lasting a few tens of seconds and a lower-intensity, waning phase lasting 1 to 3 hours. In all but one explosion, fountain collapse during the first 10-20 seconds generated pyroclastic surges that swept out to 1-2 km before lofting, as well as high-concentration pumiceous pyroclastic flows that travelled up to 6 km down all major drainages around the dome. Buoyant plumes ascended 3-15 km into the atmosphere, where they spread out as umbrella clouds. Most umbrella clouds were blown to the north or NW by high-level (8-18 km) winds, whereas the lower, waning plumes were dispersed to the west or NW by low-level (<5 km) winds. Exit velocities measured from videos ranged from 40 to 140 ms-1 and ballistic blocks were thrown as far as 1.7 km from the dome. Each explosion discharged on average 3 x 105m3 of magma, about one-third forming fallout and two-thirds forming pyroclastic flows and surges, and emptied the conduit to a depth of 0.5-2 km or more. Two overlapping components were distinguished in the explosion seismic signals: a low-frequency (c. 1 Hz) one due to the explosion itself, and a high-frequency (>2 Hz) one due to fountain collapse, ballistic impact and pyroclastic flow. In many explosions a delay between the explosion onset and start of the pyroclastic flow signal (typically 10-20 seconds) recorded the time necessary for ballistics and the collapsing fountain to hit the ground. The explosions in August were accompanied by cyclic patterns of seismicity and edifice deformation due to repeated pressurization of the upper conduit. The angular, tabular forms of many fallout pumices show that they preserve vesicularities and shapes acquired upon fragmentation, and suggest that the explosions were driven by brittle fragmentation of overpressured magmatic foam with at least 55 vol% bubbles present in the upper conduit prior to each event.

Pyroclastic flows and surges generated by the 25 June 1997 dome collapse, Soufrière Hills Volcano, Montserrat

On 25 June 1997, an unsteady, retrogressive, partial collapse of the lava dome at Soufrière Hills Volcano lasted 25 minutes and generated a major pulsatory block-and-ash flow, associated pyroclastic surges and a surge-derived pyroclastic flow that inundated an area of 4 km2 on the north and NE flanks of the volcano. Three main pulses are estimated to have involved 0.78, 2.36 and 2.36 x 106m3 of debris and the average velocities of the fronts of the related block-and-ash flow pulses were calculated to be 15 ms-1, 16.1 ms-1 and 21.9 ms-1 respectively.

Deposits of block-and-ash flow pulses 1 and 2 partially filled the main drainage channel so that material of the third pulse spilled out of the channel at several places, inundating villages on the eastern coastal plain. Bends and constrictions in the main drainage channel, together with depositional filling of the channel, assisted detachment of pyroclastic surges from the pulsatory block-and-ash flow. The most extensive pyroclastic surge detached at an early stage from the third block-and-ash flow pulse, swept down the north flank of the volcano and then climbed 70 m in elevation before dissipating. Rapid sedimentation from this surge generated a high-concentration granular flow (surge-derived pyroclastic flow) that drained westwards into a valley not anticipated to be at high risk.

Observations support the hypothesis that the interior of the Soufrière Hills Volcano lava dome was pressurized and that pyroclastic surge development became more substantial as deeper, more highly pressurized parts of the dome were incorporated into the pyroclastic flow. Surge development was at times so violent that expanded clouds detached from the block-and-ash flow within a few tens of metres of the lava dome.

Instability of magma flow from volatile-dependent viscosity

Volatiles dissolved in silicic magma at depth exsolve as the magma nears the surface and cause an increase in viscosity of the magma. A model of a volcanic conduit within an elastic medium and a viscosity dependent on the volatile content of the magma produces oscillatory magma flow for a critical range of steady input flow rates. Oscillatory flow is recognized as a fundamental mode of behavior at silicic volcanoes, and understanding it allows improved short-term forecasting of timing and eruption style.

Magma flow instability and cyclic activity at soufriere hills volcano, montserrat, british west indies

Dome growth at the Soufriere Hills volcano (1996 to 1998) was frequently accompanied by repetitive cycles of earthquakes, ground deformation, degassing, and explosive eruptions. The cycles reflected unsteady conduit flow of volatile-charged magma resulting from gas exsolution, rheological stiffening, and pressurization. The cycles, over hours to days, initiated when degassed stiff magma retarded flow in the upper conduit. Conduit pressure built with gas exsolution, causing shallow seismicity and edifice inflation. Magma and gas were then expelled and the edifice deflated. The repeat time-scale is controlled by magma ascent rates, degassing, and microlite crystallization kinetics. Cyclic behavior allows short-term forecasting of timing, and of eruption style related to explosivity potential.

Injury reporting in Connecticut newspapers

OBJECTIVES

To describe how newspapers report injury events and how often they contain information about injury prevention measures.

METHODS

A commercial service provided all newspaper clippings reporting unintentional injury events between July and September 1995 from 17 daily and 55 weekly newspapers published in Connecticut, USA. Each clipping was reviewed to determine the presence or absence of 35 content variables.

RESULTS

There were 962 articles and excluding 35 editorials, 927 reported injury events and 17% pertained to persons under 21 years. Of the 60% that described motor vehicle collisions only 3% mentioned driver alcohol use, 9% seat belt use, and fewer than 1% airbag use. In the 17 motorcycle and 44 bicycle stories, 29% and 20% respectively, mentioned helmet use. In the 16 articles about house fires only 13% mentioned smoke detector use. There were no significant differences in injury reporting by circulation size.

CONCLUSIONS

Newspapers are an important source of public information but are woefully deficient in providing information on injury prevention.

A Relation to Describe Rate-Dependent Material Failure

The simple relation OmegaOmega-alpha = 0, where Omega is a measurable quantity such as strain and A and alpha are empirical constants, describes the behavior of materials in terminal stages of failure under conditions of approximately constant stress and temperature. Applicable to metals and alloys, ice, concrete, polymers, rock, and soil, the relation may be extended to conditions of variable and multiaxial stress and may be used to predict time to failure.

Eruption-Triggered Avalanche, Flood, and Lahar at Mount St. Helens—Effects of Winter Snowpack

An explosive eruption of Mount St. Helens on 19 March 1982 had substantial impact beyond the vent because hot eruption products interacted with a thick snowpack. A blast of hot pumice, dome rocks, and gas dislodged crater-wall snow that avalanched through the crater and down the north flank. Snow in the crater swiftly melted to form a transient lake, from which a destructive flood and lahar swept down the north flank and the North Fork Toutle River.