University Of Colorado Denver

NIH Research Projects · FY 2025 · 2022-09

AKI and CKD are highly prevalent diseases that are associated with significant morbidity and mortality. Unfortunately, there are not currently any specific treatments for either of these conditions. Both diseases are caused by a range of underlying diseases and processes. AKI, for example, can result from hemodynamic, toxic, infectious, and immune insults to the kidney. In both AKI and CKD, the diagnosis is based on changes in the serum creatinine and albuminuria, but these tests do not discriminate among the various etiologies of injury. Thus, beyond detecting a reduction in kidney function, clinicians typically have little information regarding the underlying pathologic process. Better understanding of the cellular and molecular patterns in the kidneys of patients with AKI and CKD will provide key insights into these diseases and will lead to new diagnostic and therapeutic approaches. In recent years, multi-omics analyses have had a major impact on our understanding of several fields, such as cancer biology, and have supported the identification and development of new treatments. These same technologies could transform our understanding of AKI and CKD, particularly when spatial resolution is complemented with proteomic and transcriptomic cellular analyses. Although kidney biopsies are not usually performed in patients with AKI and CKD, biopsy samples obtained through the Kidney Precision Medicine Project (KPMP) offer a valuable opportunity to analyze kidney tissue using state-of-the-art high-dimensional multi-omic platforms. We propose to utilize complementary spatial protein and RNA technologies to generate comprehensive tissue atlases for AKI and CKD. We will pursue the following specific aims: Aim 1. Generate a kidney cellular map via phenotypic and functional protein expression profiling. We will analyze biopsies using Multiplexed Ion Beam Imaging (MIBI), which detects 40+ protein targets at single-cell resolution (250 nm) with tissue-specific spatial information. Aim 2. Generate a kidney morphological map via phenotypic and functional gene expression profiling. We will analyze biopsies using Visium Spatial Transcriptomics (ST), which provides the whole transcriptome with morphological context. Aim 3. Generate an integrated cellular and molecular protein and gene expression kidney atlas. We will apply statistical and bioinformatic approaches to integrate the results from Aims 1 and 2 to create a composite map of the cellular protein and transcriptional expression profiles in the kidney. To accomplish these goals, we have assembled a multidisciplinary research team that includes nephrologists, renal pathologists, immunologists, and experts on multi-omics systems biology analyses. The proposed experiments are expected to reveal subsets of AKI and CKD patients based on the patterns of cells and molecular pathways present in the kidney, and to support identification of novel candidate biomarkers and therapeutic targets.

NIH Research Projects · FY 2026 · 2022-09

ABSTRACT Alzheimer's disease (AD) is a devastating, age-associated, and ultimately fatal neurodegenerative disorder. Although the prevalence of AD is increasing, there are no effective therapies that can prevent or delay AD onset. Brain-derived Lipoproteins (BLps), transport lipids throughout the brain, and are an emerging target for AD therapeutics. For example, the E4 isoform of the major BLp scaffold protein APOE can stabilize amyloid- beta (Aβ), leading to plaque formation and increased AD risk. However, due to the suboptimal isolation of BLps in earlier studies, and the use of unlipidated APOE4, important questions have been left unanswered. What factors regulate BLp processing, and can they be targeted to treat AD? Microglia play a major role in BLp processing and AD pathophysiology. Recent studies have shown that phagocytic microglia are defined by their elevated expression of lipoprotein lipase (LPL); the rate-limiting enzyme in lipoprotein hydrolysis and uptake. Notably, LPL-expressing microglia engulf Aβ to protect against Aβ plaque formation. The notion that LPL is protective is consistent with epidemiological studies showing reduced Aβ plaque formation and decreased AD prevalence in individuals harboring gain-of-function LPL variants. Although LPL is a potential target for the treatment of AD, this has not been validated in vivo. My laboratory has substantial expertise in lipid metabolism, LPL biology, and microglia and is uniquely positioned to investigate LPL as a therapeutic target for AD. We have previously shown that LPL regulates microglial phagocytosis, lipoprotein uptake, and immune function, hence identifying LPL as an immunometabolic gatekeeper in microglia (Bruce et al., 2018; Loving et al., 2021). Furthermore, our compelling preliminary data has shown that increasing LPL activity can enhance microglial uptake of Aβ and BLps. Therefore, we hypothesize that microglial-LPL helps to clear Aβ and excess BLps to protect against AD development and that increasing LPL activity in vivo can ameliorate AD progression. To test this, in AIM I, we will use microglial-specific knockdown mice (MiLPLKD) and AD susceptible mice (5xFAD) to empirically determine whether pharmacological LPL activation can halt AD progression. We will also use state-of-the-art metabolic imaging and `omics approaches to identify LPL-dependent mechanisms controlling microglial metabolism and function. In AIM II, we will use native BLps carefully isolated from human CSF to define LPL- dependent mechanisms governing lipoprotein processing by microglia and to determine whether enhancing LPL activity is a rational strategy to restore lipid handling in APOE4 carriers. The findings from this study will be transformative to our understanding of lipoprotein handling in the brain and the mechanisms leading to AD neuropathogenesis. Our study will not only determine LPL-dependent mechanisms regulating microglial metabolism and function but will also ascertain whether novel LPL activators can improve microglial function to ameliorate AD pathology, a new strategy with major clinical impact.

NIH Research Projects · FY 2024 · 2022-09

Project Summary Type 1 diabetes (T1D) is a tissue-specific autoimmune disorder. Strong genetic association with the HLA class II gene locus suggests the importance of CD4 T cells in initiating and driving the disease process. We and others have isolated T cells from the pancreas of T1D organ donors and identified T cell epitopes specific to insulin, and its precursor preproinsulin, as well as fusion peptides. An important next step is to elucidate the phenotypes of such islet-derived T cells in health and disease. Concurrently, the previous studies uncovered the fact that antigens for the majority of T cells in the islets are still unknown, and we do not even know whether those T cells are islet antigen-specific. Identifying antigen specificity of islet-CD4 T cells is critical to dissect disease pathogenicity and heterogeneity to develop antigen-specific immunotherapy to halt disease progression using appropriate antigens in a given individual. Therefore, the goal of this grant is to identify antigen specificity of CD4 T cells in the islets and link antigen-specific responses to T cell phenotypes. Multiple lines of evidence suggest that there may be `common' or preferred CD4 T cell epitopes within subsets of T1D patients. First, the vast majority of T1D patients have risk HLA class II alleles, and specific class II alleles are associated with development of an initial islet autoantibody (e.g. insulin autoantibodies develop in those with HLA-DR4, and glutamic acid decarboxylase-65 antibodies with HLA-DR3). Second, CD4 T cells having the same antigen specificity (e.g. proinsulin peptides and hybrid insulin peptides) are detected in the pancreata from multiple T1D organ donors, and the same reactivity is found in the blood of those with early stages of T1D. Finally, CD4 T cells specific to these epitopes have an inflammatory phenotype in the blood of T1D patients compared to non-diabetic controls. This leads us to hypothesize that islet autoimmunity is promoted and regulated by CD4 T cells reacting to `common' antigens that are shared by T1D patients having specific HLA class II molecules. We will determine the proportion of tissue-specific CD4 T cells in the islets (Aim 1) and seek to identify epitopes targeted by CD4 T cells in the islets of T1D organ donors (Aim 2). Furthermore, we will determine the molecular phenotype of islet antigen-specific T cells in the pancreatic lymph nodes and spleen of organ donors with and without T1D (Aim 3). The successful completion of this proposal will: (1) identify antigens and epitopes targeted by CD4 T cells from pancreatic islets across the stages of T1D development and (2) elucidate the molecular phenotype and features that render these T cells pathogenic. Thus, these studies will enhance our understanding of human T1D pathogenesis, dissect disease heterogeneity, and aid in improving the design of clinical trials evaluating antigen-specific immunotherapy for diabetes prevention.

NIH Research Projects · FY 2024 · 2022-09

Despite the notable scale up of antiretroviral therapy (ART) coverage among pregnant and postpartum women living with HIV (PWLWH) globally, reductions in new HIV infections in children have plateaued and significant numbers of PWLWH are still not able to achieve optimal health outcomes. In sub-Saharan Africa, emerging evidence indicates some vulnerable sub-groups of PWLWH are at higher risk of poor ART adherence, disengagement from HIV care, and unsuppressed viral loads. In order to eliminate mother-to-child transmission and protect maternal health, it is critical to identify these PWLWH at risk of suboptimal outcomes early and provide effective interventions that address key challenges. There is significant evidence that psychosocial stressors—HIV-related stigma, intimate partner violence, and lack of ability to disclose HIV status—are major drivers of treatment lapses in this population. Problem Management Plus (PM+) is a lay health worker-delivered intervention that has high potential to address psychosocial stressors and promote treatment engagement for high risk PWLWH. PM+ combines problem-solving therapy and behavioral strategies to address mental distress and has been adapted and implemented in other populations in Kenya. In the current study, we propose to develop and validate a multivariable prediction tool (i.e., “risk calculator”) using socio-demographic, clinical, and psychosocial data from our recent longitudinal studies with large samples of PWLWH in southwestern Kenya, the same setting where our current study is proposed (Aim 1). We will establish risk prioritization scores (critical, moderate, minor) that predict the combined outcome of a missed visit (> 30 days) or treatment failure (elevated viral load >400 copies/ml). Next, we will utilize a human centered design (HCD) approach to work collaboratively with PWLWH and key stakeholders to tailor modifiable components of the PM+ intervention to address challenges to achieving optimal HIV treatment outcomes in this population (Aim 2). We will collaborate with PWLWH and lay health workers to develop both mobile phone (mHealth) and in-person PM+ delivery formats to be able to deliver the intervention safely and efficiently to a mobile population. Finally, we will pilot our tailored intervention in a hybrid type 2 effectiveness-implementation trial in which pregnant women identified as critical or moderate risk are randomized to one of three study arms 1:1:1 standard of care, in-person PM+, or mHealth PM+ and followed through 6 months postpartum (N=120). Feasibility, acceptability, intervention satisfaction, and preliminary effects on mental health and HIV outcomes will be assessed. Findings from this research will prepare us for a large-scale trial in which we intend to use an adaptive design to test which interventions (including adapted PM+), combination of interventions, and sequence of interventions are the most effective and efficient to support the most vulnerable PWLWH in low-resource settings. This research will result in effective tools and adaptive intervention modalities which will contribute to eliminating mother-to-child transmission and achieving related global maternal and child health goals.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY The triplication of chromosome 21, which encodes ~225 genes, is the cause of Down syndrome. Individuals with Down syndrome experience a wide and variable spectrum of co-occurring conditions. Though we know the cause, which is trisomy 21, we have a poor understanding of how and why this chromosomal abnormality drives associated co-occurring conditions. A better mechanistic understanding of these connections will provide the basis for not only improving the care of individuals with Down syndrome but also for the general population. Research efforts such as the Human Trisome and INCLUDE Project are generating multi-omics data on large cohorts of individuals with trisomy 21 to gain such mechanistic insights. Given the complexity of the problem – the dosage increased of ~225 genes connected to a wide spectrum of conditions – existing tools for -omic data analysis struggle to leverage this information properly and separate generic from context-specific cellular responses. We must be able to analyze these data in the context of the full disease spectrum that individuals with DS experience, from genes to proteins to pathways. Further complicating these analyses, we and others have shown that certain genes and pathways are hypersensitive to perturbation, thus we often identify generic responses through standard analysis methods, when our goal is to find disease- and context-specific changes. These hyperresponsive genes and pathways obscure context-specific signals. We propose to develop the methodology to find the context-specific signal associated with trisomy 21. Our first aim is to develop methods to identify shared genetic mechanisms between complex diseases and molecular changes in Down syndrome co-occurring conditions. We will leverage genomic and transcriptomic datasets from a wide array of previously collected association studies. Our second aim is to develop a method to separate generic from context-specific signals in -omic datasets. We will employ a novel generative neural network simulation to generate different disease contexts, for which individual -omic samples can be compared. Our third aim is to determine the molecular connections between chromosome 21 genes and the co-occurring condition using search over knowledge graphs. All methods developed will be made public through the INCLUDE Data Coordination Center platforms.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY. Down syndrome (DS) is the most common genetic cause of intellectual disability and results from triplication of chromosome 21 (Hsa21), also known as trisomy 21 (T21). Individuals with DS demonstrate cognitive deficits and are at an increased risk of developing central nervous system (CNS) conditions, including neurological and psychological impairment, and Alzheimer’s disease (AD). With the exception of AD, which is linked to overexpression of the Has21-encoded amyloid precursor protein, the mechanisms underlying these CNS conditions remain largely unclear. This knowledge gap is hindering therapies for these conditions. People with DS are also exquisitely sensitive to environmental and social risk factors such as higher susceptibility to serious infection and to stress-triggered regression, consistent with the notion that external factors can be combined with T21-related genetic factors to reveal otherwise subtle pre-exiting defects in individuals with DS. Our exciting preliminary findings indicate that mild traumatic brain injury (mTBI) is a sensitizing stressor that reveals T21- associated neurovascular defects. mTBI results from a mild blow to or a sudden jolt of the head leading to neuroinflammation and oxidative stress that damage brain cells. It is a serious public health concern on its own, affecting ~3 million Americans each year with ~20% of them experiencing long-term neurological deficits. While examining the interaction between DS and mTBI, we recently uncovered a striking susceptibility of the Dp16 DS model mouse to mTBI-induced neurological and cognitive impairments. Young Dp16 mice exhibit a longer period of coma immediately after the head injury and display more severe sensorimotor and cognitive deficits even days later. Surprisingly, older Dp16 mice, but not age-matched controls, sustain severe post-injury intracerebral hemorrhage, indicating a cerebrovascular fragility that worsens with age. Moreover, expression of CtBP2, a proinflammatory transcriptional coactivator that is induced by mTBI, is elevated in the brains of injury-free Dp16 mice. These findings suggest the presence of T21-associated alterations in neuronal, glial, and vascular cells, which are the building blocks of the neurovascular unit (NVU). We postulate that T21 promotes NVU dysfunction through an interplay among developmental abnormalities, immune dysregulation, and oxidative stress, which predisposes the DS brain to a higher risk of TBI-induced long-term impairment. To test this hypothesis, we will firs establish how T21-related cellular defects and/or specific candidate genes exacerbate mTBI-induced sensorimotor and cognitive impairments (Aim 1). We will then define the cerebrovascular abnormalities in DS and aging brains with the aid of mTBI (Aim 2). We envision that these studies will help establish the molecular and cellular basis for DS-associated CNS conditions. The combined expertise in TBI, cerebrovascular function, DS mouse models, and DS biology of this collaborative multi-PI team will ensure the successful completion of the proposed studies.

NIH Research Projects · FY 2025 · 2022-09

Exposure to interpersonal violence (IPV) is associated with long-term negative mental health consequences, including an increased risk for posttraumatic stress disorder (PTSD), especially in women. The specific developmental timing of IPV is likely to play a significant role in disease outcomes where trauma experienced in late adolescence increases PTSD risk by 3-fold. However, little is known as to timing effects of IPV and PTSD risk related to sensitive periods of brain development and maturation. Our previous studies examined IPV experienced during specific developmental windows on health outcomes in a predominantly Black cohort of adult women. Our results revealed that psychophysiological reactivity related to PTSD risk, skin conductance response (SCR) and fear-potentiated startle, was uniquely observed when IPV was experienced between 14-18 yrs. Using an unbiased proteomic approach in extracellular vesicles (EV) to identify potential biomarkers specific to timing of IPV experience, we found a unique EV protein signature belonging to a 17q21 gene cluster and associated with skin keratinocytes, specifically unique to Merkel cells. Merkel cells are mechanosensitive neuroendocrine cells in the skin innervated by sensory Ab neurons that detect light touch stimuli via Piezo2 cation channels. We found similar changes in a mouse model in which multimodal sensory stress was experienced during the pubertal period, including EV proteins associated with the mouse keratin I gene cluster 11qD, and increased adult fear-potentiated startle responses and freezing behaviors. Taken together, these results support tactile-based trauma exposure during late adolescence may increase sensitivity of threat circuitry: the proposed cross-species translational study will examine molecular and physiological levels of analyses of the RDoC Acute Threat construct. In this proposal, we have the unique opportunity to investigate a 30-yr prospective longitudinal Black cohort who have been followed since birth, including collection of IPV data during late adolescence, and to capture their transition through young adulthood, providing insight into the mechanisms and biomarkers related to PTSD risk. Our overarching hypothesis to be tested is that IPV occurring during a sensitive period of late adolescence specifically programs distinct biological pathways along the threat-response axis involving the skin Merkel cell-neurite complex, and that these changes are detectable as accessible biomarkers to be tested in the following Aims: 1) To establish that a sensitive period of late adolescence for IPV experience uniquely associates with psychophysiological measures of acute threat, including SCR, fear- potentiated startle, and quantitative sensory testing in a prospective longitudinal birth cohort of Black men and women; 2) To identify biomarkers from examination of EV proteomics and characteristics relevant to PTSD risk from a prospective longitudinal cohort; and 3) To identify the Merkel cell involvement in production of EVs and alteration of behaviors relevant to PTSD risk using pubertal multimodal sensory stress in a mouse.

NIH Research Projects · FY 2026 · 2022-09

Project Summary Abstract Patient facing advanced serious illness have many complex decisions to make regarding their medical care. The range of options spans the most aggressive life prolonging care to care that is focused mainly on comfort. In 1997, the Death with Dignity Act was passed legalizing Medical Aid in Dying (MAiD) for the state of Oregon. Since that time, 11 other states have passed MAiD laws and 12 others are considering similar legislation. Yet despite the widespread access patients may have to this option, there is a paucity of research about patient’s experiences with decision making around MAiD and how aging may affect these decisions. We also lack data about the experiences and outcomes for caregivers, and the experiences of clinicians who are involved in the care of patients pursuing MAiD. To address these critical gaps in our understanding, we propose to conduct a longitudinal cohort study of patients who are pursuing MAiD from a national sample as well as their caregivers and clinicians. Aim 1: To understand quantitative and qualitative outcomes of seriously ill older and younger persons pursuing MAID and the patient-level factors that are associated with subsequently using MAiD. Aim 2: To understand the quantitative and qualitative outcomes of caregivers of older and younger patients pursuing MAiD. Aim 3: To qualitatively examine the attitudes and experiences of clinicians prescribing and caring for patients considering MAiD. This research is highly innovative because we will capture a national cohort of patients pre-MAiD as well as their caregivers and follow them forward. We bring together a highly experienced and multi-disciplinary team of investigators who have a demonstrated track record of collaboration and expertise across palliative care research and bioethics. Without understanding the diverse perspectives of patients, caregivers, and clinicians, we are unable to create or implement interventions to support these populations. Given the broad population that has access to MAiD, epidemiologic, experiential, and decision-making characteristics of individuals considering and pursuing MAiD may be critical to inform evidence-based policies and practices.

NIH Research Projects · FY 2026 · 2022-09

PROJECT SUMMARY Radiotherapy (RT) is often the only curative option for patients with inoperable tumors. However, radiation is also known to impair tumor metabolism, leading to radioresistance, the main reason for RT failure. Metabolic reprogramming (MR) in cancer is defined as the ability of the tumor to rewire its energy to fulfill the needs for tumorigenesis and progression. Our group observed for the first time that MR toward the Hexosamine Biosynthesis Pathway (HBP), an understudied glucose pathway leading to protein glycosylation, is associated with poor survival in the lung adenocarcinoma. Precisely, we showed that this metabolic switch happens primarily in Cancer-Associated Fibroblasts (CAFs). This suggests that CAFs redirect their glucose toward HBP, which increases O-glycosylation, a Post-Translational Modification (PTM) known to modulate radioresistance. However, very little is known about 1) which proteins are O-glycosylated after MR toward HBP and 2) how these PTMs affect the cellular behavior and modulate radioresistance. My preliminary results show that metabolic cooperation between cancer and stromal cells alters protein O-glycosylation in both cell types. Therefore, I hypothesize that tumor-stroma crosstalk in the Tumor Microenvironment (TME), leading to changes in the O-glycoproteome, plays a role in radioresistance. To validate this hypothesis, we developed a novel approach that precisely measures the outcome of MR towards HBP (e.g., O-glycoproteome) in the context of tumor-stroma crosstalk. We propose to apply this technique to tumor-stroma organoids designated here as “assembloids” that recapitulate metabolically heterogeneous cell neighborhoods and characterize their O-glycoproteome before and after RT. First, to visualize HBP metabolic heterogeneity in the TME, I will construct an in-situ map of the primary tumor compartments (endothelial, malignant, fibroblast, and immune) enriched for HBP metabolic markers and glycoform structures, using CODEX. CODEX is a cutting- edge multiplexed imaging method that allows for single-cell quantification of up to 50 markers in situ (aim 1). Then, I will deconvolute cell neighborhoods using machine learning and clustering biocomputational approaches to quantify and inform which neighborhoods are active regions of protein O-glycosylation. In aim 2, I will recapitulate HBP-enriched cell neighborhoods using a 3D assembloid model, irradiate them, then characterize metabolic radioresistance patterns using CODEX. Lastly, in aim 3, I will analyze the O-glycoproteome and spatial information of radioresistant assembloids. The O-glycoproteins or upstream drivers to O-glycosylation involved in critical tumor-stroma interactions will be inhibited in an attempt to restore radiosensitivity. The resulting data will generate the first hypothesis synthesis tool exploring an understudied dimension of cell signaling, the O- glycoproteome. They will lead to the discovery of new molecular targets involved in both tumor metabolism and stromal interactions with the primary goal of improving RT response in cancer patients with inoperable tumors.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY Unhealthy alcohol use, common among persons with (PWH) and at risk for HIV, is associated with multiple deleterious effects that increase the risk of HIV transmission. However, identifying individuals with unhealthy alcohol use in practice remains challenging because self-report consistently underrepresents true alcohol consumption. An objective measure of alcohol use, with clearly defined associations with clinical outcomes relevant for HIV prevention and transmission, would eliminate the time and resources dedicated to trying to subjectively quantify alcohol use, and would instead direct efforts towards swift and effective clinical interventions. Phosphatidylethanol (PEth) holds tremendous untapped potential as an objective, quantitative alcohol biomarker that could fill this unmet need. However, PEth has primarily been used in a qualitative and inconsistent manner which complicates interpretation and hinders actionable interventions. PEth's application to HIV prevention and treatment is also limited, especially with contemporary HIV pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) with injectable long-acting agents such as cabotegravir (CAB-LA) and cabotegravir/rilpivirine (CAB/RPV-LA). Delays in PEth concentration results in practice also impedes real-time interventions. This proposal will address these significant knowledge gaps and is directly responsive to RFA- AA-21-016. The long-term objective of this work is to advance PEth as an objective and actionable alcohol biomarker for HIV prevention and treatment. This will be accomplished as follows: Aim 1. Establish the relationship between PEth concentrations, PrEP adherence, and HIV acquisition among persons at risk for HIV. Using a seminal PrEP trial, HPTN-083, which compared CAB-LA vs. emtricitabine/tenofovir disoproxil fumarate (F/TDF) for HIV prevention in men and transgender women who have sex with men, the relationship between PEth and (1) time to drop-out, (2) time between cabotegravir/placebo injections, (3) intracellular tenofovir-diphosphate concentrations (an objective PrEP adherence biomarker) and (4) the risk of acquiring HIV will be established. Aim 2. Determine the ability of PEth to predict the undetectable=untransmissible (U=U) threshold among PWH with adherence barriers. To prevent HIV transmission and end the epidemic, suppression of viral replication to <200 copies/mL among PWH is essential. ACTG A5359 is a trial comparing CAB/RPV-LA vs. oral ART in PWH with a history of non-adherence to ART. A5359 includes a 12-24 week oral ART induction period with economic incentives (Step 1), followed by randomization to continued oral ART vs. monthly CAB/RPV-LA injections for 52 weeks (Step 2). The primary objective is to determine the ability of PEth in Step 1 to predict failure to achieve the U=U threshold in Steps 1 and 2. Aim 3. Develop a point-of-care test for PEth in whole blood. Using a commercially available miniature mass spectrometer, a point-of-care test will be developed for PEth. Immediate identification of unhealthy alcohol use will greatly accelerate clinical interventions and prevent deleterious clinical outcomes in persons at risk for HIV, PWH, and beyond.

NIH Research Projects · FY 2024 · 2022-09

(PLEASE KEEP IN WORD, DO NOT PDF) Enter the text here that is the new abstract information for your application. This section must be no longer than 30 lines of text. Congenital hematopoietic defects have been linked to a variety of co-morbidities affecting cardiovascular lineages, the kidneys, and limbs; curiously, their progenitor cells in the developing vertebrate embryo share a common embryonic origin in the lateral plate mesoderm (LPM). Understanding the developmental connection between hematopoietic lineage determination and other organ precursors forming from in part joint progenitor cells promises to shed light on the mechanisms of syndromic hematopoietic disorders. Thrombocytopenia Absent Radius (TAR) syndrome is a rare, congenital malformation that manifests as blood platelet defects and absent radius bones, concurrent with heart and kidney anomalies. TAR syndrome associates with chromosome 1q21.1 microdeletions that remove at least 20 genes including the exon junction complex (EJC) gene RBM8A/Y14 involved in splicing and mRNA degradation. Combined 1q21.1 microdeletion with compound inheritance of hypomorphic RBM8A alleles has found in a cohort of TAR patients, but how perturbed RBM8A/Y14 as general ubiquitous mRNA-processing factor causes the selective TAR phenotype remains to be uncovered. The syndrome’s phenotypes provide a paradigm for syndromic hematopoietic defects with complex co-morbidities which suggest that hypomorphic RBM8A perturbation predominantly impairs the lateral plate LPM when forming the progenitors for blood, limb, heart, and kidney. Using zebrafish as a model system and our leading CRISPR-Cas9-based protocols, we have successfully established a first mutant allelic series for rbm8a. In live in toto imaging of developing rbm8a mutants in transgenic zebrafish reporter strains, we detected migration defects of the hematopoietic progenitor-harboring LPM stripes, indicating an early defect in LPM patterning. Our data define the first embryonic rbm8a phenotypes in the LPM and hematopoietic progenitors using zebrafish as in vivo platform to identify the developmental cause of distinctive hematopoietic lineage perturbation in TAR syndrome. Mechanistically, from our transcriptome analysis of rbm8a-mutant zebrafish embryos, we found that planar cell polarity (PCP) signaling components are deregulated, providing a key candidate pathway for perturbed hematopoietic progenitor migration in rbm8a mutants. We hypothesize that PCP/non-canonical WNT signaling results in a selective, pathological phenotype in the LPM. We will identify the mechanism as to how select mRNAs, in particular components of PCP signaling, are perturbed in rbm8a mutants, resulting in higher sensitivity to migration defects using genetic interaction studies and enhanced crosslinking immunoprecipitation (eCLIP). Our results will connect the control of early PCP/non-canonical WNT-based LPM migration to consequences in hematopoietic progenitor formation and establish a proxy to better understand the causes and connections between hematological and related phenotypes of syndromic birth defects.

NIH Research Projects · FY 2025 · 2022-09

ABSTRACT Hypoxic Pulmonary hypertension (HPH) is characterized by elevated right ventricle pressures, increased vascular remodeling and resistance, and it is often fatal. Dysregulated immunity underlies the pathophysiology of the disease, which is supported by the elevated numbers of inflammatory cells around the remodeled vessels, as well as high levels of inflammatory cytokines present in the plasma of patients from different PH groups. Dendritic cells (DCs) are professional-antigen presenting cells that scan and sense their tissue microenvironment, coordinating innate and adaptive immune responses. Classical dendritic cells (cDCs) are divided in two different subsets: cDC1 (CD11b-/CD103+) and cDC2 (CD11b+). Activated DCs modify their immediate tissue microenvironment by secreting chemokines and cytokines that attract other inflammatory cells, including monocytes/ macrophages. Besides, activated cDCs drive polarization of naïve T cells into different effector phenotypes, most importantly CD4+/Th17 cells, which have been linked to experimental HPH. Therefore, there is a substantial body of evidence indicating that dendritic cells are orchestrators of the PH-related immune response, including their augmented presence around remodeled vessels in different etiologies of PH; however, there are few studies that address pathogenic mechanisms in which these cells could participate in PH. Our preliminary data indicate that bone-marrow-derived cDCs, particularly cDC2 that is increased in hypoxic PH lungs, are triggers of hypoxia-induced HPH; that monocyte/ macrophage recruitment and Th17 polarization may be dependent on cDC. The overall goal of this project is to determine the mechanistic role of the classical dendritic cell subset cDC2, in driving the recruitment of pro-remodeling thrombospondin-1- expressing monocytes to the lung, as well as directing T cell responses, which cause vascular remodeling in hypoxic pulmonary hypertension (HPH). This project will be highly innovative in pulmonary vascular diseases and will serve as a foundation to continue exploring this rich investigative research field, which will be essential to my transition to an independent investigator.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY Colorectal cancer (CRC) is frequently accompanied by the development of cachexia, a multi-systemic wasting syndrome that affects the majority of patients, especially when the disease recurs by forming liver metastases (LMs). Muscle and bone loss are amongst the most detrimental symptoms of cachexia and directly cause increased morbidity and mortality. We and others have shown that CRC also promotes metabolic and genomic perturbations of the liver, and further, that formation of LMs exacerbates muscle and bone wasting. Unfortunately, no cure is available for cachexia, and research on liver contribution to musculoskeletal wasting in cancer has been lacking; hence, there is an urgent need to develop novel treatments for cachexia-related musculoskeletal symptoms. In this regard, our preliminary findings suggest that IGFBP1, a liver-derived hormone belonging to the insulin-like growth factor family of binding proteins (IGFBPs), plays a causative role in cancer- associated musculoskeletal complications. In our preliminary studies, IGFBP1 was found elevated in CRC patients and in CRC hosts, along with muscle and bone loss. IGFBP1 induced myotube atrophy and osteoclast differentiation. Mice bearing subcutaneous C26 CRC displayed muscle atrophy, but no bone loss, whereas mice bearing C26 LMs showed marked muscle and bone wasting, along with dramatically elevated IGFBP1. Anti-IGFBP1 treatments prevented CRC-induced myofiber atrophy and osteoclastogenesis in vitro, whereas depletion of liver IGFBP1 abolished bone loss and improved muscle wasting in CRC hosts. IGFBP1 was also found elevated in mixed hepatocyte-CRC cultures and in the liver of metastatic CRC hosts, suggesting a role of IGFBP1 in cancer dissemination. The objective of this proposal is to define the mechanisms by which IGFBP1 drives bone loss and contributes to muscle wasting in CRC. Our central hypothesis is that elevated IGFBP1 exacerbates CRC-induced cachexia by triggering events consistent with musculoskeletal wasting. In Aim 1, we will determine the mechanism(s) by which IGFBP1 triggers bone loss in CRC. We hypothesize that in CRC elevated IGFBP1 signals through ITGB1 and promotes osteoclastogenesis, hence bone loss. In Aim 2, we will elucidate the mechanism(s) by which IGFBP1 causes muscle wasting in CRC. We hypothesize that high IGFBP1 participates in muscle atrophy. In Aim 3, we will explore the role of the liver microenvironment in the exacerbation of CRC cachexia. We hypothesize that tumor dissemination to the liver determines changes in gene expression in both hepatocytes and cancer cells consistent with enhanced growth rates and altered expression of IGFBP1 and other liver- and tumor-derived soluble factors. Our findings will define the mechanistic effects of IGFBP1 in cachexia and identify IGFBP1 as a new therapeutic target for the treatment of multi-organ complications in CRC. These results will also open new avenues for cachexia research.

NIH Research Projects · FY 2025 · 2022-09

Abstract: Intermediate filaments are highly conserved eukaryotic cytoskeletal proteins present in nearly every cell in the body. Although initially thought to simply provide structural support to cells, intermediate filaments are now implicated in a variety of biological processes due to their numerous protein interactions. Due to the number of intermediate filament monomers, more than 70 in humans, and the complexity of their regulation, more than 100 posttranslational modification sites, gaps remain in our understanding of the molecular mechanisms by which they are regulated and by which they contribute to many biological processes. To begin to fill these gaps, we seek to define molecular mechanisms by which intermediate filaments are regulated in cells and to define how intermediate filaments contribute to inflammation by focusing on their role in neutrophil inflammatory processes and migration. This proposal builds on the PIs previous experience investigating intermediate filament function during bacterial infection by proposing to leverage new cellular models of immortalized neutrophil populations with established screening approaches successfully use by the PI to define molecular mechanisms by which the intermediate filament vimentin contributes to inflammatory processes. The flexibility in funding provided by this R35 program will enable the PI the flexibility to follow the most promising lines of investigation and to leverage the proposed approaches to train junior scientists within the laboratory. The successful completion of the proposed studies is highly likely to improve our general understanding about the biological processes in cells to which intermediate filaments contribute and to our understanding of the mechanisms by which neutrophil function is regulated during inflammation.

NIH Research Projects · FY 2024 · 2022-09

PROJECT SUMMARY Many species, including mice, use ballistic reorienting movements called saccades to actively explore their environment for salient stimuli. Saccades result in a transient modification of visual perception such that it becomes difficult to see visual stimuli which appear around the time of saccades. This phenomenon is called saccadic suppression and it is associated with a decrease in neural activity across the visual system. Converging lines of evidence show that this neural correlate of saccadic suppression arises from a combination of visual and premotor mechanisms. Several studies have shown that the simulating the self-generated motion associated with saccades is sufficient to reduce visual sensitivity in the retina and reproduces the perceptual deficits associated with actual saccades. Complementary studies have hypothesized that the saccade motor plan is broadcast to the visual system where it is used to suppress visual activity during the peri-saccadic epoch. This is supported by studies which demonstrate the persistence of saccadic suppression under conditions which minimize or preclude the effect of visual mechanisms. In this proposal, we seek to understand how the visual and premotor components of saccadic suppression are implemented by neural circuits. We will focus our investigation on the midbrain superior colliculus (SC), a visuomotor brain structure which has long been suspected as the source of a corollary discharge that suppresses visual activity around the time of saccades. We would like to add to this idea that the visual output of the retina is itself modulated by saccades. We hypothesize that a corollary discharge of premotor activity in the SC and the peri-saccadic modulation of retinal signals cooperate to produce suppression of visual activity in the superficial layers of the SC around the time of saccades. In Aim 1 of the proposal, we will dissect the premotor circuitry in the SC using optogenetics, chemogenetics, and high-density in vivo recordings of single-unit activity while mice make saccades. In Aim 2 of this proposal, we will examine SC-projecting retinal ganglion cells for peri-saccadic modulation using two-photon calcium imaging and naturalistic visual stimulation. Public health significance. This proposal aims to understand how saccadic suppression is implemented by dissecting the visual and premotor circuitry in the midbrain SC. This research will advance our understanding of the neural basis for stable and continuous visual perception across saccades which is critical for the conduct of normal visual behavior. In addition, this research could lead to improvements in the diagnosis and treatment of injury and diseases which affect the oculomotor system.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY Clinical decision support (CDS) tools are pervasive and can “nudge” clinicians to make the best decisions easy, yet currently lead to minimal improvements in patient outcomes. Although often ignored, consideration of contextual factors and minimizing irrelevant information improves CDS outcomes. To minimize irrelevance, currently existing, ‘traditional CDS’ are often designed to be patient-specific, but are not tailored to clinicians. For example, traditional CDS address common prescribing misconceptions that are not relevant for all clinicians. However, prescribing patterns could be used to determine whether prescribing misconceptions might exist and then conditionally present information within a ‘personalized CDS’ to address a specific clinician’s misconceptions; thereby minimizing irrelevance and alert fatigue. A ‘personalized CDS’ could substantially improve guideline-directed management and therapy (GDMT) for the many suboptimally treated patients with heart failure and reduced ejection fraction (HFrEF). Aim 1: Design and build prototypes of traditional and personalized CDS to address common misconceptions of GDMT for HFrEF. We will create a personalized and traditional CDS prototype for 4 categories of GDMT: beta blockers, sacubitril/valsartan, mineralocorticoid receptor antagonists and sodium/glucose cotransport 2 inhibitors. Clinicians will prioritize the misconceptions to address. The traditional CDS will address all prioritized misconceptions, while the personalized CDS will conditionally address the misconceptions based on clinician-specific prescribing patterns. To account for contextual factors, we will use the Practical Robust Implementation and Sustainability Model (PRISM) to guide design and usability testing. Aim 2: Pilot the traditional and personalized CDS tools in real-world care settings. Aim 3: Compare the traditional and personalized CDS in a pragmatic randomized controlled trial. Cardiology and primary care clinics at one health system will be cluster-randomized. We will use sequential mixed methods and PRISM evaluation metrics to compare the two CDS tools. Quantitative outcomes include reach, adoption and effectiveness of prescribing. We will interview 15 frontline clinicians and 5 leaders to 1) identify PRISM factors influencing implementation outcomes, and 2) plan for external dissemination. This proposal was designed to address my training gaps: 1) EHR architecture, 2) behavioral economics/nudges, and 3) pragmatic trial design. Completion of this proposal will ensure my development into an independent investigator that leverages implementation science to create innovative CDS solutions that consistently and effectively optimize GDMT for HFrEF across health systems. This research is significant because it has the potential to substantially improve GDMT and outcomes for high-risk patients with HFrEF. Our innovative, personalized CDS challenges the status quo of “one size fits all” CDS by individualizing CDS to both patients and clinicians; a paradigm-shift that will have far-reaching influence on CDS development and GDMT.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY / ABSTRACT Invasive lobular carcinoma (ILC) is an understudied subtype of breast cancer. Clinical and epidemiological features of ILC are consistent with an exquisite dependence on estrogen and estrogen receptor alpha (ER), and ILC biomarkers suggest that patients should have good outcomes with anti-estrogen treatment. However, recent studies show that relative to other breast cancers, ILC patients have poorer long-term outcomes, have poorer response to anti-estrogen therapy, and also do not benefit from chemotherapy. New treatments are needed to improve ILC patient outcomes. However, advances are hindered by a fundamental lack of understanding of the distinct biology of ILC, in particular regarding ER signaling. We and others identified de novo anti-estrogen resistance in ILC models, and see that ER in ILC cells is activated by tamoxifen and next- generation ER antagonists. Based on these observations, the limited efficacy of anti-estrogens in treating ILC may be due to differences in ER function in ILC. Our work has identified unique ER functions in ILC, including ILC-specific ER target genes, ER DNA binding, and ER signaling pathways, which in part explain endocrine response and resistance. As a basis for these unique ER functions and anti-estrogen resistance in ILC, we identified mediator of DNA damage checkpoint 1 (MDC1) as a novel transcriptional co-regulator of ER in ILC cells. MDC1 is a cornerstone of DNA damage response, but in ILC, MDC1 acts as an ER co-regulator and is required for ER-driven growth and ER regulation of key target genes, as well as anti-estrogen resistance. Our data indicate that MDC1 regulates ER at least in part through epigenomic remodeling. MDC1 ER co-regulator functions interplay with canonical roles of MDC1 in DNA damage response, implicating these functions in clinical chemoresistance in ILC. The objective of this proposal is to define how MDC1 controls ER-driven gene regulation and how ER:MDC1 mediates DDR functions in ILC cells. Our central hypothesis is that MDC1 is a critical ER co-regulator mediating ER target gene regulation in ILC, creating targetable cross-talk between ER and DNA damage response. In this study, we will: i) Define how ER and MDC1 interact to build a gene regulation complex; ii) Define how ER and MDC1 influence their collective genome interactions; iii) Define the DNA damage response that is associated with ER and MDC1 function. This project will lead to mechanistic understanding of MDC1-driven ER functions in ILC, and link the unique functions of ER in ILC to new precision treatment strategies using DDR inhibitors. Defining the role of MDC1 will also provide insight into the unique ER-dependent etiology of ILC. This proposal will advance translational study of MDC1 by identifying ER:MDC1 biomarkers and therapeutic strategies to target MDC1-related DDR dependencies. Characterizing the role of MDC1 is critical to understand ILC biology and improve outcomes for patients with ILC.

NIH Research Projects · FY 2024 · 2022-09

Project Summary/Abstract For clinical decision support to be effective it must provide the right information, to the right persons, at the right times, in the right formats, and via the right channels (aka ‘“The 5 Rights of CDS”). The “5 Rights of CDS” framework also applies to shared decision-making support. Shared decision-making is a patient-centered form of clinical decision-making. Patient decision aids (PDAs) are increasingly recognized as valuable tools to support shared decision making, and several are mandated by CMS for coverage determinations. To facilitate successful PDA implementation a PDA containing the right information must be provided to the right patient at the right time, in the right format, and be delivered in the right channel. Despite the proven clinical benefits of PDAs, informatics systems to reduce the barriers health systems, physicians, and patients face in using PDAs are lacking. Known limitations of PDA use include having to locate the right PDA, knowing the quality of the PDA, having to leave the electronic health record (EHR) environment to find and use the PDA, having to manually enter data into the PDA, and documenting the process of shared decision-making that was undertaken. The objective of this proposal is to create an informatics system that addresses know PDA implementation barriers, supports the “5 Rights” framework, and is built to be reusable, interoperable, and scalable. The proposed Shared Decision Aid Navigator System (SDANS) will address PDA implementation limitations by (1) creating a repository of the PDAs metadata needed to support “5 Rights” implementation, (2) creating a SMARonFHIR (SoF) EHR-embedded PDA navigator that relies on PDA metadata, patient data, and organizational data to implement the “5 Rights” and to support documentation (3) using the Fast Healthcare Interoperability Resources (FHIR) standard to retrieve patient data that can be used to support the “5 Rights” of implementation and to provide data to data-enabled PDA tools, (4) using CQL and creating a Clinical Quality Rules (CQL) rules repository to maintain PDA implementation rules, and (5) creating an administrative application for health systems and practices to modify and maintain their PDA repository and CQL implementation rules. In Aim 1 we will employ co-design principles and qualitative methods with patients, clinicians, and health information technology (HIT) experts to design and build the SDANS to ensure it meets the needs of those who will use the system. We will also convert three current high-quality, evidence-based CMS-mandated PDAs into SMARTonFHIR applications to allow us to test the full functionality of the SDANS. In Aim 2, four medical centers will deploy the SDANS and the three SOF-converted PDAs into a proof-of- concept environment and we will evaluate the feasibility, functionality and satisfaction with the system. In the long-term, the SDANS will lead to improved implementation of PDAs and meet AHRQ’s mission to improve the use of CDS, including PDAs, and to improved patient-centered outcomes.

NIH Research Projects · FY 2025 · 2022-08

ABSTRACT Subjects with type 1 diabetes (T1D) have three- to six-fold higher fracture risk compared with subjects without diabetes, and although bone mineral density (BMD) – the clinical standard to assess osteoporosis and fracture risk – is lower in subjects with T1D compared to controls, BMD alone cannot explain the disproportionate increase in fracture risk associated with T1D. The risk of fracture in middle-age and older subjects with long- standing T1D might be compounded by young-onset T1D, the accumulation of advanced glycation end products (AGEs) due to chronic hyperglycemia, or by a potential superimposition of aging and long-term T1D effects on bone. The “Bone Health in Adults with Type 1 Diabetes” study (R01DK122554) aims to explore BMD and bone strength at the hip using quantitative computed tomography (QCT) in subjects with long-standing T1D and age-, sex- and body mass index-matched controls, as well as to investigate the effects of chronic hyperglycemia and hypoglycemia on bone health. However, bone strength – the main determinant of bone fracture – is determined by BMD, bone quality, and its microenvironment including bone marrow adipose tissue. Therefore, we propose an ancillary study to the “Bone Health in Adults with Type 1 Diabetes” parent study and leverage its well-characterized cohort of subjects, clinical, laboratory, and imaging data to assess phenotypes of bone marrow adiposity (BMA) and bone microstructure in middle-age and older subjects with long-standing T1D using advanced imaging and image analysis techniques. Using chemical shift-based water- fat separation magnetic resonance imaging and high-resolution peripheral quantitative computed tomography (HR-pQCT) we aim to assess differences in 24-month changes in BMA at the proximal femur and in bone microstructure at the distal radius and distal tibia between middle-age and older subjects with long-standing T1D and controls without diabetes. Furthermore, differences in the spatial distribution of 24-month changes in BMA between the two groups will be investigated using voxel-based morphometry; and the associations of chronic hyperglycemia and hypoglycemia with 24-month changes in BMA and bone microstructure will also be explored. Due to the increase incidence of T1D and improved medical care, the life expectancy of subjects with T1D is expected to increase, and although subjects with T1D have an increased risk of fracture during the entire life, most fractures occur at older age when the total fracture burden is greatest in the general population. Therefore, there is a critical need to better understand the etiology of T1D-related bone disorders to develop clinical strategies to prevent clinically and economically costly fractures in this large vulnerable population.

NIH Research Projects · FY 2024 · 2022-08

PROJECT SUMMARY Autosomal dominant polycystic kidney disease (ADPKD) is a common inherited disorder that leads to end- stage kidney disease. Despite decades of research, tolvaptan is the only approved intervention in ADPKD. However, tolvaptan does not target cardiovascular complications of ADPKD and is constrained by high cost and side effects that limit adherence. Therefore, there is an urgent need for a well-tolerated alternative intervention to slow ADPKD progression and improve vascular health. Sodium-glucose cotransporters-2 inhibitors (SGLT2i) have a track record of tolerability and safety in patients with proteinuric diabetic and non- diabetic kidney disease. Trials of SGLT2i in these conditions have been extremely encouraging, and these treatments are highly likely to become the standard of care for diabetic and non-diabetic kidney disease; however, the mechanisms of action are not fully elucidated, and may be non-specific to disease etiology. The potential benefit of SGLT2i has not been examined in patients with ADPKD, as major trials have excluded such patients. There are also potential benefits of SGLT2i to ADPKD patients beyond slowing loss of kidney function, as this class of drugs provide a cardiovascular mortality benefit for patients across the CKD spectrum. Studies testing the effects of SGLT2i in animal models of PKD have yield conflicting results. Five weeks of treatment with an SGLT1 and SLGT2 inhibitor phlorizon was shown to inhibit cystogenesis in the Han:SPRD rat model of PKD. The mechanisms by which SGLT2i slows cystic renal disease progression may be related to inhibition of cyst epithelial cell proliferation. SGLT2i have also antioxidant and anti-inflammatory actions, which are important for reducing fibrosis and improving vascular health, both of which occur in early stages of ADPKD. While many changes likely contribute to the development of arterial dysfunction in patients with ADPKD, among those of greatest concern is the development of stiffening of large elastic arteries, typically assessed by aortic pulse wave velocity (aPWV). We propose a pilot randomized clinical trial to determine the safety and tolerability of empagliflozin in ADPKD patients. To achieve this, we will conduct a 12-month parallel- group, randomized, double-blind, placebo-controlled trial in 50 ADPKD patients with an eGFR 30-90 mL/min/1.73m2. Secondary, exploratory endpoints will determine the effect of empagliflozin on kidney volume, kidney function, aPWV, plasma copeptin levels, urinary kidney injury molecule-1 (KIM-1) and quality of life. Specific Aim 1: To determine the feasibility, in terms of safety and tolerability, of prescribing empagliflozin 25 mg once a day in ADPKD patients at risk for progression with an eGFR of 30-90 mL/min/1.73m2. Specific Aim 2: To derive preliminary estimates of the effect of empagliflozin compared to placebo on 12- month change in a) total kidney volume by magnetic resonance imaging, b) eGFR, c) plasma copeptin levels (a marker of vasopressin secretion), d) urinary KIM-1 (a marker of tubular injury), e) aPWV; and f) ADPKD- specific health-related quality of life (HRQoL) as quantified by the ADPKD-Impact Scale.

NIH Research Projects · FY 2026 · 2022-08

The research proposed in this application aims to understand risk and protective factors that promote continuation and desistance of problematic substance use (SU) and antisocial behavior (ASB) that began in adolescence. We propose a fourth wave of follow-up, approximately 18 years after initial recruitment, of an extremely affected adolescent sample as they transition into middle adulthood; this is a developmental period when we expect a portion of these individuals to decrease or desist problematic SU and associated high-risk behaviors, while others will persist with the most serious, destructive behaviors leading to devastatingly high rates of morbidity and mortality. The aims of this proposal are to: Aim 1: Identify risk factors that predict level and change (growth or decline) in SU and ASB from adolescence to middle adulthood. a. We hypothesize that early age of onset, male sex, child maltreatment, neurocognitive deficits, and personality traits (behavioral undercontrol/impulsivity) will predict higher levels and more growth in SU and ASB. b. We hypothesize that genetic vulnerability as indexed by polygenic risks scores (PRS) will predict faster growth in SU and ASB that persists through later adulthood. c. We will explore mechanistic relationships; e.g., we hypothesize that the relationship between PRS and level and change of SU and ASB will be partially mediated by behavioral undercontrol/impulsivity. Aim 2: Identify protective factors associated with level and change in SU and ASB. a. We hypothesize that adopting adult prosocial roles (education, employment, marriage, parenting) will be associated with lessened growth in SU and ASB. b. We hypothesize that treatment will be associated with greater desistance of SU and ASB than incarceration. c. We will explore moderators of genetic vulnerability, specifically whether prosocial roles and treatment attenuate the effect of PRS on level of SU and ASB. Aim 3: Determine the extent to which findings are specific to our highly selected sample of individuals with early-onset SU and ASB or generalize more broadly by conducting comparative and joint analyses of data from our high-risk sample with similar longitudinal data from our currently funded study of twins, an unselected community-based sample. a. We hypothesize that risk and protective factors will operate similarly across the two samples, although we will have a greater magnitude of risk factors in the high-risk sample. b. We will confirm this hypothesis in joint analyses of the high-risk and community twin samples.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY Palliative care focuses on improving quality of life for people with serious illness and their family caregivers at any stage of illness and aligning medical treatments with a persons' values and goals. Older adults with serious illnesses such as heart failure (HF) or chronic obstructive pulmonary disease (COPD) have numerous palliative care needs. However, palliative care is often provided late in illness by palliative care specialists, near the end of life. In addition, palliative care is a limited resource that is not available to many of the patients with HF or COPD and their family caregivers, especially in urban poor and rural settings. Furthermore, many older adults with HF or COPD have comorbid cognitive impairment and dementia which are associated with worse outcomes. In prior work, I tested the effect of early palliative care interventions for adults with HF or COPD. In this application, I propose new research to determine how to adapt and implement early palliative care into the primary care setting for patients with HF or COPD who have cognitive impairment or Alzheimer's disease and related dementias. The overall goals of this proposal are to (1) train mentees (through increased mentoring time) to increase the cadre of successful patient-oriented researchers who will improve care and outcomes for older adults with serious illness and cognitive impairment, and (2) expand my research skills and experience in cognitive impairment and implementation science research for seriously ill older adults in primary care. I will accomplish these goals through additional training, research experience, and mentorship from experts in cognitive impairment, implementation science, and mentoring. During the K24, I will work closely with mentees to develop individual career plans and conduct research to further their development as independent investigators in palliative care, aging, and cognitive impairment. The research proposed in this application will: (1) determine how cognitive impairment influences participation in early palliative care and palliative care outcomes; we will analyze cognitive function and quality of life data from two of my multisite clinical trials (one completed, one active) of older adults with HF or COPD, and (2) engage primary care stakeholders (clinicians, leaders, staff, patients, and caregivers) to identify which palliative care interventions to implement in primary care and how to implement them. The proposed research, conducted with implementation science collaborators and mentees, will provide new knowledge on how to adapt and implement early palliative care into primary care for older adults with HF or COPD and cognitive impairment, including Alzheimer's disease and related dementias. I am thrilled to train the next generation of patient-oriented researchers in palliative care, aging, and cognitive impairment. With my record of research and mentoring success and the resources from the K24 and the University of Colorado, I can provide an outstanding training environment.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY/ABSTRACT A diagnosis of metastatic colorectal cancer (mCRC) and its treatment is life-altering; up to 60% of mCRC patients and a similar percentage of their intimate partners report clinically significant levels of distress.1-5 Effects of mCRC often lead to unique challenges on both an individual and relationship level,6-14 and an intervention designed to address these concerns and reduce distress in couples facing mCRC is critically needed.6-8,10-12,28,30 A mindfulness-based intervention (MBI) could fill this gap, given strong evidence for reducing distress in cancer patients32-34 and partners35 and in improving relationship outcomes.36-38 However, existing MBIs are poorly suited for couples facing mCRC due to several inadequacies in their content and format. Given significant changes that would be needed to modify an existing MBI, a new couple-based MBI designed to meet the unique needs of mCRC couples is warranted. Therefore, the overall objective of the proposed research project is to develop, refine, and evaluate a four-session, couple-based mindfulness intervention (“MIND-Together”: Mindfully Navigating Distress Together) delivered via video-conference and designed to promote mindful coping and reduce distress for mCRC patients and their partners. First, we will generate data on the needs and preferences of 12 couples facing mCRC (N=24 patients and partners) and 12 clinicians treating mCRC through qualitative interviews, which will include queries about intervention content (e.g., scope) and structure (e.g., format). Then we will develop drafts of the intervention protocol, which will be refined and finalized through cognitive interviews with 6 mCRC couples (N=12 patients and partners) and expert review. Second, we will assess the feasibility, acceptability, and preliminary effects of the intervention through a pilot randomized controlled trial among 45 mCRC couples (N=90 patients and partners), assigned 2:1 to either MIND-Together (n=30 couples) or an attention-controlled condition (n=15 couples). In an exploratory aim, we will use exit interviews to explore couples’ experiences of MIND-Together in order to further optimize the intervention content and delivery, and identify potential mechanisms to assess in future trials. Upon study completion, we will have established whether the intervention is feasible, acceptable, and preliminarily efficacious in reducing distress in a sample of couples facing mCRC. Future research will be to evaluate the intervention efficacy and assess mediators in a larger randomized trial. In addition to the research study, formal training in three content areas will support the PI’s goal of becoming an independent investigator with expertise in the development, evaluation, and delivery of interventions among individuals affected by cancer. Training areas include: (1) cancer survivorship issues among colorectal cancer patients, (2) couple-based approaches for improving psychosocial outcomes in cancer survivors, and (3) developing and evaluating psychosocial interventions. Overall, the proposed research has the potential to help address the critical psychosocial needs of couples facing mCRC and to advance the science of mindfulness and couple-based approaches in cancer care.

NIH Research Projects · FY 2024 · 2022-08

PROJECT SUMMARY: Deaths related to opioid use disorders (OUD) have sky-rocketed in recent years, leading to a widespread public health crisis. This opioid endemic is worsened by a lack of effective therapeutic intervention strategies that directly target or reverse the opioid induced neuroadaptations driving drug use and relapse. Prior research indicates that experiencing a major stressful event in life is the greatest risk factor for exacerbated opioid use and relapse among adults. Congruent with clinical data, preclinical work indicates that acute stress in adulthood increases psychostimulant seeking in intravenous drug self-administration rodent models, but the effects of acute stress on opioid seeking remain unknown. Further, the neurobiological mechanisms by which stress confers OUD susceptibility are unclear. Emerging literature shows that ventral pallidal glutamate neurons (VPGlu) are key regulators of drug seeking behavior and aversive states, which suggests that this neuronal subpopulation may be a strong candidate for mediating the effects of stress on OUD-relevant circuit function that exacerbates OUD pathology. My preliminary data sought to begin addressing these gaps in the OUD literature by examining how acute stress impacts heroin sensitization and VPGlu activity using in vivo miniscope Ca2+ imaging in non-head fixed male and female mice. To the best of my knowledge, this preliminary work represents the first in vivo characterization of VPGlu activity during intense acute stress, and I am the first to report that VPGlu are responsive to both stress and heroin. Furthermore, my sensitization data demonstrate that stress produces sexually dimorphic changes in the psychomotor effects of heroin. Taken together, these preliminary data show that adult acute stress alters the psychomotor properties of heroin and highlight VPGlu as promising mediators of stress and OUD-relevant behaviors. My data warrant further investigation into the impact of stress on clinically relevant opioid behaviors such as motivation and relapse to heroin seeking, and the systematic characterization of how stress, opioids, and their intersection regulate the activity of VPGlu by altering synaptic inputs onto these cells. Together, my preliminary data informed my main hypothesis that acute stress will enhance heroin motivation and relapse to heroin seeking and that stress and opioids interact to alter VPGlu synaptic function. The goals of this proposal are to interrogate 1) how stress impacts the motivation and relapse to heroin seeking using an intravenous self-administration model and 2) assess the effect of stress, opioids, and their interaction on synaptic function of VPGlu using ex vivo whole cell patch clamp electrophysiology. The outcomes of this proposal will determine the consequences of acute stress on clinically relevant behavioral responses to heroin and systematically characterize alterations in synaptic function of a newly established stress-reactive neuronal subpopulation. Completing this proposal will be invaluable to my development into a successful physician-scientist by providing the necessary skills to perform high-impact, rigorous substance use disorder research while gaining essential clinical proficiencies to treat patients affected by these disorders.

NIH Research Projects · FY 2025 · 2022-08

Project Summary/Abstract Metabolic syndrome (MS), characterized by a cluster of conditions including dyslipidemia, central abdominal obesity, insulin resistance, and high blood pressure, is prevalent in people living with HIV (PLWH), and puts them at greater risk of cardiovascular events. MS and related metabolic derangements have been strongly correlated with gut microbiome activity outside the context of HIV but has not been deeply explored in HIV infected or uninfected men who have sex with men (MSM), who have a highly altered gut microbiome composition. Intestinal dysbiosis, compromised intestinal barrier integrity and associated inflammation has been linked with MS in certain populations, but whether this is a driving factor of high levels of MS in HIV+ MSM has not been deeply explored, even though increased bacterial translocation and associated systemic inflammation is known to occur in PLWH. In our ongoing studies of factors that influence metabolic disease across HIV+ and HIV negative MSM, we found elevated plasma lipopolysaccharide binding protein (LBP) to be the most important predictor of poor metabolic health, with network analysis showing that LBP formed a hub joining correlated microbial and immune predictors of poor metabolic health. Our results suggest a central role of inflammatory processes linked with barrier dysfunction in the development of MS in HIV+ MSM, but further mechanistic studies are needed to fully understand how barrier function is compromised, including a potential role for gut bacteria and bacterial-derived metabolites, which are well known to influence barrier. One key finding of our ongoing work was a negative correlation between plasma LBP levels and butyrate-producing bacteria; Butyrate has a well-characterized protective influence on intestinal epithelial integrity. We also observed a positive correlation between LBP and a microbe that degrades sialic acids on mucus glycoproteins, which has also been linked with intestinal barrier dysfunction and inflammatory processes in PLWH previously. Thus, we hypothesize that intestinal dysbiosis impacts gut barrier function in HIV+ MSM, and that this promotes MS via the translocation of microbial products including LPS. To test this hypothesis, we will perform three coordinated specific aims. In Aim 1 we will determine whether intestinal barrier dysfunction is higher in HIV+ and negative MSM with MS compared to without MS and related to deficiency in butyrate- production and/or activity of mucolytic bacteria in the gut microbiome. In Aims 2 and 3 we will verify the relationship between HIV/MS-associated gut microbes and barrier dysfunction using enteroides and gnotobiotic mice, and explore the role of microbial production of butyrate and degradation of mucus glycoproteins in these processes. Taken together this work will produce a mechanistic understanding of the relationship between gut microbiome dysbiosis, barrier function, and MS in HIV-infected individuals and will have broader implications as well, since intestinal barrier dysfunction has been linked with chronic inflammation, and many associated co-morbidities in PLWH.