Stanford University

NIH Research Projects · FY 2024 · 2020-07

PROJECT SUMMARY/ABSTRACT Prescription opioids are a potent class of drugs for treating pain. However, growing body of research has described iatrogenic consequences of long-term (> 90 days) opioid use in patients with chronic pain including hyperalgesia and impaired executive function. Dopamine is a critical modulator of executive function. While changes in pain and behavior have been noted, little is known about the brain’s morphology, neural and dopaminergic activity that change over time with long-term prescription opioid use. Consistent with the NIDA Strategic Plan objective 1.3, this K25 proposal seeks to “establish the effects of drug use, addiction, and recovery on brain circuits, behavior, and health” using neuroimaging-informed tools. Specifically, the present study combines multiple levels of investigation, including structural and functional Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), Quantitative Sensory Testing (QST) and neuropsychological assessments of executive function, and employ machine learning techniques for analysis to identify the effects of long-term prescription opioid use on the brain in chronic pain patients. The applicant will use her advanced quantitative skills in neuroimaging data analysis and modeling to training in QST, and experience in cognitive neuropsychology, epidemiology of chronic pain and addiction to develop an independent research plan in translational pain and successfully compete for future R01 funding. To achieve the training needed to facilitate this investigation, the applicant has consulted with an expert in chronic pain research and opioid therapy, a substance abuse specialist, a neuropsychologist, an epidemiologist, an imaging scientist, and a machine learning leader in neuroimaging field to develop an innovative study and training plan. 40 patients with a diagnostically homogeneous chronic pain condition (i.e., chronic low back pain; CLBP) on long-term opioid therapy, as compared to 40 opioid-naïve CLBP patients, will be studied to achieve the following Aims: 1) Measure pain, cognitive performance, neural and dopaminergic activity during concurrent pain and executive function task fMRI-PET to characterize the effects of opioids on pain processing and executive function in CLBP; 2) measure intrinsic brain activity during resting state fMRI-PET to identify intrinsic brain alterations associated with long-term opioid use in CLBP; and 3) apply high-resolution structural MRI to measure opioid-induced morphological changes in CLBP. This research is innovative in its use of combined QST and neuro- psychological measures with multimodal imaging and sophisticated statistical approaches. It is significant because of its comprehensive approach towards addressing the NIDA Strategic Plan objective. Findings stand to inform medical decision-making regarding pain care and opioid prescription, as well as risk mitigation strategies. The research, training and results obtained will provide a platform for applicant’s long-term scientific research goal of becoming an independent R01-funded, faculty-level principal investigator performing translational pain research aimed at developing neuroimaging tools to have clinical application.

NIH Research Projects · FY 2024 · 2020-07

PROJECT SUMMARY/ABSTRACT Heart failure causes over 80,000 deaths and $30 billion in spending annually, yet therapies that improve survival and reduce morbidity are underutilized. Insufficient healthcare quality and high costs sparked the development of value-based payment programs, such as Medicare’s Merit-based Incentive Program (MIPS). MIPS is the largest clinician value-based payment program in use in the United States. MIPS is intended to improve the quality of care while reducing costs by altering clinician payments based on clinician performance on cost and quality measures. MIPS quality measurement is increasing its focus on patient-reported outcome (PRO) measures, including for heart failure, despite limited evidence that PROs improve heart failure care. Aim 1 will be a pragmatic, single-center randomized trial evaluating whether integration of PRO assessment into the routine heart failure clinic workflow is feasible and improves health-related quality of life at one year. This patient-oriented trial will determine if the clinical impact of PRO assessment is worth the costs of data collection. Aim 2 will evaluate the association between the introduction of MIPS (in 2017) and trends in Medicare heart failure care: guideline-recommended therapy use, mortality, and costs. This study will use multiple analytic approaches and controls (VA and commercially insured heart failure patients) to develop robust estimates of these associations. This work will have a substantial impact on heart failure clinical care and patient outcomes by defining the effect of both routine PRO assessment and MIPS as a whole. It will inform the design of future clinician value-based payment models. Dr. Sandhu will use this research along with the protected time, training, and mentorship of this K23 Award to become an independent, patient-oriented health services researcher. Dr. Sandhu’s long-term research goals are to improve the quality and efficiency of heart failure patient care by evaluating the implementation of local quality improvement and national health policy. The proposed research experience and the training in clinical trials and causal inference statistics during this award is critical to achieving those goals. He will gain these skills through coursework, local research seminars, national conferences, and direct instruction from his mentorship team. His mentors are experts in implementation trials, outcomes analysis, and advanced statistical methods. They are supplemented with an exceptional advisory committee with complementary expertise in clinical trials, heart failure, and health policy. With this mentorship team and support from the Stanford Department of Medicine, Dr. Sandhu will have the tools to efficiently complete the trial in Aim 1. His rigorous training plan, the expertise of his mentors, and his experience with the data make the sophisticated policy analysis in Aim 2 feasible. Overall, the training, research, and mentorship of this award will guide Dr. Sandhu in his transition to becoming an independent, successful patient-oriented health services researcher with the skills to compete for R-level funding.

NIH Research Projects · FY 2024 · 2020-07

HIFU-immunotherapy in pancreatic cancer Most importantly, we find that the combination of ultrasound, TLR7/8 agonists with aCD40 and checkpoint inhibition (building on a protocol in emerging human studies) efficiently eliminated implanted multisite invasive KPC murine pancreatic tumors. Recent studies have provided compelling evidence as to the utility of agonist CD40 (aCD40) antibodies within multicomponent protocols to treat pancreatic cancer, and studies combining aCD40 with checkpoint modulators and chemotherapy have shown highly encouraging data. CD40 is expressed on a subset of pancreatic cancer cells and the overwhelming majority of peritumoral lymphocytes. For PDAC, the aCD40 monoclonal antibody also promotes stromal degradation, dendritic cell maturation and alters macrophage phenotype, and therefore is an attractive approach for immunotherapy. While NCT03214250 (combining gemcitabine and Abraxane with aCD40 and aPD-1 immunotherapy) yielded very promising results in which all patients receiving all components demonstrated regression of metastatic pancreatic cancer, T cell activation was not observed and patients were not cured. Reliably delivering these treatments in human pancreatic cancer is challenging due to the dense stroma and limited vascular supply. Initial studies of MR guided focused ultrasound (MRgFUS) to ablate human pancreatic tumors are scheduled to begin in early 2020 at Stanford. Here, we will combine MRgFUS with an aCD40+checkpoint inhibitor strategy. We will immediately work to translate such a strategy if results are promising. Further, recent work has also demonstrated that toll like receptor (TLR)7/8 agonists have therapeutic utility, particularly in pancreatic cancer. TLR7/8 agonists are desirable for translation due to the distribution of receptors on subsets of DCs. Our preliminary data demonstrate synergy between TLR7/8 and aCD40, and we build on the combination of TLR7/8 agonists and aCD40 in Aim 2. While TLR7/8 agonists can be delivered intradermally, the direct delivery of TLR agonists to tumors yields an in situ vaccination that facilitates efficacy by exposing activated immune cells to cancer antigen. Our preliminary data indicate that with 2 treatments (with intravenous injection of TLR7/8 and CP4) up to 100% of directly-treated tumors and 60% of distant KPC tumors were eliminated. A major challenge for human studies is to deliver sufficient quantities of TLR7/8 agonists and antibodies to pancreatic cancer without dose-limiting toxicity. We have developed a temperature-sensitive liposomal (TSL) strategy to assure adequate delivery of TLR7/8 agonists to pancreatic cancer and add this in Aim 2. With such a strategy, it is feasible to deliver 8% or more of the injected dose to a human tumor (at least 20 fold more than free drug) and limit systemic toxicity. In summary, within Aim 1, we will incorporate MRgFUS ablation into clinically-relevant aCD40+checkpoint therapy. Within Aim 2, we will further add TLR7/8 agonists to an aCD40 protocol. As an additional step toward translation, we will assay primary human pancreatic cancer cells as to the effect of TLR7/8 and aCD40 on proliferation.

NIH Research Projects · FY 2024 · 2020-06

Project Summary Aggression—acting with the intent to inflict harm—is a universal component of social behavior, and all too often the grim subject of the daily news. One of the most reliable triggers of aggression is frustration, or failing to achieve an expected reward. This state can be adaptive, energizing behaviors to overcome barriers. But it can also lead to anger and violence. In disorders as disparate as PTSD, bipolar disorder, and autism, low frustration tolerance and uncontrolled aggression are among the most prevalent and impairing symptoms in psychiatry. Yet the neurobiology of these behaviors is poorly understood, and current treatment options are grossly inadequate. This proposal aims to define the role of two neuromodulators—dopamine (DA) and serotonin (5HT)—in the neural response to frustrating events. In Aim 1, the candidate will create a mouse model of frustration by combining conditioning tasks with the resident-intruder assay, in which an intruder mouse is added to a resident’s cage to elicit aggression. On test days, the conditioning task will end with an unexpectedly negative outcome, eliciting greater aggression from the resident mouse. In Aim 2, the candidate will use fiber photometry and optogenetics to record and manipulate DA neuron activity and DA release in the nucleus accumbens (NAc) while mice perform the frustration task. DA is a key modulator of motivated behaviors, and has long been considered pro-aggressive. Few studies, however, have recorded DA during frustration or aggression. This experiment will test whether DA release tonically increases with frustration, triggering aggression. In Aim 3, the candidate will use fiber photometry and optogenetics to record and manipulate 5HT neuron activity and 5HT release in the NAc during the frustration task. Unlike DA, 5HT is thought to inhibit behavior, including aggression. But 5HT neurons have not been recorded during aggression. This Aim will test the hypothesis that 5HT release decreases with frustration, and that larger decreases facilitate greater aggression. The proposed studies would be among the first to examine the neural circuit mechanisms of frustration. In the process, the candidate will supplement his background in electrophysiology in head-fixed animals to become proficient in social behaviors and calcium imaging. He will work with an advisory committee comprising world leaders in human (Dr. Emil Coccaro) and rodent (Dr. Klaus Miczek) aggression, frustration (Dr. Ellen Leibenluft), and 5HT (Dr. Liqun Luo), in addition to his primary mentor Dr. Rob Malenka and his career development mentor Dr. Alan Schatzberg. He will take full advantage of the intellectually vibrant environment at Stanford and supplement his technical training with high-quality didactic and professional training via frequent mentor interactions, targeted coursework, and other career and intellectual growth opportunities. By the end of the fellowship, the candidate will be positioned to launch a career as an independent investigator leading a translational research program on the neural basis of aggression and irritability.

NIH Research Projects · FY 2025 · 2020-06

SUMMARY OVERALL The National Alzheimer's Project Act (NAPA) provides an integrated national plan to overcome Alzheimer’s disease (AD) and AD related dementias (AD/ADRD). Established in 2015, the Farrukh–Jamal Stanford Alzheimer’s Disease Research Center (ADRC) supports NAPA goals. Its thematic focus is the study of the two most common neurodegenerative disorders: AD and Lewy body disease (LBD). ADRC participants are classified by clinical syndrome and by disease-defining biomarkers. The AD clinical spectrum encompasses preclinical AD, mild cognitive impairment due to AD, and AD dementia. The LBD clinical spectrum includes Parkinson’s disease without cognitive impairment, Parkinson’s disease with mild cognitive impairment, Parkinson’s disease with dementia, and dementia with Lewy bodies. AD is defined biologically by amyloid-β and tau pathology and biomarkers, and LBD can be biologically defined as neuronal α-synuclein disease. Having a valid α-synuclein biomarker enables preclinical LBD (i.e., LBD without motor or cognitive impairment) to be included in the LBD spectrum. The Stanford ADRC also enrolls and characterizes healthy older adults as a comparison cohort for AD and LBD and as an at-risk, preclinical cohort in which cognitive aging and phenotypic transitions can be studied, and in which factors related to cognitive resilience and disease resistance can be examined. Critical answers emerge more readily when investigators can delve deeply within and across multiple levels of participant data. The Stanford ADRC will continue to employ a strategy of deep phenotyping, in which we collect multiple types of clinical, imaging, and biological data from participants followed over time. Most participants consent to brain donation. Over the next five years, the Stanford ADRC will serve as a shared resource in support of NAPA goals through the following aims: 1) Provide an administrative structure to advance the theme and mission of the Stanford ADRC, including the selection and support of developmental projects. 2) Develop and maintain human resources for studies of AD, LBD, and cognitive aging. 3) Provide pathological diagnoses and make available well-characterized postmortem brain tissues, stem cell lines, and early cortical organoids. 4) Make available biospecimens and multiplex data derived from biospecimen analyses. 5) Obtain PET and MRI quantitative brain imaging that captures disease specific processes and measures of neuronal integrity. 6) Manage Stanford ADRC data, prepare research datasets, offer high-level biostatistical consultation for AD/ADRD investigators, and support innovative research on big data using tools from biostatistics, bioinformatics, and artificial intelligence. 7) With our community partners, provide respectful, culturally sensitive outreach and provide opportunities for education, training and research participation for healthy adults, people with AD and LBD, and their families. 8) Support the training of investigators and future leaders in the field of AD/ADRD.

NIH Research Projects · FY 2026 · 2020-06

Synchrotron radiation (SR) is an extremely bright and tunable x-ray source that enables forefront research in structural molecular biology (SMB). The goal of “A Synchrotron Structural Biology Resource" at the Stanford Synchrotron Radiation Lightsource (SSRL) is to provide users access to an integrated, mature SMB Resource with state-of-the-are synchrotron beam line facilities for macromolecular crystallography, x-ray absorption/emission/imaging spectroscopy and small- and wide-angle x-ray scattering/diffraction, techniques that form the three Resource’s Technical Operations Cores. Special emphasis is given to providing a high level of dedicated user support and services, to training of the users, and to performing extensive outreach on the scientific benefits of the capabilities of these specialized, yet mature facilities to the biomedical research community. Users are able to carry out experiments either on-site or from their home institutions by using sophisticated remote access instrument tools. User access is based on single experiment or program type proposals which undergo a transparent and robust external peer-review process. A multifaceted training and outreach program includes individual training, workshops, summer schools, on-the-road mini workshops, and internships by the Resource’s experienced science and technical staff, supplemented by outside experts. Training will also include techniques that complement those provided by the 3 Resource’s TOCs so as to educate users as to optimal multi-technique research strategies for solving their most complex problems. The Resource’s web portal provides streamlined scientific, technical, training, outreach and administrative material and other relevant information for the users, our sponsors and the general public. A principal aim is to optimize and maintain, for reliable and forefront performance, experimental facilities and instrumentation, detectors, software and computing and network capabilities on the SMB Resource’s 8 beam lines at SSRL, capitalizing on the high SR x-ray performance of SSRL’s 3rd generation storage ring SPEAR3, and at the MFX station at LCLS. With a specialized focus on user training, support and service, the SMB Resource will enable the scientific success for challenging and routine projects in the biomedical sciences.

NIH Research Projects · FY 2025 · 2020-06

PROJECT SUMMARY Despite chemotherapy, radiation and surgery, patients with undifferentiated pleomorphic sarcoma (UPS) frequently suffer incurable disease relapse. Immune checkpoint blockade is a promising new therapeutic approach for patients with UPS which promotes T cell mediated anti-tumor immunity. Still, the majority of patients do not benefit. Radiation therapy (RT), a cornerstone of preoperative treatment of UPS, can instigate T cell anti-tumor responses and synergize with immune checkpoint blockade. But RT can also result in the recruitment of immunosuppressive, pro-tumor myeloid cells that restrain anti-tumor T cell responses. This is particularly relevant in UPS, which is characterized by a brisk myeloid cell infiltrate. The candidate hypothesizes that reprogramming RT-induced myeloid cells toward an antigen-presenting, pro-inflammatory phenotype will promote T cell mediated anti-tumor immunity in UPS. To investigate the hypothesis the candidate proposes studies using BO-112, a synthetic nanoplexed version of poly I:C that activates double-stranded RNA sensing pathways, which are highly active in myeloid cells. These studies will be conducted in murine models of UPS (Aim 1) as well as in UPS patients (Aim 2). In Aim 1, the candidate will determine the impact of BO-112 on the fate, phenotype and immunomodulatory function of RT- induced myeloid cells. In Aim 2, the candidate evaluates the capacity of BO-112, RT, and anti-PD1 immune checkpoint blockade to remodel the myeloid compartment and instigate anti-tumor T cell responses in UPS patients enrolled on a window of opportunity phase 1 clinical trial. These studies will provide key insight into plasticity of RT-induced myeloid subsets, and their role in T cell mediated anti-tumor immunity, especially in response to BO-112. The candidate is an Assistant Professor in Radiation Oncology at UCLA specializing in the treatment of sarcoma. His scientific track record in tumor immunology and cancer immunotherapy highlights his commitment to an academic career in this field. The candidate's time is protected for research and career development (80% effort), and he has the space, equipment, personnel and resources necessary to complete the proposed studies. Along with his mentor, Dr. Antoni Ribas, and co-mentor, Dr. William McBride, the candidate has developed a comprehensive career development and training plan that will build expertise in four areas: (1) myeloid cell biology and plasticity, (2) genetic mouse models as tools to study sarcoma and the immune system, (3) analysis and interpretation of high-dimensional single cell phenotyping and transcriptomic data, and (4) conduct of a translational phase 1 clinical trial. These career development activities will support completion of the proposal and facilitate the transition to an independent scientific career conducting bench-to- bedside research, with an emphasis on leveraging translational immunology to transform the care of patients with sarcoma.

NIH Research Projects · FY 2026 · 2020-06

Project Summary / Abstract Our research is aimed at understanding the molecular mechanisms that regulate proliferation and differentiation in adult stem cell lineages. These events are of crucial importance for both short and long term health, as adult stem cell lineages underlie continued replacement of high turn over cell types in blood, skin, and the epithelial lining of the gut, as well as maintenance and repair of many other tissues in the body. Our primary focus is on elucidating the molecular circuitry that regulates the switch from precursor cell proliferation of onset of lineage appropriate differentiation. Failure to cleanly switch from proliferation to differentiation may underlie genesis of cancer in stem cell lineages, while failure to establish cell type specific gene expression for the proper differentiation program may lead to dysgenesis, scarring, fibrosis, or tissue degeneration. We utilize spermatogenesis in Drosophila as a model adult stem cell lineage in which the switch from proliferation to differentiation is especially amenable to study in vivo using an integrated combination of powerful genetic, genomic, cytological and biochemical tools. During spermatogenesis, mitotically proliferating spermatogonia switch to onset of meiotic prophase, during which spermatocytes express hundreds of novel transcripts required to regulate and mediate the dramatic changes in cell behavior and morphogenesis that eventually produce mature sperm. Our goal under the MIRA is an integrated, systems level understanding of how the different molecular mechanisms we have uncovered act in a pathway to trigger a clean switch from precursor cell proliferation, establish a stable program of cell type-specific gene expression, and regulate its execution to time and drive key steps in differentiation. Our approach will build upon recent technical advances and new discoveries made in the current funding period. Springing from our discovery that the key role of the RNA binding protein Bam required to trigger the switch from mitosis to meiosis is to repress expression of the nuclear RNA binding protein How, we will identify RNAs bound by How by immunoprecipitation, score for alternative splicing events that change immediately after How protein disappears from spermatogonia, and assess function of candidate How targets in vivo, for example, whether they modulate expression of cell cycle regulators or bind to promoters of differentiation genes as potential transcriptional regulators. Based on our finding that cell type specific isoforms of RNA binding proteins expressed in the first wave of spermatocyte transcription modulate alternative splicing, stability or translation of selected mRNAs expressed in the second wave, we will investigate how early onset RNA binding proteins regulate timing and execution of the meiotic cell cycle and cell type specific post meiotic cellular differentiation. Exploiting our genome wide, stage specific transcriptomic analysis, we will work upstream from the earliest promoters that turn on in young spermatocytes to explore potential transcription factors, chromatin regulators and nuclear architecture that may link onset of the gene expression program for terminal differentiation with action of How to stop mitotic proliferation and trigger onset of the meiotic program.

NIH Research Projects · FY 2024 · 2020-06

Project Summary/Abstract Chemotherapy-induced peripheral neuropathy (CIPN) affects more than two-thirds of adults with invasive cancer who receive select adjuvant chemotherapies (e.g., taxanes, platinum analogs). Severe CIPN symptoms can lead to chemotherapy dose reductions, treatment delays, or changes in treatment regimens; thereby affecting the potential curative effects of chemotherapy. For some patients, CIPN symptoms can persist over time, contributing to lower quality of life. Little is known about risk factors for CIPN. Chemotoxicity risk scores have been developed and evaluated for use among elderly patients receiving chemotherapy. However, these tools generally report moderate predictive accuracy (60%-70%), small sample sizes, and short-term follow up. We are aware of no publicly available, validated risk models to assess risk of severe and chronic CIPN among diverse patients at risk for this potentially disabling side effect. The goal of this proposal is to identify patients at risk for CIPN and to understand how patients and provider interpret and use CIPN risk information in clinical decision-making. Focusing on more than 8,500 insured adults (18+) diagnosed with invasive, stage I-III breast and II-IIIA colorectal cancers (2013-2021) who received adjuvant chemotherapy treatment with known risk for CIPN, we will develop and validate predictive models to quantify the risk of severe CIPN and incident chronic CIPN and assess how CIPN risk information might be used to inform clinical decision-making about cancer treatment and survivorship care planning. We hypothesize that CIPN risk is a high priority for patients in thinking about treatment choice and survivorship care planning. In addition, we hypothesize that the relative importance of CIPN risk for patient and provider decision-making will vary by patient characteristics (e.g., age, cancer stage). We anticipate that the risk of severe and chronic CIPN can be predicted with a high degree of accuracy using electronic health records and machine learning methods. The study team has significant and complementary expertise in health services research, biostatistics and predictive modeling, oncology practice, cancer epidemiology, pharmacotherapy, drug safety and the patient care experience. To our knowledge, this will be one of the first studies to develop and validate a CIPN predictive model that can be used by oncology teams to inform treatment and care planning decisions and improve patient-valued outcomes. Translation and replication of the findings will be catalyzed through publication in peer-reviewed journals and the development and distribution of free software to facilitate testing and adaptation of the resulting risk models across diverse systems of care.

NIH Research Projects · FY 2025 · 2020-05

PROJECT SUMMARY Mitral valve disease is a significant cause of global morbidity and mortality. Evolving treatment guidelines support earlier intervention and valve repair when possible. Advances in repair techniques have progressed in the clinical arena primarily based upon anatomic and physiologic premises as well as surgeon experience. Yet, the biomechanical engineering fundamentals and principles underlying mitral valve interventions are rarely investigated. A more robust understanding of such principles and incorporation into surgical procedures may enhance valve reparability and durability and thus ultimately translate into less thromboembolic and hemorrhagic sequelae of long-term anticoagulation for mechanical valve replacement and less perioperative risks of reintervention for bioprosthetic valve deterioration. We have designed and produced a novel 3D-printed heart simulator into which mitral valve specimens can be mounted and studied throughout the cardiac cycle. Complex disease states such as primary (degenerative) mitral regurgitation can be reproduced, allowing the investigation of the biomechanical characteristics of various repair operations and novel devices. Innovative biomechanical sensors within this simulator and state-of-the-art imaging modalities facilitate the detailed analysis of the engineering principles behind these operations. We propose to study primary mitral valve regurgitation and engineer novel minimally invasive devices and platforms to improve the treatment of this disease. We will then validate these findings and devices in pre-clinical large animal models. We are optimistic that the proposed experiments and devices will yield important knowledge on current and potential future clinical therapies for mitral valve disease and can be rapidly translated to intraoperative patient care.

NIH Research Projects · FY 2025 · 2020-05

Limited mobility due to conditions like osteoarthritis (OA), cerebral palsy, and Parkinson’s disease affects millions of individuals, at enormous personal and societal cost. Rehabilitation can dramatically improve mobility and function, but current rehabilitation practice requires in-person guidance by a skilled clinician, increasing expense and limiting access. Mobile sensing technologies are now ubiquitous and have the potential to measure patient function and guide treatment outside the clinic, but they currently fail to capture the characteristics of motion required to accurately monitor function and customize treatment. Millions of low-cost mobile sensors are generating terabytes of data that could be analyzed in combination with other data, such as images, clinical records, and video, to enable studies of unprecedented scale, but machine learning models for analyzing these large-scale, heterogeneous, time-varying data are lacking. To address these challenges, we will establish a Biomedical Technology Resource Center —The Mobilize Center. Through the leadership of an experienced scientific team, we will create and disseminate innovative tools to quantify movement biomechanics with mobile sensors. Specifically, we will: 1. Push the bounds of what we can measure via wearable sensors using models that compute muscle and joint forces and metabolic cost of locomotion. These models, based on biomechanical and machine learning models, will be disseminated via our newly created OpenSense software, which will be used by thousands of researchers to gain new insights into patient biomechanics using mobile sensors. 2. Meet the need for tools that analyze data about movement dynamics and develop machine learning models to analyze and generate insights from unstructured, high-dimensional data, including time- series (e.g., from mobile sensors), images (e.g., MRI), and video (e.g., smartphone video of a patient’s gait). 3. Provide tools needed to intervene in the real-world. We will develop algorithms to accurately quantify kinematics outside the lab for long durations using data from inertial measurement units (IMUs). We will also build behavioral models to adapt and personalize goal setting, drawing on movement records from 6 million individuals, as well as health goals and exercise for 1.7 million people. Through intensive interactions with our Collaborative Projects, we will focus on improving rehabilitation outcomes for individuals with limited mobility due to osteoarthritis, obesity, Parkinson’s disease, and cerebral palsy. The Center’s tools and services will enable researchers to revolutionize how we diagnose, monitor, and treat mobility disorders, providing tools needed to deliver precision rehabilitation at low cost and on a massive scale in the future.

NIH Research Projects · FY 2026 · 2020-05

REGULATORY VARIANTS IN HUMAN SKIN DISEASE PROJECT SUMMARY Polygenic skin diseases, such as psoriasis, atopic dermatitis, acne vulgaris, and skin cancer, arise from interactions between inherited pathogenic DNA variants and the environment. During the current funding cycle, AR076965 identified 355 noncoding, differentially-active single nucleotide variants (daSNVs) linked to risk for 10 prevalent polygenic skin disorders. These daSNVs alter transcription-directing function and concentrate in the promoters and enhancers of genes critical for epidermal homeostasis, including those involved in epidermal differentiation, inflammation, and gene regulation. This supports a model in which altered regulatory DNA sequence may interact with environmental factors to alter gene expression in ways that predispose to genetically complex disorders. This competing renewal will define the impacts of these daSNVs on their disease- relevant target genes as well as the transcription factors (TFs) whose DNA binding they alter. Prominent among putative daSNV target genes (ptGenes) were those encoding specific epidermal TFs, including IRF6, OVOL1, KLF4, TP63, and STAT3. Each of these TFs plays an essential role in epidermal homeostasis and each acts in a dosage-dependent fashion, suggesting that daSNVs that alter their levels may predispose to the epidermal abnormalities seen in the polygenic skin diseases studied. AR076965 identified daSNVs in the promoters and enhancers of these TFs. Aim I will define the impact of skin disease-linked daSNVs on levels of these essential epidermal TFs in tissue, the degree to which daSNV-altered TF levels impact epidermal gene expression and barrier function, and the gene regulators whose DNA binding these daSNVs alter. Class I major histocompatibility (MHC) genes were also identified as daSNV target genes. Class I MHC proteins mediate peptide antigen presentation and their down-regulation can trigger inflammation via a “missing self” immune response. At the HLA-Cw*06:02 MHC allele, which is the strongest risk locus for psoriasis vulgaris, AR076965 found that multiple daSNVs downregulate HLA-C expression in keratinocytes, but not immune cells and that expression of HLA-C protein, but not HLA-A or HLA-B, is decreased in lesional psoriatic epidermis. AR076965 also observed that HLA-C knockout induces psoriasiform dermatitis in human skin xenografts in vivo, indicating that decreased keratinocyte HLA-C expression can drive cutaneous inflammation and epidermal hyperplasia. Aim II will examine a model in which psoriasis risk daSNVs down-regulate keratinocyte HLA-C levels to enhance cutaneous inflammation and disrupt epidermal homeostasis. This effort will expand insight into how inherited variation in regulatory DNA predisposes to the emergence of the abnormalities in epidermal homeostasis characteristic of prevalent skin diseases.

NIH Research Projects · FY 2024 · 2020-05

PROJECT SUMMARY Multiple myeloma (MM) is an incurable plasma cell malignancy with a 50% survival rate. MM is the leading hematological cancer in African Americans, who are diagnosed 2-3 times more commonly than whites. The factors contributing to this disparity remain unclear, but genetics and immune dysregulation are believed to play a key role. The scientific goals of this proposal are: (1) to apply integrative and innovative methods that leverage genetic and transcriptomic data to elucidate biological pathways contributing to this disparity and (2) to contribute evidence to inform future precision health efforts in this population. The first objective will be to identify putative causal genes associated with MM susceptibility by conducting a transcriptome-wide association study (TWAS), using genetic prediction models of gene expression developed specifically in African Americans. TWAS will be performed by imputing gene expression profiles in 1813 cases from the African American Multiple Myeloma Study (AAMMS) and 8871 controls, the largest genome-wide association study of MM in African Americans. The next objective will focus on white blood cell (WBC) traits, which are important intermediate phenotypes for hematologic and immune-related cancers. The distribution and genetic architecture of WBC traits varies substantially across ethnicities and may contribute important information for deciphering MM risk in African Americans. The shared genetic basis of WBC variation and MM susceptibility will be examined by conducting: (1) genome-wide genetic correlation analyses and (2) developing genetic scores for predicting an individual’s inherited predisposition to a specific WBC profile. Genetic scores will be applied to AAMMS data to test their association with MM, and comparative analyses of WBC-predictors from African and European ancestry populations will be conducted. The last research component will aim to elucidate genetic factors that are associated with specific features of MM tumors. Analyses will focus on examining the contribution of local genetic ancestry to somatic events, such as translocations and amplifications that are more commonly observed in African American patients. The role of genetic mechanisms involved in gene expression or alternative splicing will also be investigated, to test the hypothesis that some tumor features seen in African Americans are due to germline genetic effects on these processes. This research plan is complemented by a training plan that builds on the applicant’s strengths in cancer and genetic epidemiology to develop new expertise in integrative and ancestry-aware genomic analyses, hematological cancer, and cancer disparities. Novel insights into MM etiology in African Americans will be important for improving health outcomes in this population that is disproportionately affected by MM, yet under- represented in genetics studies. The research and training plan will prepare the applicant for a successful independent career in cancer research with an interdisciplinary focus on risk stratification and cancer control.

NIH Research Projects · FY 2025 · 2020-04

PROJECT SUMMARY / ABSTRACT The Stanford Department of Epidemiology and Population Health requests five more years of support for its Behavioral and Social Science Research Pre-Doctoral Training program at the intersection of data science and population health research. The objective of the program is to support and train a community of scholars with the skills and knowledge necessary to apply advanced quantitative skills to novel and complex datasets to better understand and prevent heart, lung, blood, and sleep disorders. Our first four cohorts have been successful and productive with the cohort that has graduated all finding related positions in academia or private sector research. The request for continued support builds on those successes and expands the current project with more focused training the analysis of real-world data for social science research. We have refined the mentorship team but retain the diverse set of research backgrounds from across the social and quantitative sciences at Stanford University. We will continue to provide a transformative multi-disciplinary predoctoral training environment that draws mentors from social science disciplines (economics, psychology, sociology) and quantitative disciplines (computer science, informatics, statistics). The graduates of our program will have rigorous training in their own scientific disciplines, combined with extensive expertise working on a broad range of innovative research projects that rely on data of primarily two types: (1) intensive or voluminous longitudinal data from mHealth, smartphone and sensor technologies or electronic health records, and/or (2) large and complex data from internet, commercial, health administrative records, large population databases, internet data and social media platforms, crowd sourcing, and citizen science data. We are requesting support for 5 pre-doctoral students per year whose training will last 2 or more years. They will emerge from the program with a thorough understanding of their own fundamental discipline combined with advanced expertise in cutting- edge statistical and computational methods for analyzing increasingly complex and multidimensional longitudinal sets. The training program components will include both department or discipline-specific training in addition to program-wide data science components including: (1) innovative curriculum, including specialized quantitative curriculum customized to the experience and background of each trainee; (2) a mentored research experience with a dual mentor model (one disciplinary mentor, one methodological mentor); (3) exposure to team science approaches to problem solving, including design thinking, cross-disciplinary collaborations, and team building; (4) experiential components, including availability of Stanford dry-lab rotations and short-term internships in Silicon Valley companies; (5) forums for intellectual exchanges; and (6) many opportunities to develop professional skills in grant writing and collaboration. The graduates from this training program will have the capability to conduct cutting edge social science based research applied to the prevention and treatment of heart, lung, blood, and sleep disorders and improve outcomes among patients with these disorders.

NIH Research Projects · FY 2025 · 2020-04

Project Summary/Abstract The goal of Dr. Shannon Yan's career development application is to understand the energetic and mechanistic principles that govern structural and functional switching by proteins critical for cellular regulation. Dr. Yan will begin with studying transitions of human mitotic-arrest deficient 2 protein MAD2 in the context of co-translational protein folding, and ultimately focus on its dynamic fold-switching flux established in vivo by folding effectors and chaperones. As structure dictates the function of a biomolecule, MAD2 is capable of switching folds between an inactive open state and mitotic-arrest closed state to modulate the formation of spindle assembly during mitosis—otherwise leading to detrimental chromosome instability or cancerous development. This proposal will explore the molecular details regarding MAD2 structure-function transitions, aiming to elucidate the underlying principles for the operation of protein switches: 1) Is there a default native fold, or an initial equilibrium condition, when MAD2 is first synthesized? Dr. Yan's invention of the first single-human-ribosome translation assay on optical tweezers will directly resolve in real-time the co-translational folding trajectory for a single MAD2 protein as its nascent polypeptide gradually emerges on the human ribosome surface. 2) Is the co-translational folding pathway, and thus the prevalence of one conformer over the other, influenced by folding effectors dependent on the physiological state of cells? Dr. Yan will examine how translation rates, the presence of folding effectors/chaperons, and other cellular factors that may reshape the folding energy landscape for MAD2 protein switch. Knowledge gained from her single-molecule work in the K99 phase will fuel the subsequent cell imaging studies proposed for the R00 phase: 3) How does MAD2 oscillate between different conformer distributions—both spatially and temporally—in accordance with phases of the cell cycle? The flux of open and closed MAD2 protein switches at various stages during mitosis will be characterized and correlated to other concurrent cellular events. Results obtained during this period will enable Dr. Yan to establish herself in the field of cellular biology and cellular mechanics, in which she aims to lead a research group as a tenure-track principal investigator at an academic research institute. Dr. Yan will apply a multidisciplinary approach combining biophysics, molecular and cellular biology, and single-molecule methods, together with genetic manipulations to formulate a unique research line aimed at resolving cellular dynamics and probing the associated cellular mechanics during cell division. This five-year career development program is tailored to prepare Dr. Yan for an independent scientific career. It will build on Dr. Yan's extensive background in ribosome translation and single-molecule techniques, while expanding her skill sets in molecular biology and biochemistry to investigate folding of metamorphic protein switches. Her training program will be directed by Dr. Carlos Bustamante at UC Berkeley—an internationally recognized leader in protein folding and with extensive records of mentorship. Dr. Tanaka and Dr. Legname will also join in to support Dr. Yan's research, professional growth, and her transition into independence. The long-term objective of Dr. Yan's independent research is to expand our understanding on how cells modulate biological signals to grow and multiply, and to identify the origins of regulatory deviations that lead to diseases in humans.

NIH Research Projects · FY 2026 · 2020-04

Abstract Pharmacogenomics is the study of how geneƟc variaƟon influences drug response phenotypes and is a pillar of precision medicine — choosing the right drug for the right paƟent at the right dose and Ɵme. A public resource of pharmacogenomics knowledge is criƟcal — both to catalyze basic discovery of the molecular mechanisms that drive variability in drug response and to support the implementaƟon of clinical research to understand how to best deliver pharmacogenomics in the clinic. The Pharmacogenomics Knowledgebase (PharmGKB) is the premier public repository of pharmacogenomics knowledge. PharmGKB curators focus on high quality extracƟon and representaƟon of knowledge in the primary literature, and capture informaƟon about individual geneƟc variaƟons that impact drug response, the potenƟal clinical impact of these variaƟons, the pharmacokineƟc and pharmacodynamic pathways of drug response, the pharmacogenomic requirements in regulatory documents (labels), and guidelines for genome-driven prescribing. The PharmGKB website hosts annually on average 5.2 million webpage views (without bots) and provides flexible access to pharmacogenomics knowledge on mulƟple devices. Most importantly, PharmGKB serves as a hub for the research community in pharmacogenomics and precision medicine — integraƟng its contents with criƟcal resources and organizaƟons including ClinVar, the Clinical Genome Resource (ClinGen), the FDA, the Clinical PharmacogeneƟcs ImplementaƟon ConsorƟum (CPIC), and others. In this proposal, we request support for PharmGKB as a Biomedical Knowledgebase, and outline a plan to (1) annotate, aggregate, integrate, and disseminate pharmacogenomic knowledge from sources uƟlizing community curaƟon and semi-automated methods to assist knowledge acquisiƟon, (2) build curaƟon and user- specific interfaces that catalyze the discovery and use of pharmacogenomic knowledge, providing the content of our knowledgebase in novel ways that are useful to our users, (3) collaborate and integrate with ongoing naƟonal and internaƟonal efforts dedicated to the implementaƟon of genomic medicine by providing the best scienƟfic knowledge to support these important programs, and (4) develop a new long-term and conceptual framework for broadly integraƟng available PGx knowledgebases into genomic medicine.

NIH Research Projects · FY 2026 · 2020-04

Abstract Prostate-specific antigen (PSA) screening is controversial because it can lead to overdiagnosis and overtreatment of prostate cancer when individuals have high PSA levels for reasons other than aggressive disease. It is thus important to ask the question how PSA screening can be improved. Preliminary evidence from our team suggests that the incorporation of genetic factors into PSA screening decisions has tremendous potential. During the initial funding period of this project, we have had great success showing that accounting for genetic factors that impact constitutive, non-cancer PSA levels results in a test that ascertains more clinically relevant, aggressive disease. In parallel, we have shown that genetic factors for PSA can also be used to improve polygenic risk scores (PRS) for prostate cancer. Existing PRS are strongly predictive of prostate cancer risk, but they do not specifically predict aggressive disease because they were largely developed in men with PSA screen- detected, lower-risk disease. We have initial results demonstrating that removing PSA genetic factors from prostate cancer PRS makes the PRS more predictive of aggressive disease. Additional studies are needed to clarify how best to adjust for PSA genetics to improve screening, to develop a prostate cancer PRS that is even more predictive of aggressive disease by removing additional PSA variants, and to assess the clinical utility of these tools. In this renewal, we propose to tackle these outstanding imperatives with a comprehensive project leveraging data from 13 studies ranging from large-scale biobanks to unique clinical populations (N > 500K). In Aim 1, we will further advance our understanding of PSA genetics by identifying novel rare and common PSA variants and undertaking functional studies of epigenomic features and single-cell expression quantitative loci. We will then use this information to develop more accurate and personalized genetic adjustment of PSA levels. In Aim 2, we will develop a new PRS for prostate cancer aggressiveness by filtering out PC risk variants that are also associated with non-cancer PSA. We will first remove PSA variants from the prostate cancer PRS based on statistical significance. Then we will develop and apply a novel hierarchical modeling genome-wide approach that incorporates PSA associations and functional information. In Aim 3, we will determine the clinical utility of incorporating genetically adjusted PSA levels and the PRS for aggressive prostate cancer into validated risk calculators for biopsy outcomes (higher grade disease) and prostate cancer active surveillance upgrading. We will also investigate the relationships between genetically adjusted PSA, the aggressive prostate cancer PRS, and lethal prostate cancer. These models will allow us to assess the benefit of incorporating genetic information into decisions about frequency of screening, escalation to prostate biopsy, and selection of active surveillance following diagnosis. Our renewal aims in aggregate are promising toward reducing PSA screening harms while improving screening benefits and predicting risk of clinically important disease. In translation, clinicians and patients could make more informed decisions, reducing unnecessary procedures and improving outcomes.

NIH Research Projects · FY 2025 · 2020-04

PROJECT SUMMARY. Calcineurin (CN), the only Ca2+/calmodulin-regulated protein phosphatase, is a major effector of Ca2+ signaling. Best known for its regulation of adaptive immunity, CN is the target of immunosuppressants, FK506 and Cyclosporin A, which cause a wide range of adverse effects in patients by inhibiting CN outside the immune system. For >30 years, my work has elucidated CN signaling in yeast and human cells. With previous MIRA funding, we defined the human CN signaling network by systematically identifying proteins that harbor the CN- binding SLiMs (short linear motifs), PxIxIT and LxVP. This network reveals locations for CN signaling throughout the cell, including at nuclear pore complexes and centrioles/cilia where we have confirmed that it functions. These studies also show that many CN signaling pathways are yet to be studied, identifying a major gap in our knowledge of cellular regulation. Future studies will focus on the intersection of CN signaling with protein S- acylation (also called palmitoylation). S-acylation reversibly adds one or more fatty acid molecules (usually palmitate) to proteins to regulate their association with and/or function at membranes where Ca2+/CN signaling occurs. Dysregulation of S-acylation, which modifies up to 25% of human proteins, causes disease states ranging from neurological disorders to cancer, and our knowledge of the fundamental mechanisms that control S-acylation activity and specificity is incomplete. Thus, future efforts will focus on our discovery of two novel mechanisms that employ S-acylation to direct CN signaling to membranes. Project 1 focuses on elucidating the regulation and functions of a conserved CN isoform, CNAb1. S-acylation of the CNAb1 C-terminus promotes its direct association with membranes where it regulates PI4KIIIa, an essential enzyme complex that produces phosphatidylinositol-4-phosphate (PI4P) at the plasma membrane. Proposed studies will identify the enzymes that control CNAb1 S-acylation, which is key for understanding and manipulating its signaling pathways. We will examine regulation of PI4KIIIa by CNAb1, especially in physiological contexts such as oncogenic K-RAS signaling and store operated Ca2+ entry and pursue unbiased strategies to identify additional substrates for this isoform. Project 2 focuses on how calcimembrin (c16orf74), an uncharacterized S-acylated protein and CN substrate, regulates CN signaling by targeting the enzyme to membranes, particularly in the context of cancer. Calcimembrin contains an unusual composite LxVPxIxIT motif, which dictates unique biochemical properties including its dephosphorylation in multimeric complexes that confer sensitivity to local calcimembrin:CN ratios. Future studies aim to understand, mechanistically, how Clmb shapes CN signaling in breast cancer cells to regulate cellular processes such as estrogen receptor signaling and to test key elements of the model formulated from our in vitro findings. Together these projects, at the nexus of CN signaling and reversible S-acylation, will address multiple gaps in our knowledge of membrane-based signaling, and provide new insights into fundamental aspects of cellular regulation in both healthy and diseased cells.

NIH Research Projects · FY 2025 · 2020-03

ABSTRACT Despite identification of modifiable behavioral targets for childhood obesity prevention, prevalence of obesity remains historically high in the United States and the most severe forms are increasing among young children. Recent epidemiologic evidence shows that racial/ethnic and socioeconomic disparities in obesity prevalence persist, and already are apparent by age 24 months. Thus, childhood obesity prevention efforts must address factors beyond individual-level behavioral risk factors and should start in the first months of life. Social determinants of health (SDoH) are increasingly recognized as playing key upstream roles in etiologies of obesity, particularly in disproportionately burdened populations. Therefore, SDoH may be prime targets for interventions to prevent childhood obesity among racial/ethnic minority and low-income populations. Recently, innovative health care models have incentivized integration of SDoH screening and social service referrals into electronic health records (EHRs). While technologic advances allow implementation of individual and neighborhood measures of SDoH into EHRs, a critical gap in understanding which factors most strongly predict obesity – and thus should be prioritized as clinical measures and intervention targets – precludes implementation of these technologic advances for obesity prevention interventions. Furthermore, few studies have examined relationships of SDoH measures with growth parameters from birth to age 24 months, a critical period of plasticity and development in which stressors can lead to long-term health consequences. The overall goal of this study is to identify SDoH measures at multiple levels (family, community, and environmental) that show promise for adoption into health IT systems to prevent childhood obesity. We also will examine effects of social services referrals and utilization on associations between SDoH and infant weight outcomes. To achieve these aims, we will leverage an existing EHR-based SDoH screening and bi-directional community-based social services referral system. Patients presenting for routine well child care at a multi-site academic practice that serves a large number of racial/ethnic minority and low-income families, will form the basis of a longitudinal cohort of 1300 infants from birth to age 24 months. Additionally, we will perform in-depth interviews to explore patient, provider, and community stakeholder perceptions of EHR-based SDoH screening and social services referrals. The results of this study could strengthen our understanding of the role of specific multi-level determinants of childhood obesity. It also will provide new information about the effects of clinical- community resource linkages on SDoH and infant growth trajectories. This research will fill critical knowledge gaps to accelerate integration of SDoH measures that most strongly predict unhealthy infant weight gain into health information technology systems. The results of the proposed research will form the basis of future comparative effectiveness research to prevent childhood obesity in disproportionately burdened populations.

NIH Research Projects · FY 2025 · 2020-02

PROJECT SUMMARY Stanford University School of Medicine is a site of unparalleled excellence in biomedical research and is an innovative leader in the fields of cardiovascular and pulmonary medicine. This renewal of the Stanford Integrated Cardiovascular/Pulmonary Residency Research Training Program provides research opportunities for talented individuals engaged in the residency stage of their medical training. The program draws resident investigators from the Stanford residency programs in Internal Medicine, Pediatrics, Cardiothoracic Surgery, Vascular Surgery, and Radiology, and place them in basic, translational, and clinical research laboratories affiliated with the Stanford Cardiovascular Institute (CVI) for a mentored research experience lasting 1-2 years. Upon completion of their clinical training, successful resident-investigators are eligible for K38 funding to support continued research efforts. For this renewal of our program, we will build upon the success of the previous four years in supporting residents across multi-disciplines. Research mentors for our StARR program are members of the Stanford CVI, which offers a unique platform to train the next generation and translational scientists. Major research programs within the CVI span Cardiac, Vascular, and Pulmonary disease categories, incorporating the disciplines of Genomics, Proteomics and Bioinformatics; Cellular and Molecular Biology; Imaging; Bioengineering; and Population Science. CVI scientists share a common interest in the mechanisms underlying cardiovascular and pulmonary medicine, and work together towards creating novel therapeutic, regenerative, and preventative approaches to cardiovascular and pulmonary diseases. Furthermore, the CVI offers multifaceted educational and career development programs that enhance the experience of R38 StARR trainees and prepare them to launch successful academic careers as clinician- scientists. Our renewal of the Stanford Integrated Cardiovascular/Pulmonary Residency Research Training Program will foster the career development and research training of resident-investigators who will continue on to careers as clinician-scientists in the fields of cardiovascular and pulmonary medicine.

NIH Research Projects · FY 2026 · 2020-01

PROJECT SUMMARY The overarching goal of this project is to understand how cell growth triggers cell division in budding yeast and identify general regulatory principles applicable to eukaryotic cells. Our work aims to understand how the most basic aspect of cell morphology, cell size, is controlled. Solving this question has the potential to revolutionize our understanding of how cell division is regulated in both natural developmental contexts and in disease. In 2015, my laboratory reported a breakthrough discovery in understanding how growth triggers division in budding yeast. While it was expected that growth would act to increase the activities of the cyclin-dependent kinases (Cdk) known to promote cell division, this is not the case. Rather, we found that cell growth acts in the opposite manner. Cell growth triggers division by diluting a protein that inhibits cell division, Whi5. This discovery formed the basis of my first MIRA grant, which funded important progress in understanding G1/S cell cycle control, cell size control, and its relationship to cellular senescence in both budding yeast and human cells. This MIRA project builds on our prior discoveries by deepening our understanding of how budding yeast regulate the size. More specifically, the project defines three new research directions: 1) Investigating the molecular mechanism behind the size-independent transcription of WHI5, focusing on the role of forkhead transcription factors. 2) Identifying Whi5-independent mechanisms that regulate cell size at the G1/S transition and defining the role of the SBF transcription factor in this process. 3) Studying the role of Bck2 in the G1/S transition and its interaction with the SBF transcription factor to understand its influence on cell size control. These directions aim to uncover novel insights into the cellular machinery regulating cell size, which has broader implications for eukaryotic cell biology and medical research.

NIH Research Projects · FY 2026 · 2019-12

PROJECT SUMMARY/ABSTRACT Latha Palaniappan, MD, MS is a Professor of Cardiovascular Medicine and of Epidemiology and Population Health in the Department of Medicine at Stanford University. She is a well-recognized clinical researcher with a long track record of funding, expertise, and mentoring in patient-oriented research (POR) in cardiometabolic diseases. This K24 renewal proposal capitalizes on Dr. Palaniappan’s extensive clinical research and teaching experience to help her mentor and train the next generation of clinical and translational scientists in POR. Having completed over 240 studies spanning 24 years, Dr. Palaniappan is a nationally and internationally recognized leader in chronic disease prevention research with a focus on cardiometabolic risk. Dr. Palaniappan aims to build upon the successes of her initial K24 award through this Mentor, Educate, Train, Advocate: Patient Oriented Researchers in Cardiometabolic Disease (META2) renewal. The Specific Aims of this renewal proposal are to: 1) engage mentees by leveraging her extensive experience to provide an exceptional environment for POR training, 2) expand the impact of Dr. Palaniappan’s mentorship by imparting mentorship and leadership skills to her new mentees to facilitate their transition into independent researchers, and 3) enhance mentorship skills through further career development and mentorship training. Through the initial K24, her 7 junior faculty mentees have achieved research and funding independence, securing 5 career development awards (4 Ks, 1 Foundation) and 5 R-level grants. They have authored 566 papers with 176 as first author. Through META2, she aims on recruiting 1-2 new mentees per year. POR is critical for the translation of scientific knowledge into population health benefits - it is key for the POR workforce to be highly trained. Effective mentoring at early career stages is necessary to support POR scientists in becoming independent investigators. Dr. Palaniappan’s breadth of experience provides an innovative and dynamic setting to train mentees in POR. Her mentees can leverage the existing research platform available through her recently completed NIH studies (IMPACT, STRONG-D) as well as her newly funded AHA and NIH projects (TOTAL,ARISE). The projects in her research portfolio are complementary and well positioned to expand on the fruitful work done through META. Paired with Dr. Palaniappan’s mentee-centered mentorship, these projects are rich with opportunities for mentees to further their training and hone their POR skills. Her research agenda is reinforced by teaching and mentoring activities to develop the trainees’ and her own skillset in data science. Mentoring trainees in POR not only provides a multidisciplinary and intellectually stimulating environment that promotes community, but also creates successful independent investigators and future leaders in POR.

NIH Research Projects · FY 2025 · 2019-09

Narcotic use in chronic pain treatment has played a major role in the ongoing opioid crisis. Convergent evidence indicates that the activity of the anterior cingulate cortex (ACC) is critical in the pathophysiology of chronic pain. Local therapies directed to the ACC yield benefit for chronic pain clinically and preclinical data suggest that locally applying the drug ketamine to the ACC should yield acute-onset and long-acting remission of the pain phenotype through a non-opioid mechanism. In this manner, local ketamine infusion into this critical brain target is a promising non-opioid pain treatment that could yield remission of chronic pain with potentially more predictable dose-response relationships than systemic administration, with personalization based on the imaging defined sensitivity of the ACC to pain, and without limiting side effects due to off-target drug action in the rest of the brain or body. To translate these results into a clinical treatment, one would ideally be able to locally apply ketamine to only the ACC, without any off-target ketamine action and without invasive interventions to the brain. Towards this end, we have developed ultrasonic drug uncaging for neuroscience, in which neuromodulatory agents are uncaged from ultrasound-sensitive biocompatible and biodegradable drug-loaded nanocarriers. We have validated that we can use this technique for selective ultrasound-induced release of ketamine, and that ultrasonic uncaging yields drug effects that are limited precisely by when and where the ultrasound is applied. Further, we have developed a straightforward path to translate this technology to clinical practice. We now propose to clinically translate ultrasonic ketamine uncaging for chronic pain therapy. Given the variety of potential therapeutic effects that are increasingly ascribed to ketamine, we anticipate that this first-in-human clinical trial would establish the safety of this technique and generate the efficacy data necessary to enable regulatory approval for larger clinical trials for each application of ultrasonic ketamine uncaging. Overall, we expect that completion of this proposal will provide the prototype for subsequent translation of ultrasonic drug uncaging for numerous other drugs of interest. Specifically, in the proposed preclinical UG3 phase, we will scale up our nanoparticle production processes to human scales and adapt them to pharmaceutical standards. We will also complete the animal testing needed to obtain regulatory approval for an initial clinical trial. In the proposed clinical UH3 phase, we will complete a first- in-human evaluation of the safety and efficacy of ultrasonic ketamine uncaging by quantifying how much ketamine is released relative to the ultrasound dose, and assessing whether the uncaged ketamine can modulate the sensitivity and affective response to pain, in patients suffering from chronic osteoarthritic pain. Successful completion of this proposal will yield a novel, noninvasive, and non-opioid therapy for chronic pain that maximizes the therapeutic efficacy of ketamine over its side effects, by targeting its action to a critical hub of pain processing.

NIH Research Projects · FY 2024 · 2019-09

PROJECT SUMMARY Up to 5% of adolescents (~3.5 million in the US alone) suffer from high impact chronic musculoskeletal (MSK) pain, affecting all life domains and posing a significant economic burden. Current treatments for chronic MSK pain are suboptimal and have been tied to the opioid crisis. Only ~50% of adolescents with chronic MSK pain who present for multidisciplinary pain treatment recover, as measured by clinical endpoints of pain severity and functional disability. Discovery of robust markers of the recovery vs. persistence of pain and disability is essential to develop more resourceful and patient-specific treatment strategies and to conceive novel approaches that benefit patients who are refractory. Given that chronic pain is a biopsychosocial process, the discovery and validation of a prognostic and robust signature for pain recovery vs. persistence requires measurements across multiple dimensions in the same patient cohort in combination with a suitable ‘big data’ computational analysis pipeline for the extraction of reliable and cross-validated results from a multilayered and complex dataset. We are well positioned to execute the study aims with: (1) A highly skilled and experienced team of scientists and clinicians from Stanford University, University of Toronto/Hospital for Sick Children, and Cincinnati Children’s Hospital Medical Center; (2) A standardized specimen collection, processing, storage, and distribution system, leveraging Stanford Biobank’s platform, BioCatalyst, to aggregate the sample inventory with clinical annotations for an accessible, virtual biobank, within the Signature of Pain Recovery IN Teens (SPRINT) Biobank and Analysis Core (SBAC); (3) Cutting-edge preliminary data implicating novel candidates for neuroimaging, immune, quantitative sensory, and psychological markers for discovery; and (4) Expertise in machine learning approaches to extract reliable and prognostic bio-signatures from a large and complex data set. We expect that the results from this project will facilitate risk stratification in patients with chronic MSK, a more resourceful selection of patients who are likely to respond for undergoing current multidisciplinary pain treatment approaches, and new insight into biological and behavioral processes that may be exploited to develop novel strategies profiting those who are refractory. For the R61/Discovery Phase Aim individuals will be thoroughly characterized via biological (i.e. brain structure and function, immune, sensory profiles), psychological state, and clinical endpoint (i.e., pain intensity, disability) data. Unbiased machine learning algorithms will identify a multivariate model comprised of the most prognostic biological, psychological, and clinical endpoints. The model will classify adolescents with and without resolving chronic MSK pain after a state-of-the art multidisciplinary pain treatment intervention. R33/Validation Phase Aim will validate the biological signature derived in the R61 study. This signature will be useful for a range of adolescent-based clinical trials in which identification of the highest risk individuals is necessary, providing a clinically actionable intervention algorithm.

NIH Research Projects · FY 2025 · 2019-09

PROJECT SUMMARY/ABSTRACT BACKGROUND: Several independent lines of evidence suggest that sleep disturbance may directly contribute to the generation and maintenance of neuropsychiatric symptoms (NPS) including anxiety, depression, agitation, irritability, and apathy through fronto-limbic brain networks that regulate emotion, particularly in regions of the prefrontal cortex (PFC) and limbic areas (amygdala). However, the model of sleep disturbance contributing to increased NPS through impairments in fronto-limbic function has not yet been tested in a sample of participants with or at high-risk for developing Alzheimer’s Disease (AD). OBJECTIVE: We aim to test this model in patients with mild cognitive impairment (MCI) and mild AD by characterizing associations between sleep disruption, fronto-limbic function while regulating emotion, and NPS at baseline and by experimentally manipulating sleep to determine whether changes in sleep cause downstream alterations in fronto-limbic functioning and NPS. DESIGN/METHODS: Our hypotheses will be tested in a 2-arm randomized controlled mechanistic trial with 150 patients with MCI and mild AD experiencing sleep disturbances who are also experiencing emotional distress and other behavioral symptoms. Participants will be randomized in a 1:1 ratio to receive a sleep manipulation (Cognitive Behavioral Therapy for Insomnia; CBT-I) or to the credible control treatment for insomnia group. Both interventions will be administered in six sessions delivered over eight weeks. CBT-I is an efficacious behavioral intervention specifically targeted at improving sleep patterns through a combination of sleep restriction, stimulus control, cognitive therapy targeting dysfunctional beliefs about sleep, and sleep hygiene education. At baseline, and post-sleep manipulation we will assay each participant’s fronto-limbic functioning while regulating emotions (amygdala reactivity and PFC-amygdala connectivity), NPS using the Neuropsychiatric Inventory (NPI), and sleep efficiency using high-density EEG collected overnight during sleep. SPECIFIC AIMS are to 1) characterize baseline associations among sleep disturbances, emotion regulation brain function, and NPS prior to a sleep manipulation, 2) test that sleep-induced fronto-limbic brain function improvement mediates the association between sleep improvement and NPS reductions, and 3) determine baseline predictors of the NPS improvement. NOVELTY & IMPACT: Using a multi-methodological approach within a mechanistic trial framework by causally manipulating sleep, we will uncover potential NPS mechanisms across multiple units of analysis (brain circuit, physiological, behavioral, and self-report). Our results will advance a mechanistic understanding of how sleep disturbances and fronto-limbic brain function while regulating emotions may underlie the emotionally distressing and economically relevant problem of NPS in early AD patients. These results would be a necessary first step in the development of sleep based, mechanism-focused preventative strategies and treatments that are more personalized for the individual.