University Of Pennsylvania

NIH Research Projects · FY 2025 · 2022-08

Project Summary/Abstract Candidate: Catherine Auriemma, MD, is a pulmonary and critical care physician-scientist passionate about understanding and improving long-term outcomes of patients with acute respiratory failure (ARF). To advance her career towards research independence, she seeks didactic and experiential training to develop expertise in consensus methods, prospective study design, and statistical modeling and simulation. Research Context: Rising incidence and decreasing mortality of ARF has produced a growing population of survivors facing significant physical, cognitive, and social impairments requiring increased healthcare utilization. A crucial barrier to advancing ARF survivorship research is the lack of an outcome measure that is patient-centered and appropriate for evaluating interventions with either palliative or restorative intent. Hospital- free days (HFDs), the number of days spent alive and outside an acute care hospital, has become common in studies of other acutely ill populations. However, HFDs does not account for decrements in functional status or quality of life; and the bimodal distribution of HFDs among ARF patients raises questions regarding the statistical power and construct validity of HFDs for ARF. This study proposes to design and evaluate a method to quality-weight HFDs using patient-reported assessments of function, quality of life, or caregiver burden. Specific Aims: 1) Develop an optimal approach to quality-weight HFDs using consensus methods with key stakeholders; 2) Assess quality-weighted HFDs among a prospective cohort of ARF patients; 3) Compare statistical power and construct validity of HFDs with and without quality-weighting in a large ARF cohort. Research Plan: To accomplish these aims, Dr. Auriemma will convene a Delphi panel of ARF survivors, family caregivers, clinicians, and trialists to develop best practices for integrating patient- and caregiver-reported data into assessments of HFDs. She will then apply the novel method to a prospective cohort of ARF patients to assess acceptability, responsiveness, and variability of quality-weighted HFDs. Finally, she will use observed values in the Aim 2 cohort to simulate quality-weighted HFDs in a large clinical trial among patients with ARF to compare statistical power and construct validity of unweighted and quality-weighted HFDs. Career Development Plan: Working closely with her mentors and advisors, Dr. Auriemma will 1) develop expertise in consensus methods necessary to convert multiple patient-identified core values into measurable outcomes; 2) obtain the skills necessary to design, launch, oversee, and complete a multisite, prospective cohort study; and 3) gain methodologic expertise in advanced statistical modeling and simulation techniques. Environment: The University of Pennsylvania offers an ideal environment to pursue this training, with well- established mentors and her home department heavily dedicated to Dr. Auriemma’s success, and several multi-disciplinary research centers with long track records of producing successful, independent investigators.

NIH Research Projects · FY 2025 · 2022-08

Project Summary/Abstract: We are using the small nematode C. elegans as an experimentally tractable model to study the molecular roles of conserved genes in neuronal, circuit, and behavioral plasticity. We aim to study the generation of behavior at a level and scope not possible in other organisms, including parallel analysis of many genes across multiple behaviors and circuits. This includes the goal of understanding the contribution and interactions of genes, and even single isoforms of genes, in behavior. By focusing on conserved orthologs of genes associated with neurodevelopmental and neuropsychiatric disorders, characterized by changes in behavior, we hope to expand our understanding of the role of genes in behavior. Our molecular dissection of gene function in single neurons between and across behavioral circuits has led to identification of novel molecular mechanisms and genetic interactions in experience-dependent neuronal plasticity and behavioral plasticity. Here we focus on synaptic cell adhesion molecule (sCAMs) genes, including neurexins and neuroligins, which are extremely complex and redundant gene families in vertebrates. The complexity and diversity of vertebrate neurons, circuits, and sCAM genes have prevented simultaneous analysis at the genetic, molecular, circuit, and behavioral resolution we hope to achieve. We propose to use C. elegans as a tractable experimental system to simultaneously investigate the molecular and circuit mechanisms of many synaptic adhesion genes in multiple behaviors. Our research plans over the coming years are to expand the list of sCAM genes we are studying in depth to gain a more nuanced and complete picture of the molecular coordination of sCAM genes in behavior. Using a suite of modern genetic and neuroscience techniques we plan to 1) Identify networks of sCAM genes involved in multiple foraging behaviors, 2) Define the cellular, subcellular, molecular, and temporal requirements of each identified sCAM gene, and 3) Characterize the impact of each sCAM gene on the structure and functional connectivity of a foraging circuit, all at single neuron resolution. Our top-down approach relies heavily on using behavior as a readout of gene and circuit function, with the hope this will provide a unique window into the genetic and molecular basis of behavior. Successful completion of our work will result in a deeper understanding of the principles of neuronal circuit formation, function, and behavioral output with implications across basic and disease-focused disciplines. C. elegans are not only a uniquely tractable experimental model for the resolution of experiments we propose, but also provide an inclusive experimental system to train/mentor undergraduates, graduate students, and postdocs at all levels of experience.

NIH Research Projects · FY 2026 · 2022-08

Electroconvulsive therapy (ECT) is one of the most effective antidepressant non-invasive brain stimulation therapies for adults with major depression. However, a number of patients fail to respond despite adequate trials, and while clinically beneficial, ECT can produce adverse cognitive effects including amnesia, executive dysfunction, and verbal dysfluency. Previous single- and multi-site ECT-imaging investigations have been limited by insufficient sample size and/or non-standardization of methodology. Therefore, in answer to NIMH Strategic Objective 3.2 "Develop strategies for tailoring existing interventions to optimize outcomes," our investigative teams have conducted clinical studies to develop standardized methods for acute ECT course administration, antidepressant and cognitive measures for phenotyping, optimal neuroimaging protocols and E-field modeling, and sophisticated analytic models to integrate and interpret the antidepressant-response and cognitiveimpairment biomarkers. In this prospective study we propose the first investigation integrating multiple units of analysis including clinical and cognitive phenotyping, whole-brain neuroimaging, EEG, and E-field modeling to establish the mechanisms underlying ECT-induced antidepressant response (response biomarkers) and cognitive adverse effects (safety biomarkers), as well as to find the "sweet spot" of ECT dosing for optimal antidepressant benefit and cognitive safety. Adult patients with major depressive disorder (n = 230) will receive a standardized acute ECT course, complete clinical and cognitive measures and undergo structural and functional MRI at three time points (baseline, after ECT tt6, and following treatment completion) and one-month naturalistic follow-up. All MRI data will be processed and harmonized identically at a central imaging core to ensure uniformity. We have three primary aims: 1) Determine the relationships between E-field strength, ictal power, and biomarkers; 2) Determine the relationships between E-field strength, biomarkers, and antidepressant outcomes; and 3) Determine the relationships between E-field strength, biomarkers, and cognitive outcomes. An exploratory aim will contrast antidepressant-response and cognitive-impairment biomarlcers identified in the current proposal with magnetic seizure therapy and healthy comparison subjects. The overarching hypothesis of this investigation is that the E-field variability will explain antidepressant and cognitive outcomes. Public Health Significance: Successful completion of this project will verify the optimal ECT dose (the "sweet spot'') of 112 Vim within the right hippocampus which can then inform precision and individualization of ECT amplitude with "E-field informed ECT". The standardized algorithms for E-field modeling can be generalized and widely disseminated. This proposal will result in a paradigm shift from "trial and error" approaches of ECT parameter selection to individualized, precision dosing to improve patient outcomes. Project Summary/Abstract

NIH Research Projects · FY 2024 · 2022-08

ABSTRACT Recent scientific advancements have made chimeric antigen receptor (CAR) T cell therapy a prom1s1ng treatment option for relapsed and refractory cancers. In this strategy, T cells are extracted from the patient and reprogrammed and then reinfused into the subject to seek out and destroy cancer cells. However, not all individuals respond to this treatment and therefore a better understanding of the mechanisms that underlie antitumor immune cell function is required to improve response rates. Successful therapy has been linked to increased CART expansion, long-term persistence as well as early memory differentiation, and approaches to augment these properties could greatly enhance CAR T cell potency. DNA modifying enzymes such as the methylcytosine dioxygenase TET2 may be involved in the control of T cell differentiation and function, and TET2 disruption leads to increased T cell proliferation, longevity, and early memory differentiation. However, the role of TET2 in regulating CAR T cell fate and function is not well understood. I hypothesize that TET2 catalytically and non-catalytically regulates CAR T cell differentiation and antitumor activity by direct alteration of DNA methylation status as well as through chromatin remodeling. The catalytic function of TET2 induces active DNA demethylation through successive oxidation of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC), 5- formylcytosine (5fC), and 5-carboxylcytosine (5caC). Demethylation is then achieved through either passive dilution of 5hmC or active excision of 5fC and 5caC. The biological impact of these two active demethylation pathways in CART cells is not understood. In Aim 1, I propose to elucidate the role of TET2-catalyzed changes to the methylome in mediating CART cell differentiation and effector function. I postulate that the active excision commitment step converting 5hmC to 5fC is indispensable for TET2-mediated control of T cell differentiation and antitumor function. To evaluate this, I will investigate the effect of halting oxidation at the 5hmC step on differentiation, antitumor function, and global as well as site-specific DNA methylation profiles in CAR T cells. Additionally, TET2 impacts chromatin structure through both catalytic and non-catalytic mechanisms involving interactions between histone modification proteins. The role of TET2-induced changes to chromatin structure on T cell fate is also currently unknown. In Aim 2, I will determine how chromatin remodeling by TET2 impacts regulation of CAR T cell differentiation and function. I hypothesize that TET2 influences changes to local chromatin structure through catalytic and non-catalytic activities to regulate CAR T cell differentiation and antitumor function. Thus, I will investigate the effect of eliminating TET2 catalytic function on the differentiation, antitumor efficacy and the epigenetic landscape of CAR T cells compared to simultaneous knockout of both catalytic and non-catalytic activity and stalled catalytic function. Together, these aims will improve our understanding of TET2 function in regulating T cell-mediated tumor control and inform strategies to safely modulate TET2 activity to improve outcomes with CART cell therapy.

NIH Research Projects · FY 2025 · 2022-08

It is estimated that fibrosis contributes to 45 percent of all deaths in the developed world. Inflammatory fibrosis is the histological manifestation of chronic kidney disease (CKD). The critical unresolved question in the field is the actual trigger and mechanism for the persistent low-grade inflammation in fibrosis. We propose that cytosolic nucleotide (RNA and DNA) sensing pathways plays key role in inflammatory fibrosis in CKD. Cytosolic DNA and double stranded, modified RNA is associated with infections is rapidly recognized by cytosolic pattern recognition receptors (cPRR) including the cytosolic RIG-I-like receptors (RLR), and the cyclic GMP-AMP synthase (cGAS)– stimulator of interferon genes (STING). Activation of RLR and STING, usually via the TBK1 (TANK-binding) kinase, NFkB (nuclear factor kappa-light-chain-enhancer of activated B cells) and IRF3/7 transcription factors will trigger the production cytokines, chemokines, activate dendritic cells, and promote T cell expansion, creating a fibroinflammatory milleu in the kidney. In this project; We will explore the cause of excessive activation of cytosolic DNA and RNA sensors in inflammatory fibrosis. Systematically map cytosolic DNA and RNA: A) expression of TEs and ERVs B) cytosolic mitochondrial DNA in kidneys of patients and mouse models of CKD and fibrosis and their correlation with cytosolic DNA and RNA sensors. We will define the contribution of myeloid and epithelial, DNA (cGAS/STING) and RNA (RIG-I, MDA5) sensing pathways to inflammatory fibrosis in mouse models. We will examine whether genetic variants observed in cytosolic RNA and DNA sensing pathway associated genes (TREX1, TRIM6 and IRF5) contribute to kidney disease development in patients.

NIH Research Projects · FY 2024 · 2022-08

Project Summary Episodic memory is the ability to recall details about prior experiences. Researchers have historically relied on controlled item-recognition paradigms, in complement to autobiographical recall tasks, to investigate the biological substrates of episodic memory. Contemporary theories posit that episodic memory is supported by a constellation of neocortical regions, in concert with the hippocampus and medial temporal cortices. Of these neocortical regions, the posterior cingulate cortex (PCC) stands out because it is reliably observed in neuroimaging studies of episodic memory and demonstrates engagement that is sensitive to memory strength. Although a large literature indicates that the PCC is critical for episodic memory, very little is known about its unique role in memory or cognition more broadly. Meta-analyses of functional neuroimaging studies that have investigated the relationship between memory tasks and PCC activations provide some insight as to the region’s role. Strikingly, while item-recognition tasks are associated with activity in the dorsal subregion of the PCC (dPCC), autobiographic recall tasks are uniquely associated with activity in the ventral PCC subregion (vPCC). This functional divide mirrors similar cytoarchitectural and network-connectivity differences found along the dorsal-ventral axis of the PCC. Furthermore, the dPCC is consistently implicated in decision-making studies, while the vPCC has been found to be involved in the representation of specific features and semantic associations of retrieved memories. Synthesizing across previous observations suggests that the dPCC serves as a putative accumulator of mnemonic evidence during memory-based decisions, while the vPCC serves to support the retrieval of details about previous episodes. However, progress in clarifying the contributions of PCC subregions to episodic memory have been stymied due to the location of the region within the medial surface, making it challenging to isolate the dynamics of PCC signals using traditional electrophysiological recording and neuroimaging methods. The use of cutting-edge techniques can help overcome previous limitations in spatiotemporal precision that have prevented advances in understanding the function of the PCC: high-resolution functional neuroimaging and invasive electrophysiological recordings of population and single neuron activity. An openly-available, high-resolution neuroimaging dataset containing thousands of item-recognition trials per participant will be used to isolate the functional organization of item-recognition response patterns in the PCC. Population responses collected via intracranial electrodes will be analyzed in order to temporally isolate tightly coupled memory-decision and memory-retrieval processes across the PCC. Additionally, single unit recordings from the PCC will be collected and used to test whether memory-selective and visual-selective units can be identified in the PCC, underlying population level signals observed in response to memory decisions and retrieval. Results from this work will provide a significant advance to our understanding of functional organization in the PCC, helping map the ways memory deficits can progress in healthy aging and disease.

NIH Research Projects · FY 2025 · 2022-08

SUMMARY The COVID-19 pandemic due to the SARS-CoV-2 virus has resulted in millions of deaths worldwide. The majority of COVID-19 deaths are caused by lung disease characterized by alveolar filling and severe hypoxemia. Descriptive studies of human patients, animal models and cultured cells have supported numerous pathogenic mechanisms for COVID-19 lung disease, including direct epithelial cell infection, vascular cell infection and thrombosis, and acute respiratory distress syndrome. Despite intense investigation, these hypotheses remain unproven due to a lack of cellular functional evidence for causality. SARS-CoV-2 infection requires viral binding of the human ACE2 (hACE2) cell surface protein, and wild-type virus cannot bind mouse ACE2. Existing hACE2- expressing mice either drive disease through non-endogenous transgenes that do not permit conditional analysis or fail confer severe illness after infection with SARS-CoV-2. Thus, powerful mouse genetic approaches have not yet been harnessed to test COVID-19 pathogenic mechanisms. To address this gap in knowledge we have generated new mouse genetic models that (i) express hACE2 from the mouse Ace2 locus at levels sufficient to confer lethal disease and hypoxia like that observed in human patients, (ii) permit Cre-mediated loss of hACE2 expression to functionally identify cells required to confer COVID-19 disease, and (iii) permit-Cre mediated gain of hACE2 expression to functionally identify cells sufficient for COVID-19 disease. Our preliminary studies identify both epithelial cell infection and vascular disease associated with extensive intravascular thrombosis in the lungs of hACE2 knockin animals. We therefore hypothesize that COVID-19 lung disease arises due to synergistic infection and/or dysfunction of both lung epithelial and lung vascular cells. To test this central hypothesis we will (i) use established Cre-expressing transgenes to test the requirement(s) for epithelial and vascular cell types during COVID-19 lung disease, (ii) use lung slice explants from human and hACE2 knockin mouse lungs to map the cells infected by SARS-CoV-2 virus, and (iii) compare acute and chronic lung responses to infection by the influenza and SARS-CoV-2 viruses to identify the pathogenic mechanisms that underlie the exceptional lethality of COVID-19 lung disease. These studies are expected to yield a functional and integrated understanding of the events that underlie COVID-19 lung disease and provide a solid scientific foundation for the development of novel therapeutic approaches.

NIH Research Projects · FY 2025 · 2022-08

ABSTRACT Among people with HIV, stigma and mental illness, such as depression, bar access to care and worsen health outcomes, particularly in countries like Malawi where 10% of adults are living with HIV and up to a 25% of people with HIV have co-morbid depression. As depression treatment is increasingly integrated into HIV care, interventions helping to reduce stigma for patients facing multiple stigmas— HIV and mental illness stigmas— are crucial for engagement in care and improvement of health outcomes. Yet, most individual-level stigma-reduction interventions address only one type of stigma. As such, there is a missed opportunity to address multiple stigmas at once to serve patients. The overall aim of this proposal is to consolidate an evidence-based HIV-mental illness stigma-reduction intervention with depression treatment for people with HIV and conduct a hybrid effectiveness-implementation pilot to evaluate its implementation and impact on patient outcomes in Malawi. My long-term career goal is to become a leading researcher on implementing and evaluating interventions that address stigma and meet the mental health needs of people with HIV. This K01 award will enable me to build upon my strong foundations in epidemiology, qualitive methods, and implementation science to address gaps in my training and develop the necessary expertise to transition into an independent investigator. My training goals are to obtain: 1) substantive knowledge in stigma and individual-level stigma-reduction interventions; 2) theoretical and methodological skills to combine and consolidate multiple evidence-based interventions using a participatory community-based research approach; and 3) expertise in designing and executing hybrid effectiveness-implementation studies to evaluate both implementation and clinical (e.g., HIV and mental health) outcomes. These goals will be achieved through a combination of direct mentorship, coursework, seminars, directed readings, workshops, conferences and hands-on experience. In my proposed research, I will first combine interventions that address HIV and mental illness stigma, consolidate with depression care for people and develop plans for implementation drawing from focus groups and interviews (Aim 1). I will then evaluate the implementation of the consolidated HIV-mental illness stigma-reduction intervention and its impact on patient stigma, depression, and HIV care engagement in a two-site pilot hybrid effectiveness-implementation trial (Aim 2). This innovative research will (a) address HIV and mental illness stigma while leveraging existing mental health services, (b) prepare for multi-level stigma-reduction intervention packages, and c) yield detailed insights into barriers and facilitators of implementing stigma-reduction interventions in low-resource settings. Ultimately, the proposed study and training will provide me with the skills and preliminary data for an R01 proposal to conduct a full hybrid effectiveness-implementation trial to implement and evaluate a multi-level stigma-reduction intervention in Malawi.

NIH Research Projects · FY 2025 · 2022-08

Candidate: I am a Fellow in Infectious Diseases at the University of Pennsylvania and a physician-scientist with a Master of Public Health degree and 5 years of experience working in rural Haiti. While I have a strong track record of published research at the intersection of poverty, food security, and infectious diseases, my experiences have motivated me to shift my research in two ways. First, I have developed an interest in poverty’s effects on decision-making, including the theory of poverty’s psychological impacts, the empirical measures of these impacts, and the scientific approaches used to examine the effects of poverty alleviation on health behaviors and outcomes. Second, I plan to move from observational work towards the design and execution of hybrid effectiveness-implementation clinical trials of innovative economic interventions to improve HIV outcomes. Background: Poverty is an important contributor to poor short- and long-term HIV outcomes for pregnant women with HIV. This problem is particularly salient in Haiti, where 25% of people live in extreme poverty and only half of pregnant women with HIV are retained in care 12 months after starting ART. It is also relevant in Botswana, where 15% of people live in extreme poverty, the HIV prevalence is >20%, and postpartum engagement in HIV care is similarly poor. Recent research in behavioral economics has shown that poverty can result in worse health outcomes by taxing mental bandwidth, resulting in a heightened focus on immediate needs and less attention to future-oriented decisions. Mental bandwidth is likely further taxed by the added burdens of HIV and the perinatal period. Consequently, anti-poverty interventions targeting pregnant women with HIV may be particularly effective at improving health outcomes. Training: To achieve research independence, I require additional training in 1) behavioral economics and the decision-making processes underlying health behaviors; 2) the conduct and analysis of qualitative studies; and 3) hybrid effectiveness-implementation clinical trials Research: I will use 3 aims to accomplish my objective of assessing a key pathway — mental bandwidth — by which poverty (and cash transfers to combat poverty) can affect health behaviors among pregnant women with HIV in rural Haiti and Botswana: 1) Characterize the relationship between mental bandwidth, HIV, and the perinatal period; 2) Identify key characteristics of an unconditional cash transfer intervention for pregnant women with HIV; and 3) Conduct a Hybrid Type 2 effectiveness-implementation trial of an unconditional cash transfer intervention for pregnant women with HIV. This research was originally set at St. Boniface Hospital in Fond-des-Blancs, Haiti, but because of geopolitical instability in Haiti will be completed at government-run antenatal clinics in Gaborone, Botswana. I will use the findings from this K23 as the basis for an R01 proposal to conduct a larger trial of an unconditional cash transfer powered for clinical outcomes (e.g., postpartum viral suppression).

NIH Research Projects · FY 2026 · 2022-08

The equal segregation of chromosomes during cell division ensures the accurate inheritance of genetic information. Aberrant chromosome segregation can cause an imbalance in chromosome number, or aneuploidy, which can result in spontaneous abortion and birth defects and is a major cause of cancer. The locus required for the equal segregation of chromosomes is the centromere. In humans, centromeres are comprised of repetitive α-satellite sequences that span several megabases on each chromosome. The repetitive nature of these regions has challenged efforts to determine their sequence, structure, and variation using short-read sequencing data. As a result, we have a very limited understanding of the natural variation of centromeres and the impact of this variation on essential cell biological process critical for life. In this proposal, I aim to address this gap in knowledge by sequencing and assembling centromeres from multiple humans using a combination of long-read sequencing technologies and novel computational assembly tools (Aim 1; K99 phase). Additionally, I propose to assess the natural variation of human centromeres at the genetic, epigenetic, and transcriptional level using innovative computational methods and multiomic sequencing approaches, ultimately building a model of human centromere variation (Aim 2; K99 phase). Finally, I propose to determine how variation among centromeres affects the accurate segregation of chromosomes during cell division using cell-based assays, long-read sequencing, and multiomic sequencing approaches (Aim 3; R00 phase). Together, this work will provide the first comprehensive assessment of human centromere variation and reveal how this variation affects centromere function in cells. The tools, resources, and skills developed in the K99 phase will be applied in the R00 phase to determine the functional consequences of centromere variation and its role in human health and disease. My goal is to build an independent research program that spans the gap between genomics and centromere biology. I will receive the necessary interdisciplinary training from my mentor (Dr. Evan Eichler), co-mentor (Dr. Sue Biggins), and the rest of my postdoctoral advisory committee (Drs. Deborah Nickerson, Andrew Stergachis, and Kelley Harris). In addition, I will participate in career development activities offered through the University of Washington and the Fred Hutchison Cancer Research Center. Together, my research training, mentors, advisory committee, and academic environment will prepare me well as I transition to an independent position as an academic scientist.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY While chimeric antigen receptor (CAR) T-cells can be very effective in advanced hematological malignancies, autologous products often have variable potency and require complex and expensive manufacturing, limiting their scalability and accessibility. The long-term goal of this proposal is to develop a well-characterized, ‘off- the-shelf’ (OTS) therapeutic T-cell platform using banked T-cells pre-manufactured from healthy donors, thus offering immediate availability and high potency at a reduced cost. One major limitation of this approach is potential immune rejection of infused OTS T-cells by host T- and NK-cells, which would impair persistence and clinical benefit of the T-cell therapy. Therefore, my graduate dissertation project (Aim 1) focuses on engineering OTS therapeutic T-cells to resist host immune rejection. I have developed the ‘first-in-class’ chimeric alloimmune defense receptor (ADR) which enables allogeneic OTS CAR T-cells to defend themselves by selectively eliminating activated host alloreactive lymphocytes while sparing other resting non-alloreactive cells. T-cells co-expressing a 4-1BB-directed ADR and a CAR evade immune rejection and produce long-term anti- tumor activity in mouse models of OTS CAR T-cell therapy for both liquid and solid tumors. We are now optimizing the 4-1BB-specific ADR for clinical translation and will initiate a Phase I clinical study in our center. I am also exploring other potential ADR targets, including OX40 and CD40L, to maximize the anti-rejection activity. In addition to alloimmune rejection, activity of OTS T-cells in solid tumors can be inhibited by the immunosuppressive tumor microenvironment (TME). Mounting evidence suggests that the inflammatory milieu created by therapeutic T-cells may elicit reactive changes both locally (in the TME) and systemically (in circulation) that further inhibit anti-tumor activity of therapeutic T-cells and possibly promote tumor growth and metastasis. Examples include a surge of immunosuppressive M2-like macrophages in neuroblastoma patients receiving GD2 CAR T-cells and poor responses to CD19 CAR T-cell therapy in patients with high circulating myeloid-derived suppressor cells. In addition, preclinical studies indicate that treatment-induced inflammation enhances pre-metastatic niche (PMN) formation and increases the risk of metastasis. Therefore, during my post- doctoral training (Aim 2), I will first elucidate the reactive changes (both in TME and in circulation) caused by therapeutic T-cells and identify cellular/molecular mediators of enhanced immunosuppression at the primary tumor site. I will also investigate how T-cell therapies may affect PMN formation in solid tumors. I will then further modify therapeutic T-cells to counteract these unwanted responses by arming them with secreted factors (antibodies, peptide inhibitors) to block the responsible cytokines / chemokines, or by enabling them to selectively eliminate inhibitory cellular subsets in the TME. Successful completion of both Aims will ultimately improve the efficacy of OTS T-cell therapies of cancer.

NIH Research Projects · FY 2025 · 2022-08

Modified Project Summary/Abstract Section PROJECT SUMMARY Up to 45% of all cervical cancer screening in the United States is considered to be overuse, despite consensus guidelines and strong evidence of the limited benefit and potential harm of low-value screening. Overscreening for cervical cancer includes screening more frequently than is recommended or outside the recommended age groups. Overscreening can lead to increased false positives and psychosocial harms, cause unnecessary treatment of cervical abnormalities that would likely resolve on their own, and result in excess financial and opportunity costs. While there are several implementation strategies shown to be effective for increasing cervical cancer screening, it is largely unknown how best to decrease overscreening in routine care. As such, there is a critical need to develop effective strategies for ensuring de-implementation of outdated screening practices. To help fill this gap, this study will 1) test the independent and combined effects of patient- and clinician-directed de-implementation strategies on rates of cervical cancer overscreening in comparison to usual care, and 2) evaluate contextual mechanisms contributing to the success or failure of each de-implementation strategy using coincidence analysis. To achieve these aims, a 2x2 randomized controlled trial with approximately 200 clinicians and 2,400 patients will be conducted in primary care and gynecology clinics affiliated with a large healthcare system with high rates of cervical cancer overscreening. The highly efficient factorial and pragmatic design will enable assessment of independent and combined effects of each strategy. Drawing from systematic evidence of the effectiveness of nudge strategies to increase guideline adherence and an integrated theoretical model, the specific de-implementation strategies to be tested are: 1) theory-based messaging shown to be effective at decreasing overscreening intentions (patient nudge strategy); and 2) point of care reminders alerting clinicians if patients are not due for screening (clinician nudge strategy). The primary de-implementation outcome is reduction in the rate of cervical cancer overscreening among females who are not due for screening based on evidence-based guidelines. Secondary de-implementation outcomes, including reach, acceptability, and feasibility, and implementation costs, and clinical outcomes including rate of abnormal results, false-positives, and diagnostic procedures will also be measured. Following the trial, a stratified, embedded cohort of patients and clinicians will be surveyed and interviewed to evaluate contextual factors contributing to the success or failure of each strategy using coincidence analysis. This innovative project responds directly to the call by the National Cancer Institute to develop and test de-implementation strategies in cancer control. Further, the proposed low-touch strategies are designed to support widespread and equitable implementation across diverse settings, and, if successful, be translated to address other forms of overuse across primary and specialty care. This work will also help to broadly advance causal theory in de-implementation science by evaluating underlying contextual mechanisms that contribute to the effectiveness of strategies among diverse populations.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY/ABSTRACT (OVERALL) The University of Pennsylvania Telehealth Research Center of Excellence in Cancer Care (Penn TRACE) will apply insights from communication science and behavioral economics to design and test innovative telehealth strategies to improve effectiveness and access across the cancer care continuum, with an emphasis on understanding mechanisms of action. The COVID-19 pandemic led to dramatic growth in the use of telehealth for cancer care delivery, fostered by both clinical need and temporary waivers. Telehealth strategies have included both synchronous communication (real-time video or telephone conferencing) and asynchronous communication (sequential health information exchange through text messaging or secure portals). Yet, fundamental knowledge gaps include the extent to which telehealth may be superior to non-telehealth care delivery strategies for access, quality, and outcomes; how telehealth may enhance or detract from increased access to cancer care in the context of the digital divide and persistent differences in cancer outcomes; and the impact of telehealth on health care efficiency. Penn TRACE will address an overarching research theme: to apply insights from communication science and behavioral economics to design and test synchronous telehealth strategies, supported by asynchronous elements, to improve access, quality, outcomes, and efficiency across the cancer care continuum. We focus on lung cancer as a model for telehealth across the care continuum, from screening to treatment to survivorship. We bring together a team of international experts in communication science, behavioral economics, cancer care delivery, telehealth, health care innovation, mixed methods, and health outcomes to achieve the following specific aims: 1) Apply concepts, strategies, tools, and methods from communication science and behavioral economics to design and test synchronous telehealth strategies, supported by asynchronous elements, to improve access, quality, outcomes, and efficiency for patients across the care continuum; 2) Conduct a pragmatic randomized clinical trial to compare the effectiveness of telehealth strategies to increase shared decision making for lung cancer screening using a Sequential Multiple Assignment Randomized Trial (SMART) design; 3) Conduct two rapid-cycle pilot projects, with methods and measures aligned with the pragmatic trial, to design and test the effectiveness of telehealth to improve cancer care, identify multilevel mechanisms of action, and lay the foundation for future, more definitive pragmatic trials; and 4) Build capacity to advance a national telehealth research agenda and train the next generation of investigators with expertise in cancer care, telehealth, and health outcomes. By joining together interdisciplinary faculty across Penn, the Penn TRACE will result in novel, scalable, and generalizable disseminated strategies to drive lasting improvements in cancer care for all populations. Penn has an unparalleled environment in which to bring together these areas of study.

NIH Research Projects · FY 2026 · 2022-08

The discovery of CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) systems led to creative new applications that are transforming science and medicine. However, the rapid discovery of new CRISPR systems outpaces our understanding of their biological roles in anti-phage defense and their development for novel applications. To acquire immunity to new phages, CRISPR-associated proteins (Cas1 and Cas2) integrate fragments of phage DNA ("spacers") at the "leader-end" of the CRISPR locus, near the transcription start site. But how Cas1-2 recognizes the leader-end of the CRISPR remains poorly understood. Next, the CRISPR locus is transcribed and processed into "guide RNAs" that are loaded into surveillance complexes (i.e., Csm complex). Upon sensing viral RNA, the Csm complex makes cyclic oligonucleotide messengers that regulate CRISPR adaptation and nucleases critical for phage defense. But the biological roles of many of these immune effectors remain understudied. The 1961 discovery of regulatory DNA motifs kindled an interest in the "grammatical rules" of DNA motifs that control the storage and retrieval of genetic information. In Aim 1, I will use a bioinformatic approach to discover DNA motifs in CRISPR leaders with highly conserved sequences and positions, that I hypothesize regulate key steps in CRISPR biology such as integration, transcription, or RNA processing. I will determine the role of novel DNA motifs and host factors in CRISPR integration using in vitro biochemical assays and cryo-EM structural biology. Nucleotide messengers regulate critical cellular processes across the tree of life, including anti-viral immune responses, cell morphology, and motility. To address a growing need for rapid and sensitive diagnostics, I co-invented an innovative RNA-guided Csm system for sensitive and sequence-specific detection of SARS-CoV-2 RNA, that repurposes a nuclease immune effector. However, nucleases represent a fraction of the diversity of enzymatic activities predicted to be activated by nucleotide messengers. In Aim 2, I will determine a biochemical and structural understanding of novel immune proteins that I predict to be activated by CRISPR-generated nucleotide messengers.The long-term objectives of this proposal are to address knowledge gaps in our understanding of how bacterial CRISPR adaptive immune systems function and are regulated, and to repurpose basic mechanistic insights for the development of biotech and medical applications.

NIH Research Projects · FY 2025 · 2022-08

Project Summary: Throughout biomedical research, progress is impeded due to a lack of rigor, which could be ameliorated with better training and with community buy-in. While many papers have been written and countless presentations delivered on rigorous practices, the average scientist fails to consistently follow the relevant principles. We structure our proposal based on three insights. (1) Adoption of the principles of rigorous science is a question of culture, which can only be changed by a broad community effort. This work requires buy-in from all stakeholders, including students, professors, and other champions of rigor. (2) To enable this cultural change, materials must be engaging, high quality, and inspiring for learners. Above all, these materials need to serve the community; they must be available for direct consumption, for incorporation into teaching by many professors, and their structure should be a template for research itself. (3) The development and rollout of such high-quality materials necessitates a tight feedback loop with the community; by evaluating their use, we can see how these materials actually influence scientific rigor. The grass-roots, community-driven movement toward a more rigor-infused scientific culture that we envision requires excellent and visually engaging materials with the following key features: learning by doing, short lectures, open languages, easy delivery mechanism, adaptable content, simple interfaces, group-based learning, open-source bidirectional collaboration with the community, and thoroughly evaluated. Our main goal is to enable the principles underlying scientific rigor to become part of everyday culture in science.

NIH Research Projects · FY 2025 · 2022-08

Project Summary/Abstract Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease, affecting 0.3% of children. Before correction, its four defects lead to increased right heart pressures and mixing of oxygenated and deoxygenated blood. Even after surgical repair, patients may experience elevated right heart pressures and volumes due to residual pulmonary stenosis, pulmonary regurgitation, scar formation, and conduction abnormalities. These changes in geometry, wall thickness, and pressure-volume relationships all contribute to right ventricular (RV) remodeling, which can eventually lead to adverse events such as ventricular arrhythmias, RV dysfunction, and the need for pulmonic valve repair, affecting up to 44% of patients overall. Despite the great advances that have been made in medical and surgical care of ToF patients, there is still limited understanding of which patients will experience adverse RV remodeling and subsequent clinical events. ToF patients’ cardiac function is normally assessed annually using cardiovascular magnetic resonance (CMR) imaging, which provides excellent views of the right heart and its valves. However, manual analysis of these images is time-consuming and subject to inter- and intra-user variability. Additionally, CMR provides anatomic and flow data enabling quantification of pulmonary artery hemodynamics, but has not yet been investigated in post-repair ToF patients. Detailed characterization of pulmonary artery stresses and pressures, through the application of computational fluid dynamics (CFD) simulations, could provide insight into factors affecting RV remodeling. There remains an unmet need to comprehensively identify features that characterize and predict progression from primary ToF repair to adverse RV remodeling and poor outcomes. My objectives in this proposal are to identify the structural and hemodynamic parameters of ToF that are associated with RV remodeling in order to improve both clinical care and quality of life. I plan to approach these objectives using two specific aims. In Aim 1, I will develop a supervised machine learning algorithm to accurately and automatically segment 3D cardiac volumes using CMR images. This algorithm will enable robust and repeatable measurements of cardiac structure and function for both cross-sectional and longitudinal analyses. I hypothesize that this algorithm will achieve accurate and precise segmentation results as assessed by Dice scores and intraclass correlation coefficients. In Aim 2, I will study patient-specific pulmonary artery hemodynamics and determine associations with adverse RV remodeling. Specifically, I will generate 3D and 1D CFD models based upon CMR-derived geometries and phase-contrast flow data. I hypothesize that hemodynamic parameters such as wall shear stress and total pathway resistance will be associated with and provide mechanistic insight into RV remodeling. Overall, I anticipate that this project will provide me with the experience and skills to help achieve my goal of becoming a physician-scientist with expertise in cardiovascular physiology, medical imaging, and fluid dynamics, while leading to validated technologies that will support clinicians and researchers in their understanding of ToF.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY/ABSTRACT All genetic variation—including that underlying heritable disease, cancer, and human evolution—originate from mutation. Recent large-scale genome sequencing efforts and innovative statistical analysis have uncovered substantial variation in mutation rate along the human genome, revealing strong impacts of the mutation type and flanking sequence. However, the molecular mechanisms of this context-dependency of mutation rate are poorly understood. In addition, mutation rate variation across genomic sites may bias inferences of selection signals from genomic data, which in turn hinders the identification and functional study of genes that drive disease. The goal of our research program is to develop computational methods to draw insights into the molecular mechanisms as well as functional and evolutionary consequences of context-dependent mutation rate variation. We will first focus on the hypermutability of CpG sites and take a multifaceted approach to investigate the lesion formation and repair at methylated cytosines in different regions of the genome, by utilizing existing genomic and epigenomic data from human populations and other species. Successful completion of this research will contribute to a mechanistic and quantitative understanding of the mutational processes at methylated cytosines. Next, we will improve computational methods for inferring selection on human genes by leveraging the inherent mutation rate variation across genomic sites. We propose to combine population genetics models and machine learning techniques to integrate the allele frequency, site-specific mutation rate, and functional information of variants. The application of these newly developed methods to the ever-growing genomic data will identify genes crucial to human health and reproduction, and improve estimates of the burden of deleterious variants introduced by new mutations in each generation. Finally, we will expand our research scope to somatic mutations and leverage the context-dependency of mutation rates to better understand cancer driver genes. We will evaluate the relative mutability of cancer driver genes under different mutational processes, and investigate how tissue-specific relative mutability and selective effect interact during somatic evolution of tumor. By taking an evolutionary perspective of tumorigenesis, this research promises to shed new light on the tissue-specificity of cancer driver genes. Together, the proposed research will develop novel computational approaches that translate the rich genomic and epigenomic data available into insights into mutational mechanisms, as well as selective forces acting on genes and genetic variants in human populations and somatic cells.

NIH Research Projects · FY 2025 · 2022-07

Project Summary/Abstract Acute myeloid leukemia (AML) is the second most common malignancy among children and adolescents. The prognosis of pediatric AML has improved significantly over recent decades, but still nearly half of patients suffer refractory disease or relapse following a first remission. These patients have a relatively poor prognosis, with a probability of five-year survival following relapse of only ~35%. This is achieved with intensive chemotherapy leading to potentially significant toxicity and even treatment-related mortality. While there has been substantial standardization in practice related to frontline therapy for AML, there is greater variability in treatment of relapsed disease – variability that is poorly understood. Furthermore, given the variability in treatment and the small numbers of patients at any one institution, there is a dearth of information on toxicity risks for the treatments being utilized for refractory or relapsed disease. Cardiotoxicity is a prevalent adverse consequence of AML therapy. However, given the incomplete data captured by frontline clinical trial databases once a patient experiences relapse, data on the onset, progression and potential recovery of cardiotoxicity are generally restricted to the time period during and shortly after frontline therapy and late in long-term survivorship. The current lack of data over the duration of the patient experience precludes a complete assessment of the incremental risks associated with AML therapy, including transplant and salvage. Data on how early cardiotoxicity onset during frontline therapy may impact approach to treatment for relapsed disease, the impact of salvage therapies on cardiac function, and subsequent survival outcomes is thus, also poorly understood. The aims of the proposed work are to establish a unique data resource by combining data from the Children's Oncology Group (COG) clinical trial databases, electronic medical record (EMR) abstraction for a multi-center AML cohort, longitudinal quantitative echocardiographic measures of measures of left ventricular (LV) size, systolic and diastolic function, and administrative data from the Pediatric Health Information System, that will enable assessments comparing toxicity and outcomes associated with the variety of approaches to therapy for refractory/relapsed AML. Specifically, our aims include the following: (1) determine the natural history cardiotoxicity and the incremental effects of treatment from initial diagnosis, through relapse and early post-relapse follow-up, (2) to quantify the influence of prevalent salvage therapies on longitudinal changes in LV size, systolic and diastolic function and the incidence of cardiomyopathy, and (3) to evaluate salvage chemotherapy and transplant as mediators of the documented association between early cardiotoxicity onset during frontline therapy and decreased overall survival.

NIH Research Projects · FY 2026 · 2022-07

The brain is presence of phosphorylated deposits of the neuropathological hallmark of transactive response DNA-binding protein 43 (TDP-43) in the frontotemporal lobar degeneration (FTLD-TDP) and amyotrophic lateral sclerosis (ALS). Moreover, in retrospective studies, TDP-43 proteinopathy was shown to be associated with substantial cognitive impairment that mimicked the Alzheimer's disease (AD) clinical syndrome. The co- existence of TDP-43 pathology in brains with neuropathological change of AD (ADNC) has been reported in 30-70% of AD cases, predominantly affecting predominant Recent subtype limbic and associated areas in a pattern called limbic- age-related TDP-43 encephalopathy neuropathological change (LATE-NC). studies have shown that LATE-NC is also found in individuals without ADNC, postulating a new ofTDP-43 proteinopathy designated as LATE. LATE is one of the most prevalent subsets of TDP-43 proteinopathies observed in ~30-50% of people who die beyond 85 years of age. When comparing LATE-NC with FTLD-TDP cases, recent studies have shown that besides distinct clinical manifestations, there are also differences in epidemiological, genetic, and neuroimaging features. From a neuropathological standpoint, LATE-NC and FTLD-TDP individuals share some features of TDP-43 pathology. Since phosphorylated TDP-43 was identified as the major component of ubiquitin-positive inclusions in FTLD-TDP, five distinct FTLD-TDP histopathological distribution and morphological features of TDP-43 aggregates (type between clinical symptoms, genetic forms of FTLD-TDP, and TDP-43 neuropathological subtypes have been established based on characteristic A to E) features . The association in FTLD-TDP brains have been extensively reported. Interestingly, although TDP-43 pathology in some LATE-NC cases resembles FTLD-TDP type A, a distinctive neuropathological feature related to TDP-43 proteinopathy in elderly individuals is type “Alpha” (similar to type A) or type “Beta” (co-mingling with tau tangle structures) pattern of TDP-43 immunoreactivity in the amygdala. The molecular mechanism(s) underlying the heterogeneity of the TDP-43 proteinopathies is still unknown. Such heterogeneity supports a “strain hypothesis” wherein unique pathogenic TDP-43 species (a.k.a. strains) with different conformations may play a role in such diversity. Our objective is to isolate pathogenic TDP-43 species present in FTLD-TDP and LATE-NC brains and characterize their biochemical properties and biological activities in vitro and in vivo (Aim 1). We will then generate in vitro brain-derived TDP-43 strains that recapitulate the characteristic features of their human counterparts (Aim 2). Finally, we will determine whether there are differential pathophysiological signaling pathways associated with neuropathological changes of TDP-43 pathology in the brain by performing spatial profiles between distinct TDP-43 proteinopathies transcriptomic analysis and comparing the expression (Aim 3 ).

NIH Research Projects · FY 2026 · 2022-07

Project Summary Episodic memory involves the encoding and retrieval of past experiences to support learned behavior. Aside from these mnemonic processes, it also requires the ability to regulate memory (i.e. executive processes). For example, many real-world decisions will engage episodic retrieval, for which executive processes must help to integrate and evaluate the quality of remembered information (mnemonic evidence) and guide behavior to either decision, action, or continued memory search. While the neural basis of episodic memory encoding and retrieval have been a major focus of research, far less is known about its executive aspects. Executive mnemonic functions likely involve an anatomical substrate that is (i) multisensory/associative, (ii) engaged by memory/executive processing, and (iii) strongly interconnected with both mnemonic regions in the medial temporal lobe (MTL) and executive prefrontal (PFC) regions. Prior non-human primate studies, as well as human electrophysiology and neuroimaging data, suggest that posterior cingulate cortex (PCC) fulfills these criteria. Our central hypothesis is that the PCC plays a critical and unique role in executive control of episodic memory retrieval. We further hypothesize that it comprises three subregions regions: dorsal PCC, ventral PCC and retrosplenial cortex (RSC). These subregions are proposed to play complementary roles, corresponding to retrieval regulation, retrieval integration, and scene perception and transformation, respectively. In this account, PCC is a convergence zone of memory and executive systems, whose specific functional organization accounts for prior discrepancies between studies and species. Here, we utilize human intracranial recordings, including single unit data and stimulation within PCC, to better resolve the functional organization of this region. We will therefore employ an array of cognitive experiments to delineate three PCC subregions supporting the encoding, retrieval and executive control of memory processing (Aim 1). In delineating these subregions, we will also seek to differentiate PCC responses from those occurring in memory (MTL) and executive (dlPFC & ACC) functional networks (Aim 2). Finally, based on these observations, we will demonstrate the causal role of PCC subregions on behavior and local/network activity (Aim 3). By studying PCC, a convergence zone of memory and executive systems, progress can be made in elucidating how the failure to successfully leverage past experiences in daily behavior can occur as a common symptom of both neurodegenerative disease (e.g. Alzheimer’s disease) and multiple psychiatric conditions (e.g. schizophrenia) implicating PCC dysfunction.

NIH Research Projects · FY 2025 · 2022-07

This proposal presents a curriculum and research plan focused on the services of Peer Recovery Specialists (PRS) to improve patient retention in opioid use disorder (OUD) treatment in primary care. PRS are individuals in recovery who use their experience and training to provide emotional support to patients, motivate behavior change, and help patients overcome the barriers to treatment engagement and retention. Currently, the approved standard for treating persons with OUD in primary care is medication-assisted treatment, which combines medications – most commonly, buprenorphine – with counseling. However, most patients who begin buprenorphine treatment discontinue within the first 6 months, which elevates the risk of relapse, overdose, morbidity and mortality. In Aim 1 of the research plan, I will identify the structures, functions, resources and practices of a varied set of primary care PRS programs and their potential for increasing OUD treatment retention. Data will be collected through (a) a survey of program characteristics, including PRS recruitment, qualifications, hiring practices, training and professional development, supervision, caseloads, patient matching, specific tasks performed, frequency and mode of patient contacts, incentives, and integration into the larger care team; (b) 3-5 days of direct observation at 7-10 sites to capture PRS behavior and context; and (c) in-depth interviews with patients, PRS, clinicians, and care team members. The studies will provide a granular understanding of the scope, organization, and operational differences in PRS services and their potential effect on OUD treatment retention. In Aim 2, a planning group of OUD and PRS experts will guide the development of an enhanced model of peer support services that combines the components and priorities most likely to provide a cost-effective and practical intervention for OUD treatment retention in primary care. In Aim 3, I will pilot test the enhanced model in a primary care clinic with a small sample of adult patients. The pilot will be a 180-day intervention designed to test the program logistics, operations, training, data collection, and overall management. I will assess the feasibility and acceptability of the intervention, and the fidelity and sustainability of its implementation. Our proposal aligns closely with the National Institute on Drug Abuse (NIDA) 2016-2020 strategic plan to develop and test strategies for effectively and sustainably implementing well-established treatments (Objective 3.4), and with the goals of the NIDA 2021-2025 draft outline strategic plan to develop and test novel prevention, treatment and recovery support initiatives (Goal 2), and implement them in real-world settings (Goal 3). The proposed research and didactic work will position the candidate with a unique set of cross disciplinary skills that will enable her transition to independence as a physician scientist focused on OUD treatment in primary care.

NIH Research Projects · FY 2025 · 2022-07

PROJECT SUMMARY / ABSTRACT Half of incident disability in older and middle-aged, adults with chronic conditions occurs after hospitalization. Often this cascade begins with mobility disability, a condition which affects 31 million adults in the United States and leads to loss of independence, increased health care utilization, and earlier mortality. Higher levels of physical activity after hospital discharge are associated with reduced disability; however, prospective interventions to promote and sustain healthy physical activity are currently lacking. We have successfully piloted a novel approach using behaviorally designed gamification and social support for physical activity promotion during a 12-week intervention among adults discharged from the hospital (N=232). The intervention led to larger increases in physical activity among older and middle-aged patients (age 50 to 65), those with higher social engagement, and lower baseline step counts. Our proposed study will build on results of this pilot to target a broader population of at-risk adults hospitalized for 1 of 3 chronic Ambulatory Care Sensitive Conditions affected by physical activity (hypertension, diabetes, and mild-moderate heart failure). Since high social support was found to lead to larger effects in the pilot study, we will add a virtual health coach to the intervention design to help patients increase their support levels. The goals are of this study are to increase physical activity after discharge from the hospital to reduce incident mobility disability associated with acute illness and to reduce acute and post-acute care utilization. We will also evaluate the sustainability of this approach over a longer period (6 months intervention, 6 months follow up) and qualitatively assess factors associated with higher or lower performance in a population with significant ethnic/racial and socioeconomic diversity. To achieve these goals, we have assembled an expert multidisciplinary team in behavioral economics, geriatrics, nursing science, clinical trials and implementation. We will study the novel application of this approach to patients who are discharged from Penn Medicine hospitals and follow them for 12 months after discharge. We will focus on 4 specific aims: 1) To evaluate the effectiveness of a 6-month intervention using gamification with social incentives and personalized coaching to increase physical activity among adults age ≥ 50 with chronic conditions at risk for disability (primary outcome); 2) To evaluate the sustainability of increased physical activity during a 6-month follow-up period (secondary outcome); 3) To evaluate the impact of physical activity on disability and acute care utilization during the study period (secondary outcomes); and 4) To conduct a mixed-methods process evaluation to explore factors associated with strong or poor response to the interventions. Our approach aligns with NIA's strategic priority to develop effective interventions to maintain function and prevent or reduce disability and also with national efforts to create an Aging Friendly Health System through the spread of scalable, sustainable, and cost-effective interventions.

NIH Research Projects · FY 2024 · 2022-07

Schizophrenia affects approximately 1.1% of the population, or approximately 3.5 million Americans. The life expectancy of persons with schizophrenia is 10-25 years less than that of the general population, and has not improved in recent decades. Sudden cardiac arrest (SCA) and ventricular arrhythmia (VA), which account for 8-10% of all deaths in this population, is three times as common among those with than without schizophrenia. The most clearly established risk factor for SCA/VA in persons with schizophrenia is the use of antipsychotic agents, and this risk is dose-dependent. Second-generation antipsychotic agents (SGAs) are the most common treatment for schizophrenia, and are also used for other common mental health conditions including bipolar disorder, major depressive disorder, and psychosis/agitation associated with dementia. The prevalence of current antipsychotic drug use in US adults is 1.6%, or 3.8 million adults. A recent meta-analysis found that several widely used SGAs are associated with an elevated risk of SCA/VA. Given the high prevalence of polypharmacy in persons with schizophrenia and other mental health conditions, and the high potential for drug interactions in persons taking SGAs, clinicians badly need evidence-based guidance on which drugs do and do not increase the risk of SCA/VA in persons taking specific SGAs. Unfortunately, almost all available evidence about the health effects of potential DDIs involving SGAs comes from either 1) spontaneously reported adverse drug events, which provide limited evidence for causation because of their anecdotal nature, or from 2) pharmacokinetic studies of serum concentrations of SGAs, which include few subjects and do not examine health end-points. A more rigorous approach to identifying and elucidating drug interactions will help to identify drug-drug pairs that truly increase the risk of SCA/VA, and improve the safety of pharmacotherapy provided to persons with schizophrenia and other mental health conditions. To address these critical knowledge gaps about which drugs should and should not be avoided in persons receiving commonly used second generation antipsychotic drugs, we will perform high-throughput pharmacoepidemiology screening to identify drugs that may increase the rate of out-of-hospital SCA/VA in persons taking commonly used second-generation antipsychotic agents. Then, in two independent validation populations, we will conduct hypothesis- driven etiologic pharmacoepidemiology studies to either confirm or refute high-priority potential drug interactions, and elucidate factors that place patients at increased risk of out-of-hospital SCA/VA associated with specific drug pairs. The results of this research will provide drug interaction compendia editors with valid, actionable evidence that will allow them to warn clinicians about truly risky drug combinations. Of equal importance, this research will allow clinicians to be relieved of unnecessary and burdensome alerts about drug combinations that can actually be administered safely. We further propose to enhance the impact of our research by disseminating key findings through our ongoing series of webinars, newsletters, and videos that we produce for our established stakeholder group of editors and curators of drug interaction compendia and computerized decision support systems.

NIH Research Projects · FY 2025 · 2022-07

Optimizing Singlet Oxygen Dosimetry for Photodynamic Therapy (PDT) Abstract The overall objective of this project is to optimize clinical singlet oxygen (1O2) dosimetry (SOD) via three complementary and competing technologies: time-resolved singlet oxygen luminescence dosimetry (TSOLD), multispectral singlet oxygen luminescence dosimetry (MSOLD), and singlet oxygen explicit dosimetry (SOED). The TSOLD instrument is optical fiber-based and achieves ultralow noise detection via infrared time-correlated single-photon counting. It can be used before and after PDT to measure cytotoxic 1O2 concentration ([1O2]) generation in tumor based on its 1270 nm luminescence emission, since it utilizes a short (ns) pulsed laser for 1O2 excitation that is independent of the PDT treatment laser. The recently developed MSOLD instrument measures the luminescence spectrum of singlet oxygen excited by the treatment light, it is thus capable of monitoring [1O2] during PDT without interfering with the treatment. However, unlike TSOLD, MSOLD may introduce additional uncertainty in [1O2] due to a phosphorescence background orders of magnitude larger than the singlet oxygen signal. The SOED instrument can be used in-vivo during PDT in real-time to measure reacted 1O2 generated by the treatment light based on explicit measurement of the light fluence rate, tissue oxygen concentration, and photosensitizer concentration. The TSOLD or MSOLD signals will be used as an input to the SOED system to make it more robust to account for the local oxygen microenvironment. Here, the immediate clinical translation is to compare and determine the most suitable combination of the three technologies for SOD by measurements at multiple sites in patients undergoing intrapleural PDT for malignant pleural mesothelioma, which has shown significant potential in Photofrin-mediated clinical trials at UPenn. In addition, comparison will be made in photosensitizer solutions, tissue-simulating phantoms, and tumors in vivo under well-controlled conditions across a wide range of treatment conditions. Correlation of the tumor response with the1O2 measurements will be evaluated for three clinical photosensitizers (Photofrin, BPD, and ALA) in preclinical models. The SOED instrument will be used at the same time and locations to calculate the “explicit” light-drug- oxygen dose parameters as well as the tissue optical properties. The latter will be used to correct the measured 1O2 signal for light attenuation in order to calculate, the absolute concentration of the cytotoxic agent. The explicit dose parameters will be used as inputs for SOED in an established macroscopic biophysical model to predict the instantaneous and cumulative singlet oxygen concentration ([1O2]) for comparison with TSOLD and MSOLD results, respectively. The outcome of this project will be the determination of the optimal combination (TSOLD/MSOLD/SOED) for SOD in an ongoing PDT mesothelioma clinical trial under clinically-relevant conditions. We hypothesize that quantitative SOD will be significantly more predictive of PDT efficacy than the explicit or implicit (photobleaching-based) techniques used at present. Moreover, we hypothesize that the optimized SOD system will give real-time feedback so that treatment can be personalized.

NIH Research Projects · FY 2024 · 2022-07

PROJECT SUMMARY North America has the highest incidence of renal cancer in the world with the most common subtype being clear cell renal cell carcinoma (ccRCC). Alarmingly, the incidence of ccRCC is on the rise in the U.S. and globally. The overall five-year survival rate for ccRCC is only 10-12% once it becomes metastatic, demonstrating the need for new therapies. Metabolic dysfunction is common in ccRCC based on histologic and molecular analysis. New therapies to treat ccRCC could target its dysregulated metabolic pathways. The etiology of ccRCC is complex but a major risk factor is obesity. High levels of branched-chain amino acids (BCAAs) are present in the serum of patients with ccRCC and obesity, suggesting a potential mechanistic link. BCAAs (leucine, isoleucine, and valine) are essential amino acids, whose concentrations are regulated by dietary intake and catabolism. BCAA metabolism promotes tumor growth in many different types of cancer, but the role of BCAAs in ccRCC is unknown. BCAA catabolism occurs primarily via the first two enzymes, BCAA transaminase (BCAT) and branched chain ketoacid dehydrogenase (BCKDH), respectively. BCKDH is an enzyme complex that catalyzes the rate-limiting reaction. The products of BCAA catabolism are then oxidized within the mitochondria to produce succinyl-CoA and acetyl-CoA, which can be used by the TCA cycle for anaplerosis and mitochondrial respiration. My preliminary data demonstrate that BCAA catabolic enzyme BCAT2 and BCKDH subunits are frequently reduced in human ccRCC tumors compared to normal adjacent kidney tissue (NAT). This decreased expression occurs as early as stage 1 and is associated with reduced overall survival. Additionally, BCAAs and their catabolic metabolites are decreased in ccRCC. These results suggest that BCAA catabolism is reduced early in ccRCC and contributes to ccRCC aggressiveness. ccRCC may reduce BCAA metabolism to decrease mitochondrial respiration and ROS because ccRCC is susceptible to ROS due to the large amount of intracellular lipids that can undergo peroxidation. ccRCC decreases mitochondrial respiration and ROS by downregulating genes involved in fatty acid oxidation and oxidative phosphorylation. I hypothesize that reduced BCAA metabolism promotes ccRCC cell growth and tumorigenesis, and does so by decreasing mitochondrial respiration and the production of ROS. Aim 1 will determine how reduced BCAA catabolism promotes ccRCC cell growth in vitro. I will use genetic and pharmacologic approaches to assess how gain or loss of BCAA metabolism affects proliferation of ccRCC and immortalized renal epithelial cell lines. Aim 2 will identify how reduced BCAA catabolism contributes to ccRCC tumorigenesis in vivo. I will use novel genetic mouse models to determine the role of BCAA catabolic flux on renal epithelial cell function and ccRCC tumorigenesis. Together, these approaches will identify the mechanisms by which BCAA catabolism regulates ccRCC tumorigenesis and identify novel therapeutic targets to combat this disease.