Yale University

NIH Research Projects · FY 2025 · 2023-09

Project Summary Understanding cellular function is intimately linked with the ability to visualize organelle ultrastructure with molecular specificity and to observe how it is altered in diseases such as cancer, neurological disease, ciliopathies and microbial pathogenesis. Super-resolution microscopy (SRM) has potential here as it bridges the gap between light and electron microscopy and provides molecular specificity. However, SRM mostly offers only a few color channels. This prohibits a comprehensive architectural map of organelles, as many are pleomorphic and exist in multiple states depending on intra- and extracellular cues, making the combination of datasets, each showing different subsets of labels, difficult. The SRM technique of DNA-PAINT allows, in principle, powerful multiplexing to image 10 or more labels in one sample, but hurdles in speed, cost and ease of use have limited its application. What is needed is a highly versatile multiplexing strategy to enable SRM of organelles with an order-of-magnitude improvement in four key areas: acquisition speed, switching between multiplex probe sets, spatial resolution, and cost. This requires new probes, instrumentation, enhanced analysis, and biological validation. We will approach these tasks through three Specific Aims: 1) the development of new versatile, DNA-PAINT probes that are both fluorogenic and provide a fast, adaptable, low-cost framework for multiplexing, 2) a new platform for automated acquisition of multiplex DNA-PAINT data and analytics to ‘connect the dots’ of single-molecule localization points in three dimensions and thereby create membrane representations of organelles, and 3) the development of multiplexed DNA-PAINT ‘organelle modules’ to validate this technology under realistic biological conditions and lower the entrance hurdle for future biological users. Achieving these aims and their concrete deliverables will have a wide impact on the use and accessibility of SRM to accelerate biological discovery.

NIH Research Projects · FY 2025 · 2023-09

Black people with disabilities (PWD) disproportionately experience poor physical and behavioral health outcomes due to compounding socioeconomic challenges and stigma-related stressors. Intersectionality theory suggests that such magnified health disparities may be in part driven by intersectional stigma, though few quantitative measures exist to capture this dynamic, multifaceted construct as it fluctuates over time and across contexts. To address this empirical gap, the proposed project will develop and validate a brief self-report measure of daily intersectional stigma experiences for Black PWD via a three-phase, multimethod approach. In Aim 1, we will generate an initial pool of items by drawing upon available literature, expert input, and feedback from Black PWD. In addition to consulting extant empirical research on the lived experiences of being Black and/or having a disability, we will conduct semi-structured interviews with 20 Black PWD community members and 10 content experts. In Aim 2, we will refine this initial item pool by gathering feedback from Black PWD via an iterative process of cognitive interviewing and pilot testing. We will conduct an initial round of cognitive interviews with 20 Black PWD, followed by a 7-day pilot daily diary study and a second round of cognitive interviews with the same participants to further ascertain that the items adequately capture contextual and temporal variability in intersectional stigma experiences. In Aim 3, we will psychometrically evaluate the newly developed intersectional stigma measure by examining its scale structure and predictive validity in relation to stigma-relevant psychosocial outcomes using a probability-based sample of Black PWD recruited from the NORC AmeriSpeak panel. We will conduct a 2-week daily diary study with 200 Black PWD, who will complete the finalized intersectional stigma measure, along with measures of emotion regulation difficulties, psychological distress, perceived social support, and connection with the disability and Black communities. We will examine the prevalence of intersectional stigma as a function of demographic and disability characteristics; additionally, we will investigate the concurrent and prospective associations between intersectional stigma and psychological distress, while also exploring potential mediators and moderators of these associations. Results from this project will provide a novel measurement tool for use in future observational and intervention research geared towards addressing the deleterious health impact of intersectional stigma for Black PWD. Findings will also yield valuable insights into the psychosocial consequences of intersectional stigma among a representative sample of Black PWD across the U.S., directly addressing NIMHD’s priority in understanding the intersectional lived experiences of PWD from health disparity populations.

NIH Research Projects · FY 2026 · 2023-09

ABSTRACT The physician-scientist workforce struggles to attract and maintain a pipeline of physician-scientist trainees. Physician-scientists, who hold dual expertise in clinical medicine and research, are uniquely skilled in addressing the challenges in health, disease, and health care, but there is a well-recognized shortage of these professionals. One population that has not received sufficient attention with regard to professional development as physician-scientist is that of undergraduate medical students. Prior work has demonstrated that research career intentions evolve significantly during medical school and that research career intentions at graduation are associated with tangible downstream measures of research success, including subsequent receipt of NIH funding. However, little is known about the individual and institution-level factors and experiences that foster professional development as physician-scientist during medical school, particularly among MD program students, who make up the vast majority of medical students in the U.S. We propose a 5-year, longitudinal study to identify trajectories (i.e., evolution over time) of research career intentions, and determinants thereof, in 600 students matriculating into U.S. MD programs. We will examine experiences at the individual level, such as quality of mentorship and research experiences, as well as experiences at the institutional level, such as education about the physician-scientist pathway and opportunities for doing research, and their impact on research career intentions during medical school. The aims are to: 1) identify trajectories of research career intentions among students throughout medical school training, from matriculation to graduation and 2) identify student- and institutional-level predictors of research career intention trajectories. This study is significant because it will identify potentially influential timepoints and predictors of change in research career intention among MD students that can be used to strengthen the physician-scientist workforce pipeline during the formative years of medical school. The impact of our findings will be enhanced by our strong partnerships with national organizations, including medical education leaders at the National Academies of Sciences, Engineering, and Medicine (NASEM) and Association of American Medical Colleges (AAMC) to disseminate our findings. This study will form the basis of a future proposal to conduct follow-up of the cohort assembled in this study through residency and into early- and mid-career positions to further disentangle the process of professional identity formation as physician-scientist among U.S. medical trainees.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT Microbial cell populations can be highly heterogeneous, which is crucial for strain survival in complex conditions such as antibiotic treatment. Apparently, the cell-to-cell heterogeneity cannot be revealed using traditional bulk sequencing techniques. Single-cell based approaches for microbial cells are emerging to tackle this question, however, the spatial context information, crucial for understanding the microbe-host interactions, is not collected. As of current, we still lack high resolution spatial omics tools to study microbes and their residing mammalian host. Most currently available NGS based spatial transcriptome platforms are not compatible with bacteria profiling due to three reasons: 1) Bacteria cell walls are highly diverse in thickness and composition, which prevents the reagents such as reverse transcriptase and primers to enter the cell, especially for Gram Positive ones with thick cell walls; 2) mRNAs of bacteria cells are sparse and have short half-life; 3) bacteria mRNA lacks poly-A tail in RNA sequence. During the past 5 years, I developed DBiT-seq (Deterministic barcoding in tissue), the first high resolution spatial proteo-transcriptome platform, which have been widely applied to neuroscience, development, and cancer studies in human. I further reported the Spatial-CITE-seq technique which can co-mapping ~300 surface proteins and the whole transcriptome of various tissue types. I propose in the next five years the development of a new spatial sequencing technology called microDBiT, which will be the first spatial proteo-transcriptome platform that can map microbes and the host cells within the spatial context. At the initial stage, we will design and use the slides of cultured Gram positive bacteria S.aureus and negative bacteria E. coli as a model to optimize the key steps of microDBiT protocol, including cell wall digestion, mRNA polyadenylation, reverse transcription and in cell ligation. We will next develop the microDBiT protocol for microbe and host cell co-mapping using gut tissues obtained from bacteria colonized germ-free C57BL/6 mice. Lastly, we will apply the microDBiT to map out the gene expression profile of pathogens and the patient cells in inflammatory bowel disease (IBD). Since metabolites of microbes are considered important pathways that influence the host cell behavior, we will meanwhile include an antibody panel of host receptors and study how the metabolites will influence the gene expression of host cells. This technique will ultimately enable high-throughput and high-resolution characterization of spatial heterogeneity of microbes and their interaction with the host cells. In the long run, we will build microDBiT into a comprehensive platform that could be applied to diverse microbe and host systems at different omics levels (Genomics, Transcriptomics, Epigenomics, etc.).

NIH Research Projects · FY 2025 · 2023-09

Personalized cancer treatment is becoming a reality. The real-world adoption of broad genomic profiling (BGP) has enabled the simultaneous testing of hundreds of potentially targetable genetic alterations in patients with cancer. Professional societies have endorsed BGP in clinical practice for several cancer types, including advanced stage non-small cell lung cancer (aNSCLC). Yet evidence regarding the impact of BGP on patient outcomes is constantly evolving, with changes in the availability, utilization, and efficacy of targeted agents. As such, BGP use raises a fundamental question in cancer care: how can stakeholders make the most informed decisions in the presence of uncertainty? We posit that Value of Information (VOI) analysis, which explicitly quantifies the trade-off between the benefits of collecting further evidence compared to a decision based on current evidence, can be used to guide decisions regarding BGP. In this proposal, we address the critical need to understand real-world 1) BGP use and its impact on 2) clinical decision-making, 3) treatment outcomes and costs and 4) the value of additional research to empirically inform decisions about the adoption of BGP into cancer care by leveraging the strengths of multiple complementary, real-world datasets. Aim 1: Utilization of BGP across contemporary U.S. cancer care. We will examine BGP use in advanced cancer and drivers of testing within patients with (Aim 1A) Medicare 100% Fee-for-Service and Medicare Advantage and (Aim 1B) Blue Cross Blue Shield insurance coverage. Aim 2: BGP results and their impact on treatment patterns in NSCLC. We will quantify the frequency of actionable mutations among patients with aNSCLC (Aim 2A) and assess the relationship between BGP and cancer management strategy, given that less than half of patients with a targetable mutation may receive the corresponding FDA-approved targeted therapy (Aim 2B). Aim 3: BGP cost and survival. We will determine the relationship between BGP use and cancer care costs (Aim 3A) and overall and cancer-specific survival (Aim 3B). Aim 4: Cost Effectiveness & Value of Information. We will use VOI analysis to determine whether additional evidence/research is needed to support the use of BGP. Specifically, we will compare the long-term health and cost outcomes associated with 1st line BGP in patients with aNSCLC (currently recommended but controversial) with two alternate strategies that focus on a smaller number of genetic tests. We will quantify critical gaps in the evidence that drive uncertainty regarding effectiveness of BGP and quantify the value of conducting additional research on BGP in order to improve decisions about optimal implementation of BGP. The proposed research is significant given uncertainty regarding the use and effectiveness of BGP, innovative given the triangulation across multiple large datasets and incorporation of VOI to guide practice and inform policy, and clinically relevant given the high burden of advanced cancer and the burgeoning use of BGP.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT Defects in DNA repair are prevalent in human cancer and present an opportunity for targeted tumor treatment with agents that induce DNA damage only in cells with specific DNA repair defects. O6-methylguanine-DNA methyltransferase (MGMT), a direct reversal repair enzyme that removes O6-alkylguanine lesions deposited by alkylating agents such as temozolomide (TMZ), is the most frequently silenced DNA repair gene in cancer, with promoter hypermethylation observed in ~10% of all tumors. Loss of MGMT occurs in the majority of lower grade gliomas, ~50% of glioblastomas (GBM), and in a broad array of other cancer types, including ~20-40% of colon cancer and melanoma. MGMT is ubiquitously expressed in normal tissue, and reduced MGMT expression in tumors predicts for clinical benefit from TMZ, owing to the accumulation of DNA damage specifically in tumor cells. Importantly, the efficacy of TMZ in MGMT-deficient tumor cells is dependent upon intact mismatch repair (MMR) proteins, and resistance to TMZ arises due to MMR loss in ~50% of recurrent gliomas and ~20% of recurrent GBM. Strategies are needed to avoid or overcome this major resistance mechanism in order to therapeutically exploit MGMT silencing in cancer. In recent work, we identified a novel 2-fluoroethylating agent, KL-50, which overcomes TMZ resistance through the induction of DNA interstrand crosslinks (ICLs) specifically in tumor cells lacking MGMT, leading to MMR-independent activity in glioma models. We aim here to evaluate more broadly the therapeutic potential of this targeted DNA modifying agent. We hypothesize that the MGMT- dependent crosslinking activity of KL-50 can be harnessed to exploit unique combinations of DNA repair defects, combined with DDR inhibitors (DDRi’s) to enhance therapeutic potential, and utilized to overcome certain mechanisms of resistance to TMZ, independent of cancer histology. In Aim 1, we will determine the prevalence of cancers with combined MGMT and ICL repair defects and establish the therapeutic potential of KL-50 in this subset of cancer. We will characterize the overlap of MGMT and ICL repair defects in a large pan-cancer database and evaluate the activity of KL-50 in experimental in vitro and in vivo models representing this subset of tumors, alone and in combination with DDRi’s. In Aim 2, we will analyze resistance mechanisms to TMZ and KL-50 in MGMT-silenced tumors and determine the ability of KL-50 to avoid or overcome TMZ-induced resistance in non-glioma tumors. Using colon cancer, melanoma, and pancreatic neuroendocrine tumor cell models, we will perform focused CRISPR-Cas9 screening and develop drug-resistant cell lines to identify key resistance factors. Emergence of drug resistance and the ability of KL-50 to target TMZ-resistant tumors will further be analyzed in patient-derived primary cells and xenograft models. These studies will advance our understanding of targeted DNA modifying agents and may support the initiation of clinical trials evaluating KL- 50 or related compounds in the treatment of DNA repair deficient tumors.

NIH Research Projects · FY 2024 · 2023-09

Project Abstract Alcohol use among women has substantially and concerningly increased over the last decade, relative to smaller increases among men. While drinking is strongly associated with significant health risks in both sexes, females have exacerbated alcohol-related health consequences when compared to males. Compounding this issue, treatment development for alcohol use has not considered, nor is responsive to known sex differences in alcohol use. For these reasons, the field requires an increased capacity to conduct translational science to study sex and gender differences in relation to alcohol use. This R13 proposal is a request for funding for a bi- annual (once every two years), one-day satellite meeting held at the site of the Research Society on Alcohol conference to focus on translational innovations in sex and gender differences in alcohol use. This meeting would serve several key functions: 1) To serve as a hub for an international group of scientists, clinicians, and trainees to support the exchange of ideas and promote new collaborations on sex/gender and alcohol use spanning T1 to T4 translation. 2) To foster the development of the next generation of translational alcohol researchers, by supporting 25 travel awards to graduate students, postdoctoral fellows, and early-career junior faculty to present their research. 3) To provide information on best practice procedures and definitional parameters relevant to the study of sex/gender and alcohol. An interactive program would feature both leading international speakers and trainees, maximizing diversity and inclusion. This proposed R13 grant will provide a unique contribution to NIAAA’s mission to incorporate sex and gender “into the design, analysis, and scientific reporting of the studies it funds. This is a critical step toward ensuring that everyone, regardless of sex or gender, benefits from alcohol research advances”32.

NIH Research Projects · FY 2025 · 2023-09

Genome editing holds great promise for the treatment of many genetic diseases; however its application in the clinic has been slow due to the lack of the safe delivery tools and significant cost and time investment required to custom-develop individual therapies. In our SCGE program phase 1 study, we developed a chemically modified ribonucleoprotein (cRNP)-based gene delivery system that specifically targets neuronal cells throughout the brain after intrathecal (IT) administration. The overarching goal of this application is to apply this novel gene editing technology towards the treatment of two severe neurodevelopmental disorders (NDD): Angelman syndrome (AS) and H1-4 syndrome (HIST1H1E syndrome). AS is a devastating neurodevelopmental disease caused by the deficiency of the maternal and brain specific imprinting UBE3A gene in human chromosome 15q11-q13 region. The structure of UBE3A is intact in the paternal chromosome in all AS cases but transcriptionally repressed by a non-coding and antisense RNA of UBE3A (UBE3A-ATS) mediated mechanism. It has been shown convincingly that reduction of UBE3A-ATS by antisense oligo (ASO), topoisomerase inhibitors, and virus delivered Cas9 gene editing can de-repress the expression of UBE3A and correct the abnormal neurological phenotypes in AS mouse models. H1-4 syndrome is caused by a gain of function mechanism due to a mutated protein with aberrant C-terminal frameshift tail (CFT). H1-4 syndrome has similar but milder clinical features than AS. There is no effective intervention for H1-4 syndrome. Thus, a long- term molecular therapy for AS and H1-4, as well as other NDDs is urgently needed. In our preclinical study using a well validated AS mouse model, we demonstrated that a single IT delivery of Ube3a antisense-targeting RNP/Cas9efficiently de-represses the expression of Ube3a from the paternal chromosome, leading to correction of neurobehavioral phenotypes. Similarly, the knockdown of H1-4 CFT rescue the abnormal phenotypes in H1- 4 humanized mice. We propose our cRNP-based platform for the treatment of AS and H1-4 syndrome utilizing the same genome editor (CRISPR), delivery system (cRNPs), route (IT), target cell type (neurons), therapeutic mechanism (genetic inactivation) and overall trial design. We have assembled an outstanding team from Yale and Rush University with strong and complementary expertise in the areas of preclinical, IND enabling studies, and clinical trials. The success of this study will lead to the first ever gene editing based therapy for AS and H1- 4. More importantly, it will support a paradigm shift for genome editing; rapidly expanding the number of neurogenetic diseases treated by in vivo gene editing and accelerating the transition of genome editing technology into clinical applications.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY Lipid-bilayer membranes form diverse and dynamic structures in cells to serve vital functions including nutrient uptake, waste managements, signal transduction, and so on. Understanding the molecular mechanisms by which the cell generates and changes its membrane structures has been a central task of cell biology. It is well established that the physical and chemical properties of membranes regulate their interactions with proteins, which in turn shape the membrane landscape. However, there are still major knowledge gaps regarding how proteins act upon different membrane curvature and tension, especially when the membrane structure and/or the membrane-protein interaction are transient. Cell-free systems using reconstituted membranes provide a powerful method to study such intricate molecular interplays. However, there is still a pressing need for a precisely engineered platform that (1) exquisitely controls the geometrical, biochemical and mechanical properties of membranes and (2) easily allows for biochemical and structural characterization of membrane- associating proteins. Using DNA nanotechnology, a bottom-up method that generates three-dimensional molecular assemblies with programmable shape, stiffness, chemical modification, and motion, we propose to build nanoengineered membranes to bridge the technical gap in membrane manipulation and to unravel the mechanisms of protein-mediated membrane dynamics. Specifically, we will develop tools to (1) generate accessible membranes with complex shapes for the quantitative study of curvature-dependent protein- membrane interactions, (2) build liposomes and lipid nanodiscs with dynamically tunable tension to study the role of membrane tension in regulating protein conformation and lipid transport, and (3) create transmembrane nanopores with tunable size and chemical selectivity for the reconstitution of organelle-like compartments. We expect these new tools to be enabling and potentially transformative for research in structural biology, biophysics, mechanobiology, and synthetic biology.

NIH Research Projects · FY 2025 · 2023-09

Abstract: This K08 proposal will expedite the principal investigator’s progress towards her goal of becoming an independent physician-scientist with a focus on increasing our understanding of mechanisms of immune related adverse events (irAEs) induced by checkpoint inhibitor (CPI) immunotherapies and identifying therapeutic targets of these complications. Candidate: Dr. Ana Perdigoto is a physician-scientist at Yale University School of Medicine. She completed clinical fellowship in Endocrinology and postdoctoral training in Immunology. She is developing an expertise at the crossroads of immuno-endocrinology and immuno- oncology through her work on investigating mechanisms of CPI-induced diabetes (CPI-DM), a complication that arises in cancer patients treated with immunotherapies targeting checkpoint inhibitors. Under the mentorship of Dr. Kevan Herold, a world-renowned Endocrinologist and Immunologist with authority on the immunology of type 1 diabetes and CPI-DM, Dr. Perdigoto investigated how immune cells modify pancreatic islets to cause CPI-DM. She will leverage the skills gained during her training to further analyze mechanisms of these irAEs. Career Development Plan: Dr. Perdigoto will pursue the research in this proposal under the primary mentorship of Dr. Herold. She will also have the guidance of an intramural and extramural advisory team with various areas of expertise and experience in nurturing independent investigators. Yale University provides a collaborative environment with state-of-the-art facilities and resources and excellent training environment and opportunities. The proposed 5-year plan builds on Dr. Perdigoto’s prior experience and further enriches her training to provide the tools needed for establishing independence, such as proficiency in bioinformatics and analysis of genomic data, knowledge in mouse genetics, and productive collaborations. Research Plan: The overall premises addressed in this proposal are that interactions of immune and islet cells in the tissue microenvironment lead to the development of CPI-DM (investigated in Specific Aim 1) and that tumor can impact autoimmunity, potentially through presentation of shared antigens (investigated in Specific Aim 2). Upon completion of the research proposed, Dr. Perdigoto will be able to: 1) characterize immune-target cell interactions that lead to autoimmunity 2) analyze novel tumor models with regards to the impact of immunotherapies and tumor on autoimmunity and 3) identify potential therapeutic targets to prevent adverse events without impacting tumor responses. The findings will enhance our understanding of the pathogenesis of CPI-DM as well as other irAEs arising from CPI treatment. After completing the proposed training, Dr. Perdigoto will have acquired the expertise required to become an independent investigator poised to continue translational studies that can lead to the development of diagnostic or therapeutic tools to protect target cells from the effects of inflammatory mediators both in the field of immuno-oncology and potentially autoimmunity.

NIH Research Projects · FY 2024 · 2023-09

SUMMARY A subset of patients with alcohol-associated liver disease (ALD) develop severe alcoholic hepatitis (AH), carrying a very poor prognosis. Control of inflammation is a key to the treatment of AH. Hepatic lymphatics are highly involved in the regulation of the inflammatory response by discharging extravasated fluids, inflammatory mediators, antigens, and antigen-presenting cells to lymph nodes outside the liver. However, how the hepatic lymphatic system is involved in the development of ALD remains largely unknown. The goal of this exploratory study is to advance our understanding of hepatic lymphatics in the progression of AH and explore whether increasing lymphatic vessels (LVs) and lymphatic drainage can be a novel therapeutic strategy for AH. Given that lymphatics generally help to reduce tissue inflammation, we hypothesize that chronic alcohol consumption may impair hepatic lymphatic endothelial cell (EC) function and lymphatic drainage, facilitating the progression to AH. Contrarily, enhancing lymphangiogenesis (new LV formation) via overexpression of vascular endothelial growth factor (VEGF)-C, the most potent lymphangiogenic factor, may ameliorate AH. To test these hypotheses, we propose the following two Aims: Aim 1. Determine the role of the hepatic lymphatic system in AH. Aim 2. Explore the potential of the VEGF-C mRNA LNP (lipid nanoparticle) technology for the treatment of severe AH. This study will explore an important, but poorly understood subject, liver lymphatics in ALD, addressing the effect of alcohol on hepatic lymphatic functions and its implications in the development of AH. Results from the two Aims above will provide the foundation for many future studies to advance our understanding of the lymphatic system in liver disease in general and AH in particular, including a study addressing the molecular mechanism of lymphatic impairment by alcohol as well as a study aiming at clinical use of VEGF-C mRNA-LNP for the treatment of AH.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT MOTIVATION: The burden of atrial fibrillation (AF) and its clinical consequences, which include stroke, heart failure, and decreased quality of life, are expected to increase dramatically over the next several decades. Despite this, few disease-modifying therapies exist, and symptomatic treatments are limited by side effects. Leveraging fundamental discoveries in cardiac tissue biomechanics, this proposal takes a novel approach to arrhythmia pathogenesis, uncovering biophysical mechanisms that underlie healthy atrial function and pathological, pro-arrhythmic remodeling. Motivated by a desire to accurately model atrial physiology and pathology, we use human induced pluripotent stem cell (hiPSC)-derived engineered heart tissue (EHT) and an electro-mechanical bioreactor to delineate “healthy” vs “diseased” mechanical loading. AIMS: In Aim 1, physiologically-inspired biomechanical strain is applied to atrial EHTs to improve their functional maturity at the gene expression, contractile, and electrophysiological level. Successful completion of this aim will broadly increase the applicability of engineered heart tissue for atrial disease modeling. In Aim 2, a substrate for atrial arrhythmias will be induced by imposing pathological mechanical strain on atrial EHTs. These abnormal mechanical strains are directly inspired by clinical imaging findings. Notably, abnormal mechanical loading of tissue causes contractile dysfunction, along with upregulation of pathological remodeling genes, such as αSMA and calmodulin kinase. This suggests that a common, mechanosensitive pathway may be an attractive upstream target for novel AF therapies. TRAINING: To enable these investigations, the applicant will pursue new learning in stem cell biology, engineered heart tissue development, in vitro electrophysiology, and electron microscopy. The training plan, overseen by two co-sponsors in complementary fields (biomedical engineering/muscle physiology and electrophysiology), will emphasize acquisition of new scientific knowledge and expertise; rigor, reproducibility, and generalizability of in vitro disease models; clinical correlations; and professional development. The proposal will leverage cutting-edge technology and expertise at Yale University and Yale School of Medicine, and fully support the applicant’s future career goal. RELEVANCE: AF affects millions of Americans, and 10% of those over 80. The public/health/relevance of this project lies in addressing the morbidity and mortality of this condition through novel mechanisms. Motivated by a lack of disease-modifying therapies, the proposal highlights the importance of biological pathways regulated by tissue-level biomechanical cues which may provide avenues for developing more effective therapeutics.

NIH Research Projects · FY 2026 · 2023-09

Project Summary/Abstract Lissencephaly is a rare developmental disorder characterized by absence or simplification of brain convolutions. With no available cure, it leads to significant health burden of developmental delay, intellectual disability, and seizures. While introduction of next-generation DNA sequencing offered unprecedented opportunities for gene discovery in human disorders, leading to the identification of an array of lissencephaly-associated genes, approximately a fifth of patients with lissencephaly still lack genetic diagnosis. Gene discovery in Mendelian disorders is hampered by locus and phenotypic heterogeneity and thus, a systems-level analysis complemented with mechanistic characterization of candidate variants is warranted. In the past decade and a half, we have identified and functionally characterized multiple genes whose disruption is associated with malformations of the human cerebral cortex. We propose to utilize patient- derived stem cell and embryonic mouse models to characterize the role of the PIDDosome protein complex in human brain development and understand how its malfunction can cause lissencephaly. We also propose to perform gene- burden and co-expression analyses to inform characterization of novel genes and pathways involved in lissencephaly through modeling in organoids. We will use patient and control keratinocytes to generate induced pluripotent stem cells and 2D and 3D neural derivatives to define the molecular and cellular consequences of PIDD1 mutations, accompanied by in vivo mouse models of PIDD1 loss during neurodevelopment. We will perform gene network-based analysis of human brain development and mutation burden analysis at the gene and pathway level of 120 lissencephaly patients with available whole-exome sequencing data to identify and prioritize novel causal genes for lissencephaly. Our multi- faceted approach is expected to reveal shared molecular pathways and affected cell types that are perturbed during human fetal neurodevelopment leading to the onset of lissencephaly in a genetically heterogenous background, also providing an analytical framework for variant prioritization in large-scale genomic investigation of human disorders.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY The past 20 years have seen significant changes in the US’s legal cannabis landscape alongside marked changes in tobacco use, the leading cause of preventable mortality. Yet recreational cannabis legalization’s (RCL’s) effects on tobacco product use remain unclear: few peer-reviewed studies directly test these effects and quasi-experimental analyses—methods to generate causal estimates in the absence of randomization— yield mixed findings on whether cannabis is an economic complement or substitute for cigarettes. These dynamics are crucial: laws increasing cannabis access will decrease use of its substitutes and increase use of its complements. Moreover, quasi-experimental studies largely ignore RCL’s effects on use of non-cigarette tobacco products like cigars and electronic nicotine delivery systems (ENDS), as well as potential effects of state cannabis policy details (e.g., tax rates, formulation restrictions) and local cannabis laws (e.g., local taxes, home delivery bans). If such effects are not anticipated, policymakers’ expectations of RCL’s costs and benefits will be incorrect, and both state and local policymakers may miss opportunities to structure cannabis laws in a manner that better protects their community’s health. To address this, we will compile a cannabis policy database covering state RCL policy details, local cannabis policies, and retailer density, and match it to nationally representative, restricted-use data from the National Survey on Drug Use and Health. Aim 1A will use these data to characterize variation in local access to cannabis retailers, local cannabis policies, and state RCL policy details likely to impact cannabis access and use within RCL states. Aim 1B will assess these policies’ relationships to cannabis retailer density, perceived ease of cannabis access, and cannabis use, elucidating their strength as unconfounded proxies for local cannabis retailer density and ease of access, and clarifying whether the policies’ effects on cannabis use are strong enough to allow instrumental variable analyses of cannabis use’s effect on tobacco product use. Considering cigarettes, cigars, ENDS, and blunts, Aim 2 will estimate RCL’s direct effects on adult tobacco product use, test for effect modification from state RCL policy details and local cannabis laws, and simulate implications for tobacco product use under alternative RCL scenarios (e.g., federal RCL, different cannabis tax rates, preempting local bans on retail sales). Aim 3 will conduct parallel analyses and simulations for 12-20 year-olds. Results will extend the literature on RCL’s effects on tobacco product use by accounting for a range of tobacco products, and increase its rigor by considering effect modification due to variation in state policy details and local cannabis laws, separately for underage versus 21+ age-groups. Moreover, simulations of alternative policies’ effects on tobacco and nicotine use will clarify potential unanticipated costs or benefits of different state and local cannabis policies, helping policymakers identify policy options to best ensure continued progress towards eliminating tobacco’s toll in their community.

NIH Research Projects · FY 2025 · 2023-09

SUMMARY | Cellular immunotherapy such as chimeric antigen receptor (CAR) T cells involves engineering and adoptive transfer of cells to directly target tumor cells in patient, and demonstrated clinical success. However, current cell forms of cell therapies face multiple major hurdles, centering around efficient generation of potent, specific and safe therapeutic immune cells. This R33 will address this significant problem, by developing and rigorously validating two sets of versatile gene delivery and cell engineering toolkits, to ease the therapeutic cell generation issue, and to offer a simple yet distinct approach to achieve high potency. Aim 1. Advanced development of MAJESTIC, a highly efficient composite gene delivery system. A vital part of cellular immunotherapies is therapeutic cell generation. Current approaches, including lentiviral or g-retroviral vectors, AAV, mRNA, DNA transposons, and genome editing such as CRISPR/Cas, all have their own limitations. In the first part of this R33, we will perform advanced development and validation of MAJESTIC technology (mRNA AAV-Sleeping-Beauty Joint Engineering of Stable Therapeutic Immune Cells). This system can transduce diverse immune cell types with minimal cellular toxicity, leading to highly efficient and stable therapeutic cargo delivery. Aim 2. Advanced development of synthetic fusion tails to enhance therapeutic cell function. Despite success in CAR-T therapy in hematopoietic malignancies, major challenges still exist such as tumor antigen loss, T cell exhaustion, T cell dysfunction, and poor in vivo persistence that hampered its widespread clinical potential. We seek to develop and validate a distinct approach for cellular engineering to add to the armamentarium of tools to enhance CAR immune cells against cancer. In the second part of this R33, we will advance the development of TAILFUSE technology, a novel and unique CAR engineering approach by cytoplasmic tail (CT) fusions, which reprograms CAR-T function and substantially enhanced in vivo anti-tumor efficacy. We achieved proof-of-concept development of the technologies (R21/R61 equivalent). In this project we will perform robust validation, optimization, extension and advanced development (R33). This R33 will mature these versatile tools for gene delivery and synthetic cell engineering, including quantitative performance measures, benchmarking, new capability extension, and validation of broader applications to cancer-related cell types. Success of this R33 will lead to novel technologies that will bring new capabilities, with substantial improvements over existing technologies. We anticipate wide-spread use of such technologies in laboratory research and therapeutic development settings by the field to reach transformative impact.

NIH Research Projects · FY 2026 · 2023-09

Project Summary Acetaminophen (N-acetyl-p-aminophenol or APAP) is recommended as a safe treatment to reduce pain and fever during pregnancy. An estimated 45-65% of pregnant women reported intake of APAP in the U.S., but there has been little data on safety for potential health effects in the prenatally exposed offspring. APAP can cross the placental barrier reaching the fetus which has limited capacity to metabolize the compound in early development. Recent experimental studies demonstrated compelling evidence suggesting APAP can induce anti-androgenic effects potentially affecting fetal brain development. The Society for Maternal-Fetal Medicine and the U.S. Food and Drug Administration have called for a more thorough investigation and better data to guide the safety of APAP use in pregnancy. Our experienced and multidisciplinary team proposes to leverage the rich data collected in the Danish National Birth Cohort (DNBC) and records from the Danish population medical registries to investigate the potential effects of APAP exposures on fetal development. In Aim 1, we will study 64,322 mother- child pairs enrolled in the DNBC and investigate the effects of prenatal exposure to APAP on a wide spectrum of neurodevelopmental outcomes, ascertained at multiple time points from infancy through age 18. Six domains of outcomes will be examined, including milestones in infancy, craniofacial markers, neurobehavioral disorders, motor function, school performance, and mental health. A rich set of confounding factors, including maternal illnesses and familial/genetic risks, will be examined in a robust multi-stage analytical framework. In addition, we will evaluate the effect of post-natal APAP exposure on neurodevelopment (aim 1a), the effect of APAP exposures on childhood ADHD, adjusting for the genetic risk of ADHD (aim 1b), and explore whether APAP exposures affect distinct neuropsychiatric phenotypes and/or behavioral trajectories across childhood and adolescence (aim 1c). In Aim 2, we will investigate the influence of prenatal co-medication exposures with APAP and their impacts on neurodevelopment. We will examine whether medications that co-occur with APAP use during pregnancy confound the associations between APAP exposure and child neurodevelopment. We will also examine the joint effects of co-medications exposures. We will focus on a list of common medications (7 major and 15 subclasses) that impact fetal growth and/or brain development documented in the literature. This timely research project will provide strong and scientifically rigorous data to inform long-term health effects of early life exposure to APAP on child neurodevelopment. This is also the most extensive cohort study investigating maternal polypharmacy exposure effects on offspring neurodevelopment. Our findings will contribute to regulatory recommendations and policymaking decisions for APAP, a widely consumed medication in pregnancy, as well as related co-medication use.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY It is well-documented that where you reside in America shapes when you die, and this has been shown to be particularly true among low-income Americans. These place-based inequalities in health have grown over time in the United States, driven by increased mid-life mortality due to drug- and alcohol-related deaths and suicides. While the drivers of this rise in mid-life mortality are complex and multifactorial, there is broad consensus that the adoption of evidence-based treatments for substance use disorder and mental illness has the potential to improve health and save lives. Despite their effectiveness, behavioral health services are generally thought to be underused, with very limited access to these services in some regions of the country. We study the drivers of place-based inequities in the Medicaid program, the primary source of insurance coverage and payer of behavioral health services for low-income populations. This application seeks to understand whether and to what extent place-based inequalities in mid-life mortality — and their gradients by gender and race/ethnicity — are driven by the causal effects of place on access to evidence-based behavioral healthcare treatment by studying the low-income population on Medicaid. Because families sort into areas based on a wide range of factors — e.g., economic opportunity, amenities, cost-of-living, etc. — if people predisposed to poor (or good) health outcomes tend to cluster in particular localities then observed health differences between areas may reflect this non-random sorting (or “selection”) rather than the causal effects of place. To address this challenge, we use a quasi-experimental movers research design that follows otherwise similar Medicaid enrollees residing in the same place that move to different destinations. Subsequent differences in their healthcare utilization and health can be attributed to place effects if movers are observed for a period of time before the move to adjust for baseline outcomes. Second, to better under social gradients we stratify by sociodemographic characteristics and recover the effects of places for distinct groups —comparing differences in the impacts of a place on different groups reveals whether it tends to narrow or widen inequalities. Finally, we examine whether place-based effects correlated with immutable characteristics of areas (e.g., climate) or features that are more readily amenable to policy intervention (e.g., the healthcare delivery system). We make an original contribution, by advancing the understanding of the relationship between “place” and health for low-income populations, with a focus on understanding the role of differential access to high-quality, behavioral healthcare services.

NIH Research Projects · FY 2025 · 2023-09

Colon cancers develop by stepwise accumulation of oncogenic mutations in epithelial stem cells. These mutated stem cells multiply by positive selection in healthy colon for years before transforming into cancers. In this proposal I aim to unravel an immune surveillance mechanism that prevents selection of mutated stem cells in healthy colon. Colon cancers with BRAFV600E mutation involve the proximal colon and disproportionately affect women above the age of 65 years. Based on the unique anatomic and demographic distribution of these cancers, I propose that BRAFV600E mutated stem cells have a strong selective advantage in the proximal colon. Regulatory T cells are part of the colonic stem cell microenvironment and, also heavily infiltrate BRAFV600E mutated cancers. Thus, I hypothesize that the regulatory T cells recognize and suppress the selection of BRAFV600E mutated stem cells in the healthy colon. To test this hypothesis, I have developed several genetically inducible lineage tracing mice that specifically induce BRAFV600E mutation in a single colonic stem cell. Using these mice, I will dissect the molecular mechanisms employed by regulatory T cells to perform surveillance against BRAFV600E mutated stem cells. Establishing the role of regulatory T cells in oncogene selection will lead to development of immune-prevention therapies against colon cancers. The proposal also includes a rigorous training program under the guidance of mentors with expertise in tumor immunology, stem cell biology and cancer evolution. Completion of the proposed activities will help me realize my goal of becoming an independent physician-scientist, investigating immune preventive strategies against colon cancer.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT A molecular imaging revolution is underway in prostate cancer. To overcome longstanding limitations in prostate cancer staging, several positron-emission tomography (PET) scans have recently been approved and rapidly integrated into clinical care based on evidence of improved diagnostic accuracy. However, the consequences of widespread PET imaging are unknown. This is because the approvals of these tests are based on improved diagnostic accuracy, a surrogate endpoint, rather than direct evidence of patient benefit. By finding small sites of cancer earlier, PET imaging could introduce a cascade of effects—both positive and negative—that could vary from patient to patient. PET imaging could lead to improved survival and fewer symptoms from metastatic cancer in a subset, but could also increase treatment toxicity, psychological burdens, and costs in others. Currently, no information is available to help guide patients or stakeholders when considering these tradeoffs. To reduce these uncertainties, our goal is to develop a decision model that considers the effects of PET imaging across multiple dimensions. To inform this model, we will generate real- world evidence from a diversity of sources. In aim one, we will conduct complementary analyses of large, nationally representative databases to evaluate the effectiveness of PET imaging, focusing on the associations between imaging initiation of systemic therapy, progression to hormone-refractory disease, and costs. In aim two, we will measure the longitudinal impact of PET imaging on patient-reported outcome measures relating to psychological effects (anxiety and uncertainty) and health-related quality of life. To gain a deeper perspective about patient experiences with testing we will also conduct longitudinal qualitative interviews among a smaller subset of patients and integrate the findings from quantitative and qualitative sources. In the third study aim we will incorporate inputs from Aims 1 and 2 to construct individual-based state-transition microsimulation models examining common scenarios for PET imaging use. The outputs from these models will include estimates of effectiveness, as well as patient characteristics that may be associated with greater or lesser degrees of benefit or harm. The results of this study will equip patients, providers, and other prostate cancer stakeholders with practical, new information about the potential short and long-term effects of PET imaging. If successful, this approach for evaluating effectiveness will be applicable to other similar molecular imaging modalities that will soon enter clinical care on the basis of surrogate endpoints of improved diagnostic accuracy, but without evidence of long-term clinical efficacy.

NIH Research Projects · FY 2025 · 2023-09

ABSTRACT Deaths due to alcohol-associated liver disease (ALD), a serious consequence of alcohol use disorder (AUD), have risen substantially over the past two decades. Although reduction and cessation of alcohol use is a vital component of treating ALD, few patients with AUD and ALD receive treatment for AUD, including behavioral treatment or medications (MAUD), due to clinician, patient, and system-level barriers ranging from lack of familiarity to stigma. Treatment of AUD, including MAUD, is associated with liver-specific benefits in patients with ALD, such as reductions in complications including cirrhosis, or scarring of the liver, and hepatic decompensation, or severe deterioration of liver function. As such, guidelines on the treatment of ALD recommend AUD treatment be provided to patients with AUD and ALD, however little is known regarding which treatments may be of greatest benefit in this population and how to deliver them most effectively. There is a lack of data regarding the comparative effectiveness of different forms of MAUD among patients with AUD and ALD and limited consideration of the perspectives of patients with AUD and ALD with regard to receipt of AUD treatment. Finally, while multidisciplinary teams of co-located hepatology and addiction specialists to facilitate AUD treatment in patients with AUD and ALD have been described, these models of care are resource- intensive and not commonly available. Therefore, alternative strategies are needed to inform delivery of AUD treatment for patients with both AUD and ALD. Hepatology clinicians are well-positioned to provide integrated AUD treatment, such as MAUD and brief counseling, for patients with AUD and ALD in the context of routine hepatology care. Existing NIAAA resources, such as the Healthcare Professional’s Core Resource on Alcohol (HPCR) and Alcohol Treatment Navigator (ATN), are readily available but have not been tailored for implementation in hepatology clinics. Therefore, the Specific Aims of this work are to: 1) Determine the comparative effectiveness of different forms of MAUD among patients with AUD by liver disease severity, relative to no MAUD, 2) Elicit AUD treatment preferences among patients with AUD and ALD, particularly regarding integrated MAUD and brief counseling in hepatology clinics, and 3) Determine the feasibility and acceptability of a novel implementation intervention to promote MAUD and brief counseling in hepatology clinics using the HPCR and ATN with clinical decision support. As a board-certified hepatologist and addiction medicine specialist with training in health services research, I am well-suited to lead efforts to integrate AUD treatment into hepatology clinics. Guided by mentors with expertise in pharmacoepidemiology, mixed-methods research, clinical trials, and implementation science, this work will generate important foundational data and provide me with the opportunity to build methodological expertise in these complementary areas. This will be critical to achieve my goal of becoming an independent clinician-investigator dedicated to optimizing the care of patients with AUD and ALD.

NIH Research Projects · FY 2025 · 2023-09

There are 38 million people living with HIV (PLWH) worldwide, 68% of whom live in sub-Saharan Africa. With the transition of HIV from an acute illness to a chronic condition, co-morbid non-communicable diseases (NCDs) such as depression and anxiety disorder, alcohol use disorder (AUD), and hypertension (HTN) have become epidemic among PLWH. Despite evidence-based interventions to promote integration of these HIV comorbidities into HIV service delivery, integration efforts face challenges. First, integration commonly fails to recognize the syndemic relationships between these conditions and the deleterious effect of social factors such as poverty, stigma, and lack of access to care that worsen their outcomes, especially in low- and middle-income countries. Second, integration commonly imposes additional clinical tasks upon overburdened healthcare workers (HCW) operating in busy clinical environments without private space needed to attend to these additional conditions that are often stigmatized. A syndemic approach, which explicitly integrates the biological and social interactions that cause these conditions to cluster, has been proposed as a means of addressing the complex needs of PLWH. Mobile health (mHealth), an evidence-based strategy that leverages the widespread penetration of mobile phones to relieve HCW of burdensome tasks while enabling their systematic, consistent implementation, has been proposed as a solution to address HIV-related syndemics, but this approach has not been tested. Our exemplary multidisciplinary team has a strong track record of collaboration. In the current proposal, which leverages the infrastructure of an ongoing implementation study of HIV/HTN integration in Uganda, we will pursue these Specific Aims: Aim 1) Adapt Medly Uganda for detection, linkage to care, and ongoing support of depression, anxiety disorder, and AUD among Ugandans with HIV and HTN using a syndemic approach. Through human-centered design (HCD), we will engage patients, caregivers, and professional/lay HCW to guide iterative adaptation of Medly Uganda with explicit attention to common biosocial drivers. The adapted application will integrate widely used (1) screening instruments along with validated measures of significant life events, economic shocks, and stigma, (2) algorithm-driven messaging and alerts, and (3) linkage to HCW for support and treatment. We will also develop and operationalize a novel syndemic care cascade (R21 phase); Aim 2) Assess the effectiveness of the Syndemic-Adapted Medly Uganda (SAMU) to improve mental health care cascade metrics by conducting a single-arm trial using real-world historical data (R33 phase); Aim 3) Evaluate the factors impacting sustained engagement in the adapted Medly Uganda using mixed methods (R33 phase). Throughout the study period, we will focus on strengthening our Uganda-based team's mHealth research capacity and furthering our partnerships with government officials to ensure that SAMU can be locally maintained and sustained. The proposed study addresses a high priority topic for use of AIDS-designated funds at NIH and aligns with multiple National Institute of Mental Health priorities as described in PAR-21-303.

NIH Research Projects · FY 2024 · 2023-09

There are 38 million people living with HIV (PLWH) worldwide, 68% of whom live in sub-Saharan Africa. With the transition of HIV from an acute illness to a chronic condition, co-morbid non-communicable diseases (NCDs) such as depression and anxiety disorder, alcohol use disorder (AUD), and hypertension (HTN) have become epidemic among PLWH. Despite evidence-based interventions to promote integration of these HIV comorbidities into HIV service delivery, integration efforts face challenges. First, integration commonly fails to recognize the syndemic relationships between these conditions and the deleterious effect of social factors such as poverty, stigma, and lack of access to care that worsen their outcomes, especially in low- and middle-income countries. Second, integration commonly imposes additional clinical tasks upon overburdened healthcare workers (HCW) operating in busy clinical environments without private space needed to attend to these additional conditions that are often stigmatized. A syndemic approach, which explicitly integrates the biological and social interactions that cause these conditions to cluster, has been proposed as a means of addressing the complex needs of PLWH. Mobile health (mHealth), an evidence-based strategy that leverages the widespread penetration of mobile phones to relieve HCW of burdensome tasks while enabling their systematic, consistent implementation, has been proposed as a solution to address HIV-related syndemics, but this approach has not been tested. Our exemplary multidisciplinary team has a strong track record of collaboration. In the current proposal, which leverages the infrastructure of an ongoing implementation study of HIV/HTN integration in Uganda, we will pursue these Specific Aims: Aim 1) Adapt Medly Uganda for detection, linkage to care, and ongoing support of depression, anxiety disorder, and AUD among Ugandans with HIV and HTN using a syndemic approach. Through human-centered design (HCD), we will engage patients, caregivers, and professional/lay HCW to guide iterative adaptation of Medly Uganda with explicit attention to common biosocial drivers. The adapted application will integrate widely used (1) screening instruments along with validated measures of significant life events, economic shocks, and stigma, (2) algorithm-driven messaging and alerts, and (3) linkage to HCW for support and treatment. We will also develop and operationalize a novel syndemic care cascade (R21 phase); Aim 2) Assess the effectiveness of the Syndemic-Adapted Medly Uganda (SAMU) to improve mental health care cascade metrics by conducting a single-arm trial using real-world historical data (R33 phase); Aim 3) Evaluate the factors impacting sustained engagement in the adapted Medly Uganda using mixed methods (R33 phase). Throughout the study period, we will focus on strengthening our Uganda-based team's mHealth research capacity and furthering our partnerships with government officials to ensure that SAMU can be locally maintained and sustained. The proposed study addresses a high priority topic for use of AIDS-designated funds at NIH and aligns with multiple National Institute of Mental Health priorities as described in PAR-21-303.

NIH Research Projects · FY 2025 · 2023-09

ABSTRACT Suicide is a top ten cause of mortality in the United States, and suicide rates have increased dramatically in recent decades. A recent meta-analysis showed that the suicide rate following discharge from a psychiatric facility was 2,078 per 100,000 person-years (versus 14.0 for the general population). Approximately one- quarter of all suicide deaths occur within 3 months of discharge from a psychiatric facility, making this a period of extremely high risk. With the advent of managed care in the 1990s and the concomitant decrease in hospital lengths of stay, Intensive Outpatient Programs/Partial Hospitalization Programs (IOP/PHPs) were instituted to manage high-risk patients outside of a locked hospital unit. Today, IOP/PHP services are frequently used in some areas as the principal discharge plan for patients upon leaving the hospital. However, there is virtually no evidence examining their clinical effects on suicide risk in this period. While these IOP/PHP services are readily available in some areas of the country, they are virtually non-existent in other regions. If IOP/PHP services have a significant protective effect against suicide following hospital discharge, implementation initiatives to broaden the availability of these services nationwide could be undertaken as a way to bend the curve against suicide. We hypothesize that the intense social and psychological support of IOP/PHPs will be reflected in a reduction in suicide risk among patients who receive treatment through these programs. We will test this hypothesis by conducting a propensity score matched observational study of patients who receive treatment at IOP/PHP services following discharge compared to patients who receive non-intensive outpatient follow-up. Cohorts for these groups will be sufficiently large (over 100,000 per group) to detect even small differences in suicide rates between intervention groups (minimum detectable rate ratio ranging from 0.82 to 0.95, see Table 4). The data for this project will be drawn from Medicaid databases and will be linked with the National Death Index, the most authoritative data source for mortality in the United States. Additionally, we will conduct a national survey of clinical directors of IOP/PHP services to identify and characterize clinical care processes. Survey results will be integrated with claims-based analyses to better understand what care processes may be effective in reducing suicide risk following hospital discharge as well as to understand the variations in quality of care throughout the country among IOP/PHP services. Results from this project would have important implications for policy and discharge planning patterns in the post-hospitalization period. Future directions would include dissemination and implementation initiatives to align discharge planning patterns with clinical evidence. A stakeholder council will be formed during the project to help implement strategies to enhance the availability of these services in locations where they are not widely accessible.

NIH Research Projects · FY 2025 · 2023-09

Project Summary/Abstract Healthy vision requires the function of parallel cellular and synaptic pathways in the neural retina. Circuits constructed from diverse cell types provide the anatomical and physiological basis for encoding diverse visual scenes. Indeed, visual inputs to the mouse retina are converted to electrical signals by photoreceptors (1 rod, 2 cone types), integrated by interneurons (1 horizontal, ~15 bipolar, ~60 amacrine cell types), and relayed to the brain by retinal ganglion cells (>40 types) whose axons form the optic nerve. In a surgical model of nerve injury, called the optic nerve crush (ONC), the axons of retinal ganglion cells (RGCs) are damaged. In response to ONC, 70-80% of RGCs die within two weeks. The death of RGCs is biased, however, and depends on the RGC type. A group of resilient RGC types persists and survives for weeks following the crush, whereas other susceptible RGC types die within a few days. A long-term goal of the ONC model is to rescue injured RGCs and enable regrowth of axons to target brain regions and restore functional vision. The field has identified transcriptomic and tissue-level mechanisms that promote RGC survival. Furthermore, RGC survival and axon regeneration are enhanced by RGC electrical activity (e.g., action potential firing). However, there is a major gap in our understanding of (1) how activity of different RGC types is affected following ONC; (2) how changes in activity align with the resilient/susceptible category of RGC types; and (3) whether there are cellular or synaptic mechanisms that are affected by ONC and prohibit the ability to enhance activity in certain RGC types following injury. I will therefore utilize electrophysiological and confocal microscopy techniques to directly address my hypothesis that dysfunction and reduced firing in RGCs post optic nerve crush depends on the RGC type and reflects a combination of synaptic and cell-intrinsic mechanisms. I will measure the anatomy and physiology of specific RGC types that are either resilient or susceptible to ONC and determine the contributions of either synaptic or intrinsic mechanisms to RGC hypoactivity after ONC. Understanding these mechanisms will generate insights into how naturally-occurring diseases that affect the optic nerve, such as glaucoma, cause dysfunction and death of RGCs and could contribute to the design of rational therapies.

NIH Research Projects · FY 2025 · 2023-09

Acute myocardial infarction (AMI), a major cause of cardiovascular disability and death in the US, can be triggered by environmental exposures like heat, cold, and fine particulate air pollution (PM2.5). However, less is known about whether temperature variability, elevated temperature-humidity metrics, or ground-level ozone exposures could also trigger AMI, especially in young (aged 18-55 years) and older (aged ≥75 years) adults. Moreover, it remains unclear whether women, persons of low socioeconomic status (SES), people with pre-existing chronic conditions, or users of certain medications have elevated vulnerability to heat-related AMI risk. Furthermore, evidence regarding whether co-exposures to extreme heat and air pollution interactively trigger AMI remains largely lacking. The overall objectives in this application are to (i) evaluate the effects of extreme heat and air pollution on AMI; and (ii) identify potential effect modification by sex, SES, medical history, and air pollution on the association between exposure to extreme heat and AMI risk. To achieve these objectives, we will use two unique US nationwide multicenter prospective observational cohort studies: VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) and SILVER-AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction). We will link patient-level medical record and interview data with highly spatiotemporally resolved estimates of ambient air temperature and air pollution predicted from satellite-based ensemble models and apply time-stratified case-crossover designs coupled with state-of-the-art distributed lag nonlinear models. Specifically, we aim to: (1) assess the association of AMI occurrence with short-term exposure to extreme heat, heat waves, temperature variability (both within and between days), and temperature-humidity metrics (i.e., heat index, humidex, and wet bulb temperature) and examine its sex and socioeconomic disparities; (2) determine whether medical history (pre-existing chronic conditions and medication use) modifies the association between extreme heat and risk of AMI occurrence; and (3) estimate the association of short-term co-exposure to extreme heat and air pollution (PM2.5 or ozone) with risk of AMI occurrence. The proposed research is significant because it is expected to provide strong and actionable scientific evidence on the roles of exposure to extreme heat and air pollution in AMI risk and on the roles of sex, SES, pre-existing conditions, medication intake, and air pollution in contributing to population vulnerability to heat-related AMI, thus greatly aiding clinicians, policymakers, and stakeholders to more effectively prevent adverse impacts of extreme heat and air pollution in relation to AMI risk.