Mayo Clinic Rochester

NIH Research Projects · FY 2026 · 2026-06

SUMMARY Choroidal melanoma is the most common primary intraocular malignancy in adults and a potentially fatal cancer that continues to be challenging in all respects. Choroidal melanoma can arise from preexisting choroidal nevus or de novo. Distinguishing early-stage choroidal melanoma from nevus can be challenging as they share similar ophthalmoscopic appearances when small. Up now, no single objective gold standard modality can successfully discriminate between these two entities. Formation of new and aberrant vascular networks are seen in de novo cases of choroidal melanoma as well as in the transformation of an existing nevus to melanoma. Our long-term goal is to combine novel artificial intelligence techniques with such new noninvasive tool for the diagnosis of early-stage choroidal melanoma. A secondary gain from such an imaging method will be assessment of treatment monitoring. Here, we propose to advance a new ultrasound-based technology, quantitative high definition microvessel imaging (qHDMI) that reveals tumor microvessels as small as 150µm and quantifies the microvessel morphological structures as new quantitative imaging biomarkers. Our goal is to combine novel artificial intelligence techniques with such new noninvasive tool for the diagnosis of early-stage choroidal melanoma. An advantage of the proposed qHDMI technique is that it does not require the use of contrast agents to produce high-resolution images of the microvasculature. We plan to address two aspects: Diagnose early- stage choroidal melanoma and assess the response to radiation therapy or transpupillary thermotherapy in patients with choroidal melanoma. The project includes 2 specific aims: Specific Aim #1 includes two sub-aims: Sub-Aim1.1: Determine the feasibility of the combined AI techniques with new qHDMI biomarkers and images for differentiation of choroidal melanoma from choroidal nevus and correlate with the clinical diagnosis based on all multimodality ophthalmic imaging together and gene expression profiling if clinically recommended. Sub-Aim 1.2: Longitudinal monitoring of the clinically diagnosed benign choroidal nevi in Aim 1.1 and determine the feasibility of qHDMI for detecting the transformation of choroidal nevus to Melanoma. Specific Aim #2: Determine the feasibility of qHDMI for treatment monitoring in patients with choroidal melanoma and correlate the results with the clinical diagnosis based on all multimodal ophthalmic imaging together. This proposal is the result of collaboration among leading experts in the field and benefits from the world-class research environment at the Mayo Clinic. Successful completion of this research will pave the way for novel, non-invasive, low-cost, and user-friendly technology for patients with ocular tumors. The qHDMI technique, enhanced with advanced AI- powered deep learning algorithms, holds strong potential for clinical translation and broad accessibility. We anticipate it will significantly benefit patients with choroidal melanoma by enabling earlier detection and timely treatment—ultimately improving the chances of preserving both vision and life.

NIH Research Projects · FY 2026 · 2026-06

PROJECT SUMMARY Germline pathogenic variants (PVs) in BRCA1 and BRCA2 are associated with increased risks of breast, ovarian, prostate and pancreatic cancer. Identification of PVs in these genes through genetic testing provides early warning of elevated risks for primary and second cancers, qualifies family members for risk assessment, allows for enhanced breast cancer screening with mammography and MRI, prophylactic mastectomy and salping-oophorectomy for risk reduction and treatment of these cancers with Poly-ADP ribose polymerase inhibitors (PARPi). While most variants are currently categorized as pathogenic, benign, or variants of uncertain significance (VUS), we have identified a fourth group composed of variants that partially alter protein function (hypomorphs) and confer reduced risks for breast and other cancers. We refer to these as hypomorphic/reduced penetrance pathogenic variants (RPPVs). We have verified 13 mainly splice site alterations as consensus RPPVs in BRCA1 and BRCA2 in collaboration with hereditary cancer testing laboratories and have verified 70 other missense RPPVs in the BRCA2 DNA Binding Domain (DBD) using a series of functional studies and case-control association studies. In further studies we have identified 152 candidate BRCA1 and 313 candidate BRCA2 hypomorphic variants. Hypomorph/RPPVs represent a new category of cancer risk variants. These variants have significant implications for clinical management because the reduced risk will not qualify carriers for risk reducing prophylactic surgeries or for PARPi treatment. Here we propose large-scale studies of RPPVs to establish that these variants have unique functional and clinical characteristics compared to BRCA1/2 PVs. We will address this hypothesis with three specific aims as follows: Aim 1: To characterize the functional implications of hypomorphic variants in the BRCA1 BRCT and BRCA2 DNA binding domains. We will identify and validate large series of hypomorphic variants using a series of functional assays. Aim 2: To establish the clinical classifications and characteristics of BRCA1/2 hypomorphic variants. We will use very large datasets from clinical testing populations and population-based studies to establish the risks of the various cancers and the cancer phenotypes associated with each hypomorph/RPPV. Aim 3: To characterize breast cancers and normal breast tissues from women with BRCA1/2 RPPVs using genomic and multiplex immunofluorescent imaging technologies. We will analyze the genome landscape of RPPV breast cancers, focusing on allele-specific loss of heterozygosity, homologous recombination deficiency, and somatic variants associated with therapeutic response, including reversion and epistatic mutations. We will also characterize the influence of RPPVs on the tissue microenvironment of normal and tumor tissues.

NIH Research Projects · FY 2026 · 2026-06

Mammography-based risk factors hold promise for broad use in breast cancer (BC) risk prediction, given >75% of women have routine screening mammography in the U.S. Mammographic breast density, the proportion of fibroglandular breast tissue, is the most established mammography-based BC risk factor. Recently, high throughput extracted radiologic imaging features (known as radiomics), reflecting the intrinsic heterogeneity and complexity of fibroglandular tissue structure, have been shown to improve risk prediction. We recently identified and validated six reproducible “intrinsic patterns” or radiomic phenotypes based on features extracted from digital mammograms (2D DM) and found them associated with future risk of invasive BC and interval invasive BC (occurring after a negative mammogram and before the next screen) in Black and White women, independent of breast density. As breast screening in the US has rapidly transitioned from 2D DM to 3D digital breast tomosynthesis (DBT), which offers superior tissue visualization, there is potential to extract more accurate radiomic features to improve BC prediction. Given known differences in breast density and BC prognosis by race, it is imperative to define radiomic phenotypes across representative racial and ethnic groups and examine their associations with advanced BC (pathologic prognostic stage II or higher), which is a strong surrogate for BC mortality. Our goal is to extract radiomic features from screening-DBT exams; characterize and validate radiomic phenotypes from these features for all women and among racial and ethnic groups; and examine their association with incident invasive and advanced BC risk. SA 1 will characterize and validate radiomic phenotypes on 36,000 screening-DBT exams among a representative sample of US women, ages 40-74, sampled from four breast screening cohorts. We will extract over 2,000 radiomic features, classify, and independently validate radiomic phenotypes, for all women and within racial and ethnic groups. SA 2 will examine the association of radiomic phenotypes (from SA 1) with incident invasive and advanced BC risk among a representative sample of US women within a nested case-control study of 8,500 invasive BC and 17,000 matched controls. We will assess radiomic features on the earliest screening- DBT performed within five years prior to diagnosis; classify them into the validated radiomic phenotypes; and examine the phenotype association with future invasive and advanced BC risk by race and ethnicity, breast density and body mass index (SA 2.1). We will also examine differential associations of radiomic phenotypes with tumor characteristics and with polygenic risk scores to inform underlying etiologic mechanisms (SA 2.2). SA 3 will evaluate the contribution of the radiomic phenotypes to clinical BC risk models and FDA approved artificial intelligence BC algorithms for risk prediction of invasive and advanced BC. Elucidating and characterizing novel radiomic phenotypes from screening-DBT relevant to all US women will improve our ability to define groups of women at differential BC risk, for personalized screening and prevention strategies.

NIH Research Projects · FY 2026 · 2026-05

This proposal addresses the interplay of key facets of pediatric cancer research: DNA damage, chromatin accessibility, and the immune response to tumors. The overarching scientific goal of this R01 proposal is to better understand and treat Ewing tumors with STAG2 (stromal antigen 2) loss, a group of Ewing tumors associated with greatly inferior patient ourcomes, by taking advantage of STAG2 deficient tumor vulnerabilities during radiation therapy noted in our preliminary studies. Patients with aggressive (e.g. upfront metastatic and relapsed) Ewing sarcoma often receive radiation therapy for local control and optimizing the therapeutic effectiveness of this treatment is of great interest. The translational goal of this work is to develop novel multi- modality treatment combinations, including agents to induce epigenetic reprogramming and tumor inflammation, to partner with radiation therapy to better treat aggressive Ewing tumors with STAG2 loss. Little is currently understood about radiation therapy-induced changes in immunobiology in Ewing sarcoma. In part, this gap-in- knowledge is due to the lack of patient samples around the time of radiation therapy and no robust immunocompetent in vivo models of Ewing sarcoma. The applicant’s laboratory has validated a humanized, immunocompetent mouse model of Ewing sarcoma and used this model to ask questions about the immunobiology of Ewing tumors with STAG2 loss. Preliminary data show that Ewing tumors with STAG2 loss demonstrate defective responses to interferon and reduced radiation therapy-induced inflammation. This finding was also noted in analyses of human Ewing tumors from patients. This proposal will now build upon the vulnerabilities of STAG2 deficient tumors identified to enhance the response to radiation therapy. This will be accomplished through the aims proposed, including investigation of epigenetic reprogramming and activation of the immune system. The proposed experiments include cutting-edge in vitro analyses, in vivo tumor animal modeling and human specimen analyses. Single-cell RNAseq, ATAC-seq and spatial transcriptomic data generated through these studies will be fully annotated and made accessable to the scientific community. Multi- modality therapies will be tested in vivo both in humanized mice and NSG mice to better understand immune specific contributions to metastatic tumor behavior and and survival. The applicant has an established network of expert collaboartors, including individuals with expertise in radiation oncology, STAG2 biology, sarcoma epigenetics, spatial transcriptomics, the tumor immune-microenvironment, and bioinformatic and statistical analyses, all of whom will contribute to the ultimate success of this proposal. Mayo Clinic is an outstanding research and clinical institution for the study of sarcomas, radiation biology, and immunology, and is an ideal environment in which to investigate multi-modality therapies to pair with radiation therapy for the treatment of aggressive, STAG2 deficient Ewing sarcoma. The Bailey laboratory is dedicated to sharing these findings as preclinical rationale for future clinical trials for patients.

NIH Research Projects · FY 2026 · 2026-05

PROJECT SUMMARY/ABSTRACT Uveal melanoma (UM), the most common primary adult intraocular malignancy, is a devastating cancer. Up to 50% of patients will develop metastatic disease with a median overall survival of <2 years. Despite extensive sequencing efforts, genomic studies of UM have failed to identify new treatment targets. Thus, novel approaches must be used to improve therapeutic efficacy for UM and prolong survival for patients with this dismal, understudied condition. A hallmark feature of aggressive UM is the loss of expression of BAP1 (BRCA1 associated protein 1), the single most consistent alteration associated with UM-related death. BAP1 is a deubiquitinating enzyme with known function in DNA damage repair, and while poly ADP ribose polymerase (PARP) inhibitors have been of interest for BAP1 deficient cancers to capitalize on their dysfunctional DNA damage repair system, clinical trials have failed to show good efficacy. Our data identified Syk as a target to sensitize UM to PARP inhibitors. Syk is a non-receptor tyrosine kinase with tumor suppressor function in some cancers and proto-oncogene function in others. Our preliminary data showed Syk upregulation in UM compared to benign melanocytes, which was greater in high-risk UM with BAP1 loss. Following these data, treatment of UM cells with Syk inhibitor improved therapeutic sensitivity to PARP inhibitors. It is our central hypothesis that Syk upregulation in UM contributes to treatment resistance and can be targeted to improve therapeutic response. We will address this hypothesis using novel models that fulfill an unmet need in UM research, including one-of-a-kind UM patient-derived organoids (PDOs) and disease-relevant orthotopic xenografts, which demonstrate progression to liver metastasis. In AIM 1 we will define the role of Syk in UM treatment response using PDOs. To explore PARP inhibitor response dependency on Syk, we will evaluate treatment response to Syk and PARP inhibition alone and in combination in a large cohort of PDOs and, separately, in Syk knockdown cell line models (Sub-AIM 1A). We will define the mechanisms associated with UM treatment response to PARP and Syk inhibition by studying DNA damage and replication stress (Sub-AIM 1B). In AIM 2 we will define the in vivo efficacy of Syk inhibition to improve PARP inhibitor response in UM. We will use PDO-generated xenograft models simulating human metastatic progression to determine the therapeutic efficacy of combination Syk and PARP inhibition for metastatic UM. Successful outcome of this proposal will fill a key knowledge gap for UM by investigating a novel therapeutic strategy, Syk inhibition, to improve treatment response. Experiments will include subanalysis by UM BAP1 status, which is of critical importance given that tumors with BAP1 loss are most likely to metastasize. The use of novel, more representative models of human disease, including PDOs and PDO-generated orthotopic xenografts, will improve the likelihood of successful translation of these findings. Together, these results will support future development of clinical trials using personalized medicine approaches to improve survival for patients with UM.

NIH Research Projects · FY 2026 · 2026-05

ABSTRACT To initiate lagging strand DNA synthesis, the polymerase α-RNA primase complex synthesizes RNA primers, which are composed largely of adenine (A) and cytosine (C) residues that start each of the millions of Okazaki fragments required for eukaryotic chromosome replication. RNA primers are synthesized in an error prone manner. Adenosine-to-inosine (A-to-I) modifications are common RNA editing events performed by adenosine deaminase acting on RNA (ADAR1). A consequence of A-to-I editing is that I is interpreted as guanine (G), functional A-to-G substitutions and correction of A:C mismatches within pre-mRNAs, mRNAs, and noncoding RNAs. There are two ADAR1 isoforms, ADAR1p150 and ADAR1p110, which are predominantly localized to the cytoplasm and nucleus, respectively. By modifying cytoplasmic double-stranded viral RNA, ADAR1 p150 suppresses interferon signaling. The functions of nuclear ADAR1p110, however, have been understudied. We have found a novel role for ADAR1p110 in editing of RNA primers during DNA replication. ADAR1p110 is overexpressed in breast cancer, particularly triple negative breast cancer (TNBC), an aggressive subset characterized by elevated levels of replication stress. Our preliminary data suggests that ADAR1p110 localizes with primase at nascent DNA, and that ADAR1p110 A to I editing of nascent DNA suppresses DNA gap formation and stabilizes the replication fork. Consistently, loss of endonucleases FEN1 and DNA2, key enzymes in Okazaki fragment maturation, were synthetic lethal with ADAR1p110. Poly (ADP-ribose) polymerase (PARP) inhibitors induce the accumulation of excessive single stranded DNA gaps in the lagging strand of replicating DNA in cancer cells, resulting in cancer cell death. PARP inhibition is approved for BRCA1 and BRCA2 associated breast cancers. However, many patients have inherent or acquired resistance, and PARP inhibition is not an option for patients without BRCA1 or BRCA2 alterations. We found that genetic deletion of ADAR1 p110 or inhibition of ADAR1p110 dimerization with a novel ADAR1p110 specific small molecule inhibitor identified through virtual screening resulted in DNA gaps and tumor specific hypersensitivity to PARP inhibition and other replication gap targeted therapy. Further, we have found that the multifunctional protein, APEX1, may regulate this new ADAR1p110 role. We hypothesize that ADAR1p110 stabilizes replication forks by editing mis- matched RNA:DNA hybrids and suppressing replication gaps and is a target to overcome resistance to breast cancer therapy. Aim 1 will investigate ADAR1p110 RNA primer editing and Okazaki fragment processing. Aim 2 will examine the molecular function of APEX1 in ADAR1p110 regulation. Aim 3 will evaluate ADAR1p110 as a target for therapeutically resistant breast cancer.

NIH Research Projects · FY 2026 · 2026-05

PROJECT SUMMARY Multiple myeloma (MM) is an incurable plasma cell malignancy and the most common blood cancer among individuals who self-identify as African American, accounting for ~20% of newly diagnosed cases. The biological factors contributing to the increased risk of MM and its precursor condition, monoclonal gammopathy of undetermined significance (MGUS), in individuals of African ancestry remain poorly understood. Strikingly, when access to healthcare is equal, African American patients experience better clinical outcomes, and their MM tumors exhibit lower genomic complexity compared to those of European American patients. It is well established that the incidence of MGUS and MM increases with age, and aging is a primary determinant for progression from MGUS to MM. African American patients are diagnosed with MGUS and MM at younger average ages than European American patients, and emerging evidence suggests that individuals of African ancestry exhibit accelerated biological aging and immunosenescence. Together, these observations suggest that accelerated biological aging may contribute to the higher prevalence of MGUS and increased incidence of MM in African Americans. In support of this, we found that African American patients with MGUS and MM, as well as healthy donors, had increased CD57+ CD8+ T cells, a hallmark of immunosenescence. This altered immune function may reduce tumor immune surveillance, decreasing the selective pressure that drives tumor immunoediting. We hypothesize that individuals with predominant African ancestry who develop MGUS or MM experience accelerated biological aging and immunosenescence compared to those with predominant European ancestry, resulting in reduced tumor immunoediting and the development of tumors with less genomic complexity- a feature linked to more favorable clinical outcomes. In Aim 1, we will assess whether patients with MGUS and MM who have predominant African ancestry exhibit accelerated biological aging compared to those with predominant European ancestry. In Aim 2, we will compare the immune tumor microenvironment in MGUS and MM patients with predominant African ancestry vs. those with predominant European ancestry to test the hypothesis that African ancestry patients exhibit increased immunosenescence. In Aim 3, we will evaluate whether MM tumors from patients with predominant African ancestry exhibit reduced immunoediting relative to those from patients with European ancestry. To mechanistically model this, we will use a mouse MM tumorigenesis model and apply unpredictable chronic mild stress to mimic chronic environmental and psychosocial stressors to test whether tumors arising under stress exhibit reduced immuno editing, evidenced by decreased genomic complexity and the reduced ability to engraft in immunocompetent recipient mice. Overall, this work will elucidate the role of accelerated biological aging and immunosenescence as potential drivers for increased MM incidence in individuals with African ancestry.

NIH Research Projects · FY 2026 · 2026-05

PROJECT SUMMARY Breast cancer is the second most common female malignancy and the second leading cause of cancer regardless of sex in the world. Nearly 80% of breast tumors express estrogen receptor alpha (ERa) which drives tumor progression. While endocrine therapies and CDK4/6 inhibitors have increased overall survival, many patients experience recurrence of metastatic disease, often years or decades after adjuvant therapy cessation, that is largely refractory to additional lines of endocrine therapy. Metastatic disease remains incurable highlighting the need for alternative treatment approaches. Through a genome-wide CRISPR knockout screen, LMTK2 was identified as the top hit exhibiting synthetic lethality in the setting of endoxifen treatment in both endocrine-sensitive and -resistant cells. LMTK2 mRNA and protein expression was increased in all cell line and patient derived models of endocrine resistance, including estrogen deprivation (mimicking an aromatase inhibitor), tamoxifen, endoxifen, fulvestrant and abemaciclib. Copy number gain/amplification was found to exist in 67% of the 195 ERa+ human metastatic tumors analyzed with only 1% of primary tumors harboring this genomic alteration. Further, siRNA-mediated knockdown of LMTK2 enhanced the efficacy of multiple endocrine therapies, while LMTK2 overexpression was sufficient to drive endocrine resistance. LMTK2 overexpression resulted in dramatic increases in AKT and ERa phosphorylation and activity. Unlike activating PIK3CA mutations that are frequent in endocrine-resistant tumors and are known to confer resistance, LMTK2 was found to employ an alternative mechanism to activate AKT signaling by inhibiting PP1a, an AKT-inhibitory phosphatase. This proposal aims to address the central hypothesis that LMTK2 is a novel driver of endocrine resistance and ERa+ breast cancer progression. To address this hypothesis, I propose two Specific Aims. In Aim 1, I will comprehensively characterize the role of LMTK2 in mediating sensitivity of ERa+ breast cancer cell line and PDX models to endocrine therapy and CDK4/6 inhibitors. In Aim 2, I will precisely define the molecular mechanisms by which LMTK2 activates AKT and ERa signaling and determine their contribution to LMTK2- mediated endocrine resistance. Completion of this proposal will delineate a novel mechanism of endocrine resistance and potentially explain the limited efficacy that has been observed in many clinical trials utilizing PI3K/AKT inhibitors. This knowledge will lay the foundation for the establishment of LMTK2, and its downstream mediators, as informative biomarkers and novel drug targets aimed at eradicating residual cancer cells in the adjuvant setting and effectively treating resistant forms of ERa+ metastatic breast cancer, ultimately revolutionizing patient outcomes.

NIH Research Projects · FY 2026 · 2026-05

Approximately 4.5 million children in the United States (US) display severe emotional and behavioral disturbance. While it is not unusual for preschoolers to have occasional temper tantrums, it is considered symptomatic when temper outbursts (characterized by sudden, violent expression of strong feeling, anger, and aggression) occur most days that are severe enough to impair their academic, social, and family functioning. Evidence-based therapies such as parent child interaction therapy (PCIT) reduce behavioral challenges in children by improving parent-child relationships through parenting practices taught over a multi-week period. Despite the widespread availability of behavioral interventions, there are significant challenges: (a) the effectiveness of interventions is contingent upon parents remembering parenting practices taught during weekly therapy sessions to engage with their children, (b) there is limited education for affected children and their parents to help preempt temper outbursts and regulate their emotion, and (c) families from rural areas and populations with limited specialized pediatric mental health providers are less likely to have access to and utilize evidence-based therapies when it is available. The overarching goal of this convergent research proposal is to investigate the development of generative methods with closed-loop feedback from parents to individualize real-time interventions for children when a temper outburst is predicted. The project will accomplish the goal through the following aims. Aim 1: This project will develop generative algorithms with closed-loop feedback using 5.4 million minutes of smartwatch data collected from 50 children (aged 3 – 7 years) and parent-provided timestamps (closed-loop feedback) of disruptive behavior (characterized by temper outbursts). Aim 2: The developed technology will then be evaluated in a cohort of 50 new children to assess if parenting practices combined with child-initiated mindfulness (i.e., new patient-education) upon a predicted temper outburst could improve behavioral outcomes. Aim 3: Elucidate the perspectives of stakeholders (e.g., parents, schoolteachers) on the use of continuous monitoring devices for adaptive generative intelligence algorithms.

NIH Research Projects · FY 2026 · 2026-04

PROJECT SUMMARY Female sex is a risk factor for gastrointestinal (GI) motor disorders such as gastroparesis (GP) and slow-transit constipation and disorders of gut-brain interaction, which include functional dyspepsia and irritable bowel syndrome and also involve altered motility. Notably, GP, defined by delayed gastric emptying without mechanical obstruction and severe symptoms, nutritional compromise, anxiety, depression, and poor quality of life, is four times more common in women than men, most often complicating diabetes. The molecular basis of female predominance in these disorders remains unclear and a major impediment to finding a cure for the patients. Interstitial cells of Cajal (ICC) are key regulators of the GI neuromuscular apparatus and have been implicated in the pathomechanisms of GP—particularly, diabetic GP—and other GI motor disorders. This project will test the hypothesis that the fundamental cause of women’s high susceptibility to diabetes- associated ICC loss and GP is the contribution of a female-biased gene regulatory circuitry, which is driven by estrogen signaling via the G protein-coupled receptor GPER1 and the noncanonical, activating Polycomb complex ncPRC1.5, to the transcriptional control of mitochondrial and ICC functions and ICC maintenance. This mode of regulation makes female ICC vulnerable to mitochondrial stress, which, if sufficiently severe, causes repression of genes involved in cell type-specific functions (Specific Aim 1). Mitochondrial stress accompanies both diabetes and immune disorders, thus our hypothesis offers a potential link between the metabolic and immune etiologies proposed for GP. In contrast, male ICC are more resistant to the transcriptional consequences of mitochondrial stress due to higher histone serotonylation, which globally amplifies gene transcription, reflecting increased “writing” of this mark due to accentuated hypoxic signaling from the male ICC’s greater reliance on oxidative phosphorylation and epigenetic repression of its “erasers” (Specific Aim 2). We will test our hypotheses by following a rigorous workflow for the discovery-based, mechanistically focused, and translationally relevant interrogation of the proposed molecular pathways. These experiments will include highly multiplexed bulk and spatial transcriptomic and epigenomic studies, which will be performed in tissues from gonadally, pharmacologically, and genetically manipulated female and male mice, in gastric tissues of male and female patients with or without diabetes and GP, and new, scalable ICC models derived from male and female patients. Findings will be mechanistically validated by RNA interference and epigenome editing in vitro and conditional deletion of genes in ICC in vivo. Pharmacological manipulation of the proposed mechanisms with nutritional supplements and repurposed drugs will be performed in previously established disease models using validated tests of gastric motor functions to demonstrate translational relevance. Results from this project will determine the fundamental mechanisms of sexual dimorphisms in ICC that contribute to the prominent sex bias of GP, with a particular focus on diabetic GP.

NIH Research Projects · FY 2026 · 2026-04

PROJECT SUMMARY Antinuclear antibody (ANA) testing is critical for the diagnosis of organ-specific and autoimmune diseases, such as systemic lupus erythematosus (SLE), which affect millions of patients. Although ANA production is not unique to a single disease, specific autoantibodies (e.g., anti-DNA, anti-centromere) can serve as highly characteristic biomarkers. However, ANA testing presents several challenges in clinical practice. In particular, a growing portion of the US population is ANA-positive (estimated at 16%), only a subset of whom have autoimmune disease, creating difficulties distinguishing pathological ANA from incidental findings. The long-term risk of autoimmune disease in ANA-positive patients without an immediate diagnosis is also unknown. In addition, the gold standard ANA test—the indirect immunofluorescence (IIF) assay using human HEp-2 cells—suffers from key technical limitations. This test identifies fluorescence staining patterns that guide further testing for specific autoantibodies; however, reliance on expert visual interpretation introduces variability and inconsistency and limits clinical utility. These issues lead to further diagnostic ambiguity, resulting in patient anxiety, unnecessary referrals, over- treatment, and strains on healthcare systems suffering from a shortage of rheumatology specialists. Here, we aim to address these issues by filling two key knowledge gaps: 1) the long-term risk of developing autoimmune diseases in ANA-positive individuals is poorly defined, and 2) the ANA IIF test lacks standardization and predictive integration. To this end, we will leverage epidemiological data, biobank resources, and advances in artificial intelligence (AI) technologies to improve ANA testing and advance understanding of ANA positivity and progression to autoimmune disease. In Aim 1, we will assess the link between ANA positivity and long-term progression to autoimmune disease, testing our hypothesis that ANA-positive patients without autoimmune disease at time of testing are at higher long-term risk of developing systemic and organ-specific autoimmune diseases than ANA-negative controls. These studies will utilize two complementary resources, the Rochester Epidemiology Project and Mayo Clinic Biobank, both with decades of longitudinal data. In Aim 2, based on our preliminary data showing that AI-based computer vision can detect specific autoantibodies with high accuracy from IIF images, we will develop and validate AI models for identifying specific autoantibodies and autoimmune diseases directly from IIF images. This novel tool will use computer vision to analyze IIF images and identify imperceptible diagnostic patterns linked to specific autoantibodies and diseases, thereby standardizing interpretation, improving precision, and facilitating the early detection of autoimmune diseases, in alignment with the NIAMS Strategic Plan (2025–2029) priority of advancing knowledge through AI. Through these studies, which integrate unique epidemiological resources, biobank data, and AI-driven advances to address longstanding challenges in ANA testing, we aim to improve diagnostic accuracy, optimize specialty referrals, and enhance care for individuals with or at risk of autoimmune diseases.

NIH Research Projects · FY 2026 · 2026-04

In 2025, an estimated 80,350 people in the US will be diagnosed with non-Hodgkin lymphoma (NHL), and 19,390 will die from this cancer. NHL survival rates began improving in the 1990s with the advent of improved treatment strategies, leading to the current 5-year survival rate of 74%. These trends led to a growth in the number of NHL survivors, estimated at 808,413 as of January 1, 2024. To address the unmet health needs of this patient population, in 2002 we established the Molecular Epidemiology Resource, which was expanded nationally in 2015 as Lymphoma Epidemiology of Outcomes (LEO) cohort study. LEO enrollment is currently over 17,000 NHL participants (and >19,000 at the start of this grant), with <1% loss to follow-up and 73% alive and in follow-up. LEO abstracts pathology, demographic, address (to derive neighborhood variables), clinical, treatment and outcome data, and collects patient reported epidemiologic risk factors and quality of life (QoL) outcomes. Importantly, LEO enrollment (2015-2020) had similar distributions of participants by demographic and NHL subtype as the national Surveillance, Epidemiology, and End Results (SEER) registry, making LEO the largest and most representative prospective cohort of lymphoma outcomes reflecting NHL patients in the US. Cumulatively, LEO has supported numerous publications, prior and ongoing grants (NIH, foundation, industry), NCI Supplements, and career development awards. Under this funding mechanism, we propose to use the LEO cohort to drive the next generation of NHL prognosis and survivorship studies, define patient subgroups with poor outcomes in need of clinical trials, and identify unmet needs for long-term survivors. We will develop and validate novel clinical risk prediction models across NHL subtypes utilizing both the extensive existing LEO data and proposed ongoing follow-up. Our aims are: 1) To develop, validate, and disseminate new clinical models for early treatment failure (ETF) across the major NHL subtypes; 2) To define the intermediate and long-term outcomes and longitudinal QoL in NHL patients who achieve a functional cure with standard of care (SOC) management; and 3) To evaluate the impact of rurality and social determinants of health (SDOH) using individual and area-level measures on NHL outcomes in the context of clinical and lifestyle factors, comorbidities, frailty and QoL. To achieve these aims, we will leverage existing data from the LEO cohort and further annotate the cohort with new data on outcomes, longitudinal and pulse surveys, and external data sources. Maintenance of the cohort also will provide outcomes for ongoing and new studies utilizing the LEO biorepository, and completion of our proposed aims will provide validated clinical models to integrate with biologic studies. This proposal addresses key research questions in outcomes and survivorship for patients with NHL (an understudied cancer) and in understudied populations, including rural and adolescent and young adults. Our results will directly inform clinical guidelines and risk assessment, and support development of novel studies and interventions to improve the outcomes of NHL patients.

NIH Research Projects · FY 2026 · 2026-04

PROJECT SUMMARY/ABSTRACT Coronary artery disease (CAD) remains the main cause of morbidity and mortality in the United States. CT imaging provides fast non-invasive assessment of CAD with a high sensitivity and negative predictive value when the arterial lumen can be clearly visualized. However, in patients with heavily calcified plaques or coronary stents, the lumen can be obscured, leading to an overestimation of the degree of luminal stenosis. The recent introduction of photon-counting detector CT (PCD-CT) has partially alleviated these concerns because of its excellent spatial resolution (best in-plane spatial resolution of 0.125 mm). However, substantial limitations remain. Excessive image noise occurs in the high-spatial-resolution images, which precludes robust quantitation of percent luminal stenosis and visualization of features associated with high-risk plaques. Further, even with the 66 ms temporal resolution from dual-source technology, motion artifacts remain a major concern, especially in challenging scenarios such as the emergency department, where high heart rates, arrhythmias, and inadequate breath holding are common. In short, methods to control image noise and motion artifacts are critically needed to take full advantage of cardiac PCD-CT’s diagnostic potential in all patients. Additionally, non-ideal properties of photon-counting detectors, particularly charge sharing, limit spectral separation, the accuracy of material decomposition, and the success of plaque characterization. Innovative solutions using coincidence counting technologies have been proposed by our team but need the partnership of a detector/scanner manufacturer to implement. Our objective is to address these limitations in cardiac CT, namely image noise, motion artifact, and limited spectral separation due to charge sharing. Our approach will use the next-generation dual-source PCD-CT system and artificial intelligence (AI) techniques to accurately assess CAD in humans, especially in patients with heavily calcified, stented, or high-risk plaques. Working with our industry partner, Siemens Healthcare, we will develop the next generation of photon counting detectors with coincidence counting. Our proposal is highly significant. Robust, accurate, non-invasive imaging of calcified and stented coronary arteries or high-risk plaques in a single non-invasive exam will greatly reduce the need for invasive diagnostic imaging, reducing the overall time and cost to comprehensively evaluate CAD. To accomplish our objectives will require numerous physics, engineering, and algorithm innovations, including novel coincidence counting and charge-sharing correction, noise reduction, motion correction, and material decomposition algorithms. These advances will culminate in a small clinical study to demonstrate not merely that the images are “better,” as is so often done, but that the next-generation dual-source PCD-CT, in combination with AI techniques, provide clinically significant improvements in the diagnosis and management of challenging to image patients with suspected CAD. Additionally, the technological developments accomplished will benefit all of CT imaging.

NIH Research Projects · FY 2026 · 2026-04

PROJECT SUMMARY Chronic villitis of unknown etiology (VUE) is an inflammatory placental diagnosis comprised of the infiltration of maternal CD8+ T cells into the chorionic villi with corresponding trophoblast death. This inflammation accompanies 40-60% of fetal growth restriction (FGR) cases, 20-30% of stillbirths, and infants with a VUE diagnosis are 4 times more likely to be neurodevelopmentally delayed. Importantly, approximately 55% of patients with a VUE diagnosis will have recurrent disease, making this a clinically significant placental finding. However, consequences of this diagnosis are rarely considered clinically due to the paucity of data surrounding the biologic mechanisms promoting VUE. These gaps have resulted in significant barriers for prediction and prevention of new and recurrent disease. The proposed studies seek to determine the inflammatory factors and antigens driving T cell infiltration and trophoblast death in VUE. We hypothesize that VUE is a breakdown of placental immune tolerance driven by maternal CD8 T cell recognition of foreign fetal ligands and antigens expressed locally by villous trophoblasts and systemically by circulating antigen presenting cells (APCs). This is supported by our recent work demonstrating that CD8 T cell responses in VUE are independent of viral infection and have a highly activated and cytotoxic phenotype, similar to allograft rejection responses. We also observed that VUE placentas downregulate T cell inhibitory ligands and upregulate human leukocyte antigen (HLA), which would promote T cell antigen recognition mechanisms. Our preliminary data demonstrates that genes and pathways critical for allorecognition and inflammatory interferon- signaling are increased in CD8 T cells and trophoblasts during VUE compared to controls. We also observe differences in T cell populations in the blood of pregnant patients who go on to have VUE diagnosed at delivery, compared to those that do not. This suggests not only a local, but also a systemic response to this pathology is generated. We will test our hypothesis with two Specific Aims: 1) define the local cell signaling and antigens that promote T cell cytotoxicity and trophoblast death in VUE, and 2) determine how systemic maternal T cell activation and expansion contributes to VUE. This study will provide transformative insights into the etiology of VUE and will contribute directly to the identification of targets to predict and treat VUE in utero.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY/ABSTRACT Cirrhotic stage liver disease is the 9th leading cause of mortality in the US, and no treatment exists for late-stage disease other than liver transplantation. Thus, the overall objective of this proposal is to elucidate novel mechanisms that drive liver fibrosis progression and to guide the development of potential treatment strategies. Liver fibrosis is characterized by the activation of hepatic stellate cells (HSCs). Our preliminary data in primary human and mouse HSCs as well as in vivo demonstrate that 1. Platelet derived growth factor (PDGF) increases acetyl-CoA levels in HSCs and the expression of one of the histone acetyltransferases, lysine acetyltransferase 2B (KAT2B); 2. PDGF-mediated glycolysis increases the epigenetic transcription activation mark, histone 3 lysine 9 acetylation (H3K9ac) in HSCs; 3. In vitro pharmacological inhibition of H3K9ac by CPTH6 prevents proliferation and migration of PDGF-stimulated HSCs; 4. In vivo drug inhibition of H3K9ac by CPTH6 reduces liver fibrosis; 5. H3K9ac levels and KAT2B expression are increased in mice fibrotic livers. We utilized our novel findings to generate the CENTAL HYPOTHESIS of the current proposal that Glycolysis-mediated H3K9ac by KAT2B promotes HSC activation and liver fibrosis. We will employ sophisticated cellular and animal models, including in vitro carbon-13 glucose tracing, chromatin immunoprecipitation sequencing (ChIP-seq), in vitro utilization of dCas-KRAB model, in vivo HSC-specific KAT2B deletion model as well as an ex vivo liver fibrosis model with human precision cut liver slices (PCLS), to investigate the following integrated, yet independent aims. In Aim 1, we will test the hypothesis that glycolysis derived acetyl-CoA promotes H3K9ac dependent pro- fibrogenic gene expression. We will uncover the gene programs regulated by glycolysis- linked H3K9ac in HSCs by: a. studying how glucose metabolism contributes to the production of acetyl-CoA, the main metabolite to acetylate the histones, and how this affects H3K9ac; and b. investigating how investigating the gene promoters in PDGF-stimulated HSCs that are enriched with H3K9ac. In Aim 2, we will test the hypothesis that KAT2B- dependent H3K9ac and subsequent HSC activation induce liver fibrosis. We will dissect how HSC-specific H3K9ac amplifies liver fibrosis by: a. studying how KAT2B, the acetyltransferase responsible for H3K9ac, impacts HSC activation in vitro, including proliferation and migration; and b. examining how H3K9ac amplifies ex vivo and in vivo liver fibrosis. This novel and innovative line of inquiry will define an HSC-specific glycolysis- dependent model of liver fibrosis amplification and set a trajectory towards new and significant advances to treat liver fibrosis and cirrhosis in humans. Lastly, completing the planned education outlined in goals for fellowship training and this project will contribute to my overall formation as an independent scientist with a career in advancing the research for digestive health.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY/ABSTRACT This project aims to refine the individualized management of patients with oligometastatic castration- sensitive prostate cancer (omCSPC) by integrating blood-based markers to identify a subset of omCSPC patients who will benefit from stereotactic body radiation therapy (SBRT) alone versus those necessitating treatment intensification with systemic therapy. While the current advanced molecular imaging modalities (e.g. PSMA and Choline PET) have limitations in detecting subclinical disease, our innovative approach addresses this gap by evaluating prostate cancer-derived extracellular vesicles (PC-EVs) and circulating tumor DNA (ctDNA) as blood markers of both visible and invisible tumor burden. Furthermore, we will study specific circulating immune markers based on our prior research to identify and predict patients with clinical responses to SBRT and delineate immunosuppressive signals for future therapeutic intervention studies. We hypothesize that proposed blood-based tumor biomarkers and anti-tumor immune markers will aid in predicting patient response to SBRT alone or in combination with systemic therapy using randomized patient samples from Specific Aim 1, thus guiding personalized treatment decisions for future omCSPC patients. In order to achieve our goal, we will conduct a randomized phase 2 trial in omCSPC to evaluate SBRT alone or in combination with 6 months doublet therapy (ADT+ARPI) with modified radiographic PFS as primary endpoint in Specific Aim 1. In Specific Aim 2, we will prospectively validate PC-EV cutoff values predetermined using patients samples from ORIOLE and STOMP-like cohorts for risk stratification and prediction of response to therapy. We will also evaluate the performance of cell-free ctDNA as an additional blood-based marker of tumor burden and minimal residual disease. In Specific Aim 3, we will validate tumor-reactive CD8 T cells (previously published using prostate and melanoma patient samples) as a marker of durable response to SBRT. We will also perform a comprehensive profiling of peripheral immune cells and cytokines to examine the effect of ADT/ARPI to SBRT in anti-prostate cancer immune response. The identification of patients who can safely avoid ADT/ARPI after SBRT will significantly impact clinical decisions, reducing morbidity and cost associated with unnecessary systemic therapies. If successful, this study will allow up to 20% of patients to avoid unnecessary toxicities associated with systemic androgen deprivation treatments. Finally, by shedding light on key players of antitumor immunity, this work will serve as the foundation for future mechanistic studies that can lead to the design of a rational combination of SBRT and immunotherapy. By advancing the paradigm of personalized prostate cancer care through the integration of fluid-based tumor and immune assays with existing imaging techniques, this research holds significance for the National Cancer Institute's priorities for significantly improving patient outcomes and optimizing the management of omCSPC.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY Use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is rapidly increasing throughout the US population, particularly in older adults (≥60 years). It has been estimated that 26.8 million adults insured by Medicare alone are eligible for a GLP-1 RA prescription. Clinical trial data indicate that these medications are effective in older adults, but clinical trial populations frequently differ from patients in general clinical practice. As GLP-1 RAs move from clinical trials into primary care and community medical practices, the effects of these medications on the general aging population are unclear. The sheer number of older adults who may eventually be prescribed a GLP-1 RA makes it necessary to determine whether these medications are as safe and effective in general practice as in carefully controlled clinical trials. To address this gap, we will use linked electronic health records (EHR) available from the Rochester Epidemiology Project (REP) research infrastructure to study age differences in response to GLP-1 RAs in a large, population-based cohort of persons living in the upper midwest (n=26,442). Specifically, we will test the following hypotheses: Aim 1. We hypothesize that older adults will have a shorter prescription duration and fewer prescription changes, but a similar total percent body weight loss compared to middle-aged adults. Aim 2. We hypothesize that older adults will be more likely to discontinue GLP-1 RAs and will experience more side effects than middle-aged adults. Aim 3. We hypothesize that risk of pancreatitis, bowel obstruction, interstitial nephritis, falls, fractures, and frailty will be higher in older persons prescribed GLP-1 RAs compared to propensity weighted persons who are not prescribed these medications. In summary, as GLP-1 RAs are increasingly prescribed to aging adults, our studies will provide essential data to better understand the risk/benefit profile of these medications in a real- world setting.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY/ABSTRACT The overdiagnosis of thyroid cancer, primarily driven by the detection of small, asymptomatic papillary thyroid cancers, imposes significant medical and financial burdens. Despite low mortality, patients often undergo unnecessary treatments, facing risks such as surgical complications and financial distress. By 2030, the annual cost of thyroid cancer care is projected to reach $3.5 billion. One key factor in thyroid nodule detection is the reporting of incidental thyroid nodules (ITNs) during imaging for non-thyroid-related concerns. ITNs appear in 10–20% of chest and neck imaging reports. With nearly 80 million computer tomographies, magnetic resonance, and other similar images performed annually in the US, millions of patients risk entering a diagnostic cascade leading to potential thyroid cancer overdiagnosis. Despite the link between increased imaging and ITNs in radiology reports, there is a substantial knowledge gap regarding the clinical outcomes of ITNs and the factors influencing their workup. Additionally, there are no standardized criteria for the appropriate evaluation of reported ITNs, hindering efforts to mitigate overdiagnosis. This project aims to reduce the unnecessary medical and financial consequences of thyroid cancer overdiagnosis. In Aim 1, we will focus on developing, externally validating, and comparing two artificial intelligence (AI) and natural language processing (NLP)-enhanced systems to identify and characterize ITNs. Using Mayo Clinic Network data, we have developed a high- performing named entity recognition (NER) system with 97% accuracy and an F1 score of 0.95 to identify ITNs and their characteristics in imaging reports. We will explore strategies to adapt large language models (LLMs) for NER, including prompting techniques, and evaluate the resilience of the models under dataset perturbations and varied report formats. Finally, the AI-NLP system will undergo external validation at the University of Florida Health Network with 4 regional sites. In Aim 2, we will deploy the NLP-enhanced AI tool for ITN identification and characterization in three large healthcare systems, including 15 regional sites representing real-world practice. We will determine the frequency of ITNs, the proportion of patients undergoing further diagnostic procedures, and the patient, clinician, practice, and ITN report factors influencing the workup and outcomes. In Aim 3, we will engage stakeholders—including patients, clinicians, and health system representatives—using a Delphi approach to develop a pathway for assessing ITN workup appropriateness. This study will validate an AI-assisted algorithm for identifying and describing ITNs across diverse imaging settings and establish guidelines to optimize ITN evaluation. The findings will support interventions to reduce low-value workups and address thyroid cancer overdiagnosis. This proposal aligns with NOT-CA-22-037 by validating an NLP-enhanced ITN identification algorithm and improving thyroid cancer overdiagnosis.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY/ABSTRACT Acute kidney injury (AKI) is an abrupt loss of kidney function that affects 1 in 5 hospitalized patients. AKI survivors experience a 1.5-2.5-fold higher risk of chronic kidney disease (CKD), a 1.4-fold higher risk of cardiovascular disease, and 50% of affected individuals are readmitted within 1 year. Despite these grave sequelae, the care of non-dialysis-dependent AKI survivors is inadequate. One-third of patients fail to receive basic kidney health follow-up (i.e., laboratory assessment of kidney function and a visit with a clinician). 87% of AKI survivors use nephrotoxic medications in the 3 years after discharge, which independently increases the risk for CKD. These gaps are especially prominent in the 20% of AKI survivors from rural settings who experience health disparities including transportation barriers, a higher comorbidity burden, decreased health literacy, and reduced access to nephrology specialist care. Addressing these gaps in care facilitates prognostication, decision making, medication reconciliation and supportive care which can limit AKI complications. We therefore developed the AKI in Care Transitions (ACT) program, a multidisciplinary bundled care delivery model tailored to individual prognosis. AKI survivors are risk-stratified according to post-discharge prognosis. Those at the lowest risk are provided access to informational resources about AKI. Patients at moderate risk receive kidney health education before discharge from nurses and coordinated follow-up in primary care with a provider and a pharmacist in the 7-14 days after discharge. The highest-risk patients are provided with home monitoring technology (e.g., blood pressure cuff, tablet for symptom assessments) and followed remotely by nephrology specialists for up to 90 days. Pilot testing in an academic medical center demonstrated feasibility, a significant increase in timely and complete follow-up, improved medication reconciliation, and a decreased incidence of kidney disease progression. This proposal extends ACT to rural settings to address the overall goal of creating effective, patient-centered, scalable care delivery models that improve health outcomes for all AKI survivors. We will test the impact of ACT on health outcomes and processes of care (e.g., kidney disease progression, excess days in acute care, adverse drug events, guideline-concordant care) in rural patients using a pragmatic cluster randomized trial conducted in the Mayo Clinic Health System (MCHS; Aim 1). We will then richly characterize the rural AKI survivor experience including illness burden, treatment burden, and patient capacity (Aim 2a) and assess the impact of ACT (Aim 2b) using qualitative data gathered from rural patients at MCHS and the University of Maryland Medical System. This innovative proposal leverages digital health and the multidisciplinary team to improve outcomes and reduce health disparities for AKI survivors in rural settings.

NIH Research Projects · FY 2026 · 2026-03

PROJECT SUMMARY/ABSTRACT Metabolic dysfunction-associated steatotic liver disease (MASLD) affects over 30% of the US population and has been identified as a leading cause of type II diabetes, hepatocellular carcinoma, and is now the most prevalent disease leading to liver transplantation. A defining feature of MASLD is the accumulation of unique triglyceride-rich organelles called lipid droplets (LDs). Understanding the fundamental mechanisms that regulate the hepatocellular storage, breakdown, and catabolism of LDs is essential to effectively prevent, reduce, and treat MASLD and is the focus of this proposal. Significant evidence, based on our work and others, implicates the selective targeting and breakdown of hepatic LDs by the autophagic machinery during a process called lipophagy. We recently identified a novel autophagic process termed “microlipophagy” (MiLi) by which lysosomes fuse, engulf, and degrade LDs directly. Our evidence indicates that MiLi is the predominant mechanism by which the hepatocyte catabolizes LDs. We also found that macropinocytosis (MP; “large cellular drinking”) plays a significant role in regulating hepatocellular lipid stores by forming large macropinosomes from the plasmalemma that traffic into the cell to mediate LD-lysosome fusion. We have demonstrated that important components of these essential cellular processes are large and small GTPases. These include the Ras-like Rab GTPases that control nearly all membrane-trafficking processes in the hepatocyte while the dynamin (Dyn2) family of large GTPase mechanoenzymes mediate membrane scission/fusion throughout the cell. Further, we have compelling evidence that this MiLi process occurs at the ER surface to catabolize nascent LDs as they form. Equally exciting to us is our finding that Mayo patients with MASLD possess mutant variants of these proteins that cause hepatocellular steatosis in culture. From these observations, the central hypothesis of this proposal predicts that together the MP and MiLi processes play a central role in hepatocellular lipid catabolism and are both supported and regulated by the synergistic actions of specific Rabs (Rab8a/10) and Dyn2 GTPases, which are altered and disrupted during steatosis. The strategy of this proposal utilizes state of the art hepatocellular imaging approaches, coupled with electron microscopy, molecular methods, and membrane biochemistry. This is correlated with data gleaned from patients, and 4 distinct and novel conditional knock out mouse models we have designed. Aim 1 will define the physiological contributions of MP to hepatocellular lipid stores and steatosis by testing how MP drives MiLi via a novel protein complex of Rab 8a/10, the large GTPase Dyn2, and a new endocytic adapter (SH3D19) we have identified. Aim 2 will define the mechanisms of a novel process we have observed that is focused on lysosomal targeting and catabolism of nascent LDs at the ER as they form that utilizes the actin cytoskeleton and ER-phagy/autophagy receptors. Completion of these studies will provide valuable insights into hepatocellular lipid metabolism, the underlying basis for hepatic steatosis, and potential novel strategies for therapeutic intervention in MASLD.

NIH Research Projects · FY 2026 · 2026-02

Abstract T cells can kill infected and tumor cells using perforin and FAS ligand, and both methods require direct contact ensuring only the infected target is killed. However, this approach is inefficient, as T cells can only kill one cell at a time. To counter fast replicating pathogens, T cells must possess a way to kill many infected cells at once, which can be carried out by diffusible cytokines. This paracrine killing requires a target specificity mechanism to ensure that only infected cells are killed by the cytokines while uninfected cells are spared. This can be achieved by endowing all cells with mechanisms that prevent the cytokines from inducing cell death, and to embed these death-resistance mechanisms within signaling molecules required for antimicrobial defense. Hence in uninfected cells, exposure to the cytokines is non-lethal. However, if a cell is infected and the pathogen disables the antimicrobial pathway, it also disables the death-resisting mechanisms. Exposure to the cytokine is now lethal and we termed this ‘pathogen-restriction.’ Using the B16 F1 tumor as a model target, we showed that T cells can use IFNg for paracrine killing of target cells, but susceptibility to this killing is regulated by two related kinases, TBK1 and IKKe. These kinases are central to antimicrobial defense – they are required for expression of antiviral type I IFN and autophagic degradation of intracellular microbes. In B16 target cells missing the two kinases, IFNg produced by T cells causes these tumor cells to undergo apoptosis, concurrent with hyperexpression of NFkB- dependent inflammatory genes. Proteomic studies revealed that in TBK1/IKKe-deficient cells, defective phosphorylation was found on several selective autophagy receptors (SARs). SARs function to bind to ubiquitin markers on damaged mitochondria, invading bacteria, and protein aggregates to shuttle these cargoes to the engulfing autophagosome for degradation. It is unclear how all these multiple roles of TBK1/IKKe are connected. To integrate these multiple roles, we hypothesize that TBK1/IKKe-mediated phosphorylation of SARs functions in aggrephagy of large ubiquitinated RIPK1 signaling complexes and when this is disrupted by loss of TBK1/IKKe, undissolved RIPK1-signaling complexes continue to activate cell death and NFkB signaling. Our understanding of how RIPK1 signaling complexes are disassembled to return cells to homeostasis remains incomplete. This issue is more fraught with RIPK1 because receptor-activated RIPK1 also has the capacity to induce cell death. Therefore, the dissolution mechanism must remove that threat as well unless there is a reason for the death to occur. In Aim 1, we will examine if receptor-activated RIPK1 signaling complexes are dismantled by TBK1/IKKe- regulated aggrephagy, and test if inhibiting this process leads to RIPK1-mediated cell death and hyperactivation of NFkB. We also postulated that there is a teleological reason for placing TBK1/IKKe within this dissolution process, which is as a pathogen-restriction mechanism to ensure that only infected cells are killed in a paracrine manner by T cells. This will be tested in Aim 2 with viruses encoding TBK1/IKKe inhibitors. We will also test whether this mechanism can be exploited to enhance tumor cell killing by T cells in immunotherapy.

NIH Research Projects · FY 2026 · 2026-02

PROJECT SUMMARY Mild autonomous cortisol secretion (MACS) is diagnosed in up to 44% of patients with adrenal adenomas, affecting 1-2% of the adult population. MACS is diagnosed based on an abnormal cortisol level following dexamethasone suppression (>1.8 mcg/dL). Patients with MACS develop high rates of cardiovascular morbidity and demonstrate increased mortality. In our preliminary data we showed that patients with MACS have an abnormal steroid metabolome and circadian cortisol secretion, findings similar to what occurs with normal aging. We also found that patients with MACS demonstrate increased markers of inflammation and senescence, have increased cardiovascular morbidity, frailty, and mortality. Metyrapone is a short-acting steroidogenesis inhibitor that is FDA approved for diagnosis of adrenal insufficiency. In our pilot open-label study, we show that when administered overnight in patients with MACS, metyrapone is safe and effective in normalizing hypothalamic-pituitary-adrenal communication. We propose to conduct a randomized double-blinded placebo-controlled trial of overnight metyrapone intervention in patients with MACS. In Aim 1, we will determine safety and tolerance of overnight metyrapone over 12 months of therapy. In Aim 2, we will determine the impact of overnight metyrapone on adrenal steroid metabolome and circadian cortisol secretion. In Aim 3, we will determine the impact of overnight metyrapone on metabolic outcomes and frailty, as well exploratory outcomes, such as cognition and senescence biomarkers. Results of the proposed studies will advance our understanding of how subtle cortisol excess impacts health and test the hypothesis that adverse health outcomes associated with MACS are reversible with therapy.

NIH Research Projects · FY 2026 · 2026-02

PROJECT ABSTRACT There is a growing epidemic of immune-mediated diseases affecting pediatric populations. Candida albicans is an opportunistic fungal species that is habitually found as part of the microbiota in humans, particularly as part of a “dysbiotic” perturbed microbiota associated with increased immune-mediate inflammation disease. Clinical observations have found a strong association with C. albicans and inflammatory diseases, though it is unclear if C. albicans initiates inflammation in an already at-risk atopic individual through acute infection, or can directly influence the development of immune responses. C. Albicans can reside within the intestinal microbiota, and exposure to C. albicans in both human and mice results in the anti-C. albicans immunoglobulins, suggesting an antigen specific immune response. This project will ask how intestinal exposure to C. albicans in early life influences the developing immune system, specifically the T cell responses. Fungal species, including C. albicans induce T cell responses that produce the inflammatory cytokine IL-17, also referred to as T helper 17 cells (Th17), and presence of fungal species can induce further microbial dysbiosis within the intestinal microbiota. It is unknown whether the Th17 cells are responding to the C. albicans or dysbiotic bacterial species in the perturbed microbiota. Additionally, animal studies of C. albicans are hampered by a decreased ability to colonize the adult murine intestinal microbiota with C. albicans without antibiotic perturbation. We have developed a model of neonatal C. albicans acquisition where oral administration of C. albicans between postnatal day 7 and 10 results in stable, robust C. albicans colonization, which is associated with microbial dysbiosis, increase in systemic IL17, increase in Th17 cells in the intestine, and disrupted regulatory T cells. To expand upon these findings, we will 1) evaluate the requirement of goblet cell-associated antigen passages in the induction of a lasting IL-17 response during early life, to assess how intestinal antigens inducing IL-17 responses are introduced to the intestinal immune system following C. albicans colonization. Next, we will 2) evaluate the ability of C. albicans to induce specific Th17 cells and increase pathology during psoriasis using tetramers for C. albicans specific cells, and a chemical-contact model of dermatitis. Through these aims we will mechanistically connect preliminary data from our novel animal model to immune perturbations following C. albicans colonization. Following the completion of this project, we will understand the nature of the antigens initiating Th17 cell responses and have a robust platform to assess the consequence of increased Th17 cells and inflammatory responses following C. albicans colonization. This work has important implications in understanding dysbiosis and microbial imprinting of the immune system in early life.

NIH Research Projects · FY 2026 · 2026-02

Project Summary/Abstract While heart transplantation is the gold standard to treat patients with end-stage heart failure, there is a shortage of donor hearts for recipients. However, many donor hearts on offer are not accepted for transplant. This can be for multiple reasons, but the risk of primary graft dysfunction (PGD) is a major factor in turning down donor hearts. Unfortunately, older donors are associated with a higher incidence of PGD19, and hearts from donors >55 years of age are often not considered for the transplant. In 2024, only 303 hearts from a total of 6608 donors > 50 years were used for transplantation. Therefore, there is a large potential donor pool that exists beyond the traditional age threshold for donor heart acceptance. Expanding our molecular understanding of aging biology in determining donor heart preservation quality is needed to fully utilize the potential donor heart pool. Brd4 is a member of the bromodomain and extraterminal domain (BET) family of epigenetic readers. It plays an important role in many cardiac diseases, such as cardiac hypertrophy and coronary atherosclerosis. Brd4 interacts with numerous factors that regulate transcription, histone modification, chromatin accessibility and architecture. We show that in-vivo inhibition of Brd4 by JQ1 or Brd4 knockdown in cardiomyocytes greatly improves ex-vivo old donor heart function after preservation-reperfusion, similar to that of young donor hearts. We also demonstrate that the BRD4-associated chromatin loop increased in the old human donor heart compared to young hearts, which is further elevated after cold preservation-reperfusion injury. Moreover, we found that the increased Brd4 genomic recruitment is associated with increased histone acetylation due to reduced NAD+ levels in old donor hearts. We hypothesize that Brd4 senses the histone acetylation increase in aging hearts and modulates genomic architectural restructuring that promotes cardiac injury. In Aim 1, we will determine the mechanism by which Brd4 modulates the epigenetic landscape of old donor hearts during preservation. We will define Brd4’s role in influencing the cardiac function of cold- preserved old donor hearts as well as the specific epigenetic architectural changes in young and old donor hearts during preservation. In Aim 2, we will determine if increased Brd4 recruitment to the genome of old donor hearts is mediated by increased histone acetylation due to changes in NAD+ availability. In Aim 3, we will determine if pharmacological BRD4 inhibition improves old human donor heart preservation quality. The proposed work will define Brd4's mechanism of modulating epigenetic and 3D chromatin conformation to promote the vulnerability of old donor hearts to preservation injury. This is expected to expand the donor pool and has broad implications for other solid organ transplants and ischemic pathologies like heart attack and stroke.

NIH Research Projects · FY 2025 · 2025-09

Project Summary Cardiovascular disease (CVD) has remained the leading cause of death in the United States for over a century. Underlying CVD is atherosclerosis, a pathogenic lipid-driven and chronic inflammatory response. Lipid buildup leads to plaque formation and artery stenosis, presenting clinically as myocardial infarction, cerebrovascular disease, peripheral arterial disease, and aortic aneurysm. In preliminary studies, we show through an integrated atheroma-derived single-cell RNA sequencing (scRNA-seq) analysis that immune cells, most of which are T cells and macrophages (Mφ), dominate the atherosclerotic milieu. Further analysis revealed five distinct Mφ subpopulations, including one showing upregulation of lipid-associated genes. Examination of this lipid- associated Mφ (LAM) demonstrated marked upregulation of bioenergetic processes. However, specialization of metabolic processing and lipid clearance came at the expense of core Mφ functions such as antigen presentation and cytokine production. Comparing LAMs to in vitro lipid-loaded Mφ confirmed that lipid feeding polarized Mφ towards the LAM phenotype. Epidemiologic data indicated that high LAM scores in the carotid atheroma placed patients at higher risk for future ischemic events, suggesting that LAMs play a pro-inflammatory and tissue- destructive role. Assessment of in vitro lipid-loaded Mφ revealed that lipid challenge increased production of extracellular adenosine triphosphate (eATP), a pro-inflammatory metabolite. Based on these data, we hypothesize that LAMs, under lipid-dependent metabolic overload, release ATP into the tissue microenvironment and utilize this metabolite as a signaling molecule to regulate surrounding Mφ. In pursuit of this hypothesis, we will execute the following aims. In Aim 1, we will characterize the effects of lipid loading on the metabolic landscape and cell fate decisions of atheroma-derived macrophages. Employing an in vitro human Mφ model, we will identify CVD-specific Mφ population enrichment, lipid-induced trajectory shifts, and gene regulatory networks with paired single-nucleus RNA-seq and scATAC-seq multi-omic analysis. We will also assess for lipid-induced bioenergetic perturbations at the bulk and single-cell level. In parallel, we will execute comprehensive analyses (e.g. phagocytosis, antigen presentation) to create a LAM functional atlas. In Aim 2, we will investigate how LAMs exacerbate plaque inflammation by controlling the function of neighboring macrophage subpopulations. Here, we will lipid load Mφ, assess for steady-state eATP production, and determine efflux kinetics. We will also develop a comprehensive understanding of how eATP affects atheroma- derived Mφ subsets by assessing for differential eATP-induced responses (e.g. inflammasome activation) in faithfully reproduced in vitro Mφ. To identify disease-specific responses, we will perform assays with CVD patient- and healthy control-derived Mφ. Ultimately, results from this proposal will clarify the link between dyslipidemia and atherosclerotic inflammation, allowing for novel diagnostic approaches and targeted CVD therapies.