Cincinnati Childrens Hosp Med Ctr

NIH Research Projects · FY 2025 · 2021-03

PROJECT SUMMARY / ABSTRACT More than one in five adolescents will experience a mental health disorder, including depression and anxiety, and the prevalence of these conditions is increasing. Among adolescents, depression and anxiety are linked to increased risk of suicide, a leading cause of death in this age group. Identifying underlying and modifiable contributors to these conditions is crucial as current research and interventions focus on screening and treatment rather than prevention. Here, we posit that air pollution, in addition to genetic susceptibility, social determinants, familial and school issues, and other factors, is a contributor to mental health disorders. Toxicological studies demonstrate that fine particulate matter (PM2.5) and traffic-related air pollution (TRAP) are neurotoxic, and epidemiologic studies consistently link these pollutants to reduced cognitive abilities and increased externalizing behaviors. However, few studies have prospectively evaluated the role of air pollution exposure on mental health disorders in childhood. Recently, we found that childhood air pollution exposure is associated with increased risk for depression and anxiety at age 12 years. However, the role of air pollution in the onset and persistence of mental health disorders during adolescence, and changes in brain structure, organization, and function linked to these outcomes, remain poorly understood. Therefore, we hypothesize that exposure to air pollution during critical periods of brain development, including adolescence, is associated with adverse mental health outcomes. We will leverage existing longitudinal data from the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS) and the Health Outcomes and Measures of the Environment (HOME) Study, two prospective cohorts located in Cincinnati, Ohio, to address this hypothesis. Both cohorts have been followed from birth and evaluated with concordant measures of mental health and neuroimaging at age 12 years. We will conduct new follow-up at age 18 years to assess the onset and persistence of mental health outcomes through adolescence and apply validated models for PM2.5 and TRAP to characterize air pollution exposure from conception through age 18 years. We will also acquire novel neuroimaging outcomes, including brain -aminobutyric acid and glutathione concentrations accompanied by anatomical and functional magnetic resonance imaging. Our aims are to: 1) determine the association between exposure to PM2.5 and TRAP during distinct developmental periods and the onset and persistence of mental health outcomes in adolescence; 2) determine the association between exposure to PM2.5 and TRAP during distinct developmental periods and neuroimaging outcomes in late adolescence; and 3) determine whether changes in brain volume, organization, metabolism, and function mediate associations between PM2.5 and TRAP exposure and mental health outcomes. Examining air pollution as a novel and modifiable risk factor will provide critical data to guide primary prevention aimed at reducing the burden of mental health disorders in adolescence.

NIH Research Projects · FY 2025 · 2021-02

Cystic fibrosis (CF) is among the most common fatal genetic diseases in the U.S. and involves progressive lung function loss and structural remodeling, leading to lung transplant or death. Though life expectancy in CF patients has increased due to improved treatments, pathological changes still occur within the first year of life. It has been difficult to detect these early changes, because conventional measures of lung function such as spirometry (e.g., forced expiratory volume in 1 second, FEV1) are lagging indicators and insensitive to early disease. In contrast, ultra-short echo-time (UTE) and hyperpolarized (HP) 129Xe MRI can detect pathology years before FEV1. Addi- tionally, proteomic biomarkers from high-precisions mass spectrometry (MS), when coupled with modeling based on Functional Data (FD) analysis, accurately forecast CF lung disease progression. However, these biomarkers have only been validated in patients with established disease. The long-term goal of this research is to validate proteomic markers that detect and predict lung function decline and structural remodeling in early lung disease. The objective of this application is to use state-of-the-art HP 129Xe and UTE MRI to validate proteomic markers in early CF. This will be accomplished using blood serum and clinically obtained bronchoalveolar lavage (BAL) fluid from CF patients with known lung pathology. Our central hypothesis is that image-guided proteomics can forecast pathophysiology before spirometric changes are observed. Our rationale is that, while 129Xe and UTE MRI are currently limited to specialized centers, MS proteomics can be performed on readily obtained clinical specimens, and translated with FD analysis into an easily disseminated tool to predict impending lung disease progression, and thus enable interventions before permanent lung damage occurs. Guided by combined MRI and proteomic data and the utility of FD analysis to predict lung function decline, our central hypothesis will be tested by completing the following Specific Aims: 1) Validate our predictive biomarkers in CF patients with normal spirometry but abnormal ventilation; 2) determine the sensitivity and specificity of systemic biomarkers in pre- dicting early structural re-modeling in CF lung disease; and 3) perform clinical bronchoscopy to identify molecular signatures of irreversible lung remodeling. We have developed the MRI sequences and reconstruction pipeline needed to complete the work. For Aims 1 & 2, we have used MRI and MS proteomics to identify key biomarkers to predict structural and functional abnormalities in CF. For Aim 3, we have used BAL proteomics to identify molecular changes at the pathway level in CF patients. The proposed research is innovative, because it will use cutting-edge imaging to validate molecular tools to assess early lung disease. These results will be significant, because they will produce an easily disseminated tool to predict permanent structural remodelling and irreversi- ble functional losses. This work will have an immediate positive impact by developing and translating non-inva- sive tests to identify CF patients at high risk of lung damage and intervene before irreversible changes occur. It will also provide a unique platform to assess pathological progression in a wide range of lung diseases.

NIH Research Projects · FY 2025 · 2021-02

PROJECT SUMMARY/ABSTRACT Cystic fibrosis (CF) is a lethal genetic disorder characterized by progressive lung disease and airway obstruction. CF is caused by mutations in the CF transmembrane conductance regulator (CFTR). Patients with CF often develop airway hyperresponsiveness (AHR) related to smooth muscle dysfunction, which worsens airway obstruction and portends faster lung function decline. TGF is a genetic modifier of CF, with higher TGF levels linked to more severe lung disease. TGF also causes worse AHR and smooth muscle abnormalities in CF mice versus non-CF mice. It is unknown how TGF modifies CF lung disease or drives CF smooth muscle dysfunction. This proposal seeks to investigate TGF’s role in CF airway smooth muscle dysfunction. Currently, no therapies directly target smooth muscle abnormalities or TGF signaling in CF. This proposal investigates the overall hypothesis that TGF regulates CFTR-mediated airway smooth muscle dysfunction through effects on both CF epithelial and smooth muscle cells. CF animal and mouse/human primary cell culture models will be used to test the tissue specific function of CFTR in TGF induced lung disease. Aim 1 will determine the role of CFTR dysfunction in airway epithelial cells in mediating TGF-driven lung disease, using TGF exposed epithelial- specific Cftr knockout mice and primary murine and human cell culture models. These studies will focus on epithelial and inflammatory mediators. Aim 2 will test the mechanisms of TGF-induced CF airway smooth muscle dysfunction by examining pulmonary and smooth muscle abnormalities in both smooth muscle-specific Cftr knockout mice and isolated murine and human CF cell culture models. Tests of TGF-mediated AHR, lung function, and smooth muscle contractility will be used to compare CF and non-CF airway smooth muscle function. The PI for this proposal, Dr. Elizabeth Kramer, is a physician scientist in Pulmonary Medicine with a focus on drivers of early CF lung disease. She has a Ph.D. in Molecular and Developmental Biology and an extensive background in mouse models and lung physiology. Her mentors provide complimentary expertise in CF mouse and cell culture models (Dr. A.P. Naren, primary mentor), translational CF research and personalized medicine (Dr. J.P. Clancy, Co-mentor), and translational research design (Dr. Raouf Amin, Co-mentor). These mentors have an established record of success in mentoring academic scientists. They are personally committed to Dr. Kramer’s success in completing this proposal and transitioning to an independent research career. The training plan outlined in this application will provide the applicant with crucial training in innovative laboratory techniques, cutting-edge bioinformatics analysis, immunology, and advanced career skills to successfully establish an independent translational science program. This training plan capitalizes on the excellent environment and support at Cincinnati Children’s Hospital. Addressing these training goals and completing the studies described in this application will build upon Dr. Kramer’s prior expertise in molecular and developmental biology, providing a solid scientific and training platform to launch her independent research career.

NIH Research Projects · FY 2025 · 2021-01

PROJECT SUMMARY Myelodysplastic Syndromes (MDS) are a cancer of the hematopoietic stem cell (HSC) on the rise in the aging population and cancer survivors. The only curative treatment for MDS is allogeneic stem cell transplantation with marked limitations in the majority of MDS patients. As a result, standard-of-care focuses on hypomethylating agents (HMA) azacytidine (AZA) and decitabine (DAC), which invariably result in resistance and disease progression. There is a dire need for new therapeutics; however, there are no robust models of MDS to accelerate preclinical testing. We have generated a breakthrough humanized xenograft-recipient mouse model which eliminates conditioning and facilitates engraftment of primary MDS. We will validate the model by single-cell genetic and genomic characterization of diagnostic MDS patient material before therapy and of the same cells engrafted in humanized mice, clearly dellineating the transcriptional impact of xenografting. Next, we will establish pharmacodynamic endpoints for AZA within the mouse model and apply the empirically-derived dose of AZA to the model. Human MDS material will be captured for single cell analyses post-AZA therapy from both patients and xenografts. The multi-omics comparative analyses will incisively determine the utility of MISTRG-W41 for MDS preclinical testing, by illustrating the extent to which AZA-affected programs in patients are similarly changed in the xenograft. This deep molecular, genotypic, and phenotypic understanding of HMA effects on subclonal and hierarchical cellular compositions of MDS will build the basis for comparison of novel-targeted-therapeutic agents as alternatives, concurrent, or post-HMA therapeutic approaches.

NIH Research Projects · FY 2025 · 2020-12

PROJECT SUMMARY/ABSTRACT Sluggish cognitive tempo (SCT) is a set of behavioral symptoms characterized by excessive daydreaming, slowed thinking, and mental confusion and fogginess. It is now established that SCT can be reliably measured across parent, teacher, and self-report ratings and is distinct from other psychopathology dimensions including ADHD and internalizing symptoms. A rapidly growing body of research also demonstrates SCT to be strongly associated with functional impairment, above and beyond other psychopathologies. However, SCT remains absent from current models of psychopathology, in large part because the field lacks rigorous longitudinal research examining SCT in relation to other psychopathologies. In cross-sectional studies, SCT symptoms are consistently and strongly associated with internalizing symptoms. Preliminary findings also document associations between SCT and increased suicide risk. Importantly, our pilot data show SCT predicts increased internalizing symptoms rather than the reverse. Further, SCT symptoms uniquely predict internalizing problems and not externalizing behaviors, suggesting that SCT may be a unique factor in understanding the development of internalizing problems specifically. Yet studies linking SCT to internalizing symptoms in youth are limited in several ways, including: (a) use of cross-sectional designs that preclude establishment of temporal associations, (b) using convenience samples (e.g., ADHD) rather than a sample enriched for SCT specifically, (c) failing to examine possible mechanisms or vulnerabilities linking SCT to internalizing symptoms, and (d) focusing on school-aged children even though SCT symptoms and internalizing problems sharply increase in adolescence. This study will address these limitations by using a prospective longitudinal, multi-informant, multi-method design across the developmentally sensitive period of early adolescence to examine SCT symptoms as a predictor of diverse internalizing outcomes and to test mechanisms and vulnerabilities linking SCT to internalizing symptoms in a community sample enriched for SCT symptomatology. Specifically, a community-based sample of 330 young adolescents (ages 10-12 years) enriched for SCT symptomatology will be recruited and assessed at three timepoints one year apart. Consistent with the NIMH Research Domain Criteria (RDoC) initiative and a developmental psychopathology framework, a multi-informant, multi-method battery that cuts across physiological, behavioral, and self-report units of analysis will be used. We will examine dimensional SCT symptoms as a predictor of internalizing psychopathology change over time, test mechanisms of the longitudinal relation between SCT and internalizing psychopathologies, and explore vulnerabilities (physiological reactivity, punishment sensitivity) that exacerbate these longitudinal relations. Findings establishing longitudinal effects and identifying mechanisms and vulnerabilities that cut across units of analysis will advance the development of theoretical models of SCT. Findings from this study will also provide avenues for targeted clinical assessment and treatment.

NIH Research Projects · FY 2025 · 2020-12

PROJECT SUMMARY/ABSTRACT I am a developmental-behavioral pediatrician who has earned an MS in Clinical Research. My long-term goal is to become an independent researcher focused on advancing developmental-behavioral outcomes of children from diverse, underserved groups by improving their adherence to treatment plans for mental health conditions, including attention-deficit hyperactivity disorder (ADHD). My current objective, which represents the next step in pursuit of this goal, is to develop a culturally-tailored family navigator Intervention to Improve ADHD-Related Treatment adherence (I2-ART) for minority children using a systematic, patient-centered, iterative approach consistent with the ORBIT model for behavioral intervention development. Key elements of the career development plan to support both my long-term goal and current objective include training in (1) the design and evaluation of clinical and mental health services trials to improve treatment adherence, (2) health disparities and community-partnered research, and (3) effective grant and manuscript writing. My mentorship team includes NIH-funded investigators with expertise in ADHD, clinical trial design, treatment adherence, health disparities, and community-partnership research. Furthermore, Cincinnati Children’s Hospital, which ranks #2 among U.S. children’s hospitals for NIH funding, provides an outstanding research environment and strong support for junior faculty, including >30 current recipients of NIH Career Development Awards. Proposed Research: ADHD is the most common pediatric neurodevelopmental disorder and is associated with significant long-term impairments. Current guidelines recommend stimulant medication and/or behavioral therapy as first-line treatments for ADHD. Despite evidence that consistent treatment is important for effectively managing ADHD symptoms, treatment adherence remains suboptimal and is especially problematic among minority children. Hypothesized reasons for racial/ethnic disparities in ADHD treatment include uncertainties about medication efficacy and side effects, distrust of the health care system, and decreased access to mental health services. This study aims to develop and test the I2-ART intervention to improve treatment adherence in minority (Latinx and African American) children with ADHD. The proposed study involves three ORBIT phases: During phase 1a, we will conduct focus groups with key stakeholders (i.e., caregivers, clinicians, and family navigators, n=24) to identify and develop I2-ART’s basic elements. Next, during phase 1b, we will train four family navigators to implement I2-ART with caregivers of treatment-naïve children with ADHD (n=8-12) in order to determine feasibility and acceptability. In phase 2, we will use phase 1b findings to modify I2-ART as needed, and then will evaluate the preliminary efficacy of the revised I2-ART (n=40), compared to the “usual care” control condition (n=20), on ADHD treatment adherence. The preliminary data collected during the proposed study will inform a subsequent R01 randomized controlled trial to examine I2-ART efficacy.

NIH Research Projects · FY 2024 · 2020-09

Abstract: While great deal is understood about mechanisms of sensory transduction from the skin, relatively little is known about this process from the muscles. As peripheral injuries resulting from repetitive ischemic/reperfusion (I/R) are a major health issue that affects millions of people in the United States, this gap in knowledge precludes us from identifying specific therapies for muscle pain or altered cardiovascular responses to exercise in the context of ischemia. Peripheral I/R occurs in blood disorders such as sickle cell disease, and in cardiovascular disorders such as peripheral vascular disease. Males and females display different features of myalgia and exercise pressor reflexes (EPRs) under conditions of reduced peripheral perfusion. The major goal of this study is to determine the sex specific molecular mechanisms of muscle afferent sensitization that may underlie the transition from acute to chronic ischemic myalgia. Pilot data in murine models of repetitive I/R injury suggest that peripheral sensitization in males is regulated by increased DRG gene expression that is modulated by glial cell line-derived neurotrophic factor (GDNF) family receptor 1 (GFR1) in muscle nociceptors. In females, afferent sensitization, pain-related behaviors and altered EPRs after repeated I/R injury may be regulated by increased interleukin 1 receptor type 1 (IL1r1) dependent gene expression. We hypothesize that the prolonged effects of successive I/R injuries are mediated by GDNF related peripheral sensitization in males and IL1 induced sensitization in females. Aim 1 will determine if myofiber produced GDNF and DRG upregulation of GFR1, regulate the observed changes in muscle afferent response properties, pain-related behaviors and altered EPRs after dual I/R in males. We will use muscle fiber specific GDNF ablation or our novel in vivo siRNA-mediated knockdown of genes in single peripheral nerves in conjunction with our ex vivo muscle afferent recording preparations or assays of pain-like behaviors and EPRs. Aim 2 will utilize a similar approach except we will determine if macrophage produced IL1 or DRG upregulation of IL1r1, regulate the novel changes in female muscle afferents or behaviors after successive I/R. Finally, Aim 3 will use ex vivo recording and pain-related behavioral analyses to determine if expression differences in AU-rich element RNA-binding protein 1 (AUF1) or the ras family member, RAN, modulates the sex specific effects of successive I/R injuries between females versus males. Each of these aims will be complemented by analysis of DRG and muscle gene expression. The studies outlined here will also provide a novel direction in muscle neurobiology research that will go well beyond the incremental expansion of current reports. Results will enable us to identify unique sex dependent mechanisms associated with muscle afferent sensitization that underlie acute to chronic ischemic myalgia development after I/R injury. This may lead to the formulation of more appropriate treatments for musculoskeletal pain or altered EPRs associated with ischemia/ reperfusion that target the proper receptor(s), primary afferent subpopulation(s) or peripheral target tissues.

NIH Research Projects · FY 2024 · 2020-09

Over the last six years our project teams have demonstrated that neurophysiology abnormalities are conserved across mice and humans in fragile X syndrome (FXS). These findings across species provide a great opportunity to advance mechanistic understanding of clinically relevant illness features and develop translational biomarkers and aid treatment discovery. These advances can bridge the significant chasm between preclinical and clinical success in new treatment development. We take mechanistic approaches to determining the drivers of neurophysiology dysregulation across three integrated projects spanning human, in vivo, and ex vivo mouse study. This allows for levels of analysis from whole brain network modeling to microcircuit and molecular analysis to aid target discovery while improving translational medicine efforts in FXS. In doing this we place emphasis on recognizing heterogeneity within FXS and using this understanding to model how to best interpret and link preclinical and clinical study. Out of this appreciation of the challenges to translational efforts in our field, we have developed a synchronized approach to the analysis and interpretation of neurophysiology data ensuring comparable results across research platforms. The striking consistency of findings across levels of investigation and species offers an unprecedented opportunity to investigate mechanisms of brain dysfunction across mouse and human study thus significantly improving opportunities for translational medicine development in FXS- a multidisciplinary mission that is ideal for a Center environment. Project 1 (Erickson/Sweeney; Cincinnati) will conduct human FXS neurophysiology, behavior, and pharmacological probe studies to pursue advanced neurophysiology modeling of cortical hyperexcitability and abnormal response to stimuli while also seeking to resolve heterogeneity across FXS in humans. Project 2 (Binder/Razak; Riverside) will develop translational neurophysiological biomarkers for FXS in the Fmr1 KO mouse using both surface and depth multi-electrode array technology. Project 3 (Huber/Gibson, UTSW) will investigate the microcircuit and molecular mechanisms of neurophysiologic dysregulation in the Fmr1 KO mouse. All Projects will examine candidate mechanisms of neurophysiologic dysregulation with a pharmacological probe strategy to test mechanisms of interest in parallel studies of mice and patients.

NIH Research Projects · FY 2024 · 2020-09

Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent neurodevelopmental psychiatric disorder (9.4% prevalence in children; 4.4% in adults) and is polygenic. A novel gene associated with ADHD is Latrophilin-3 found in striatum, hippocampus, cerebellum, prefrontal cortex (PFC), and amygdala. In humans, there are 21 variants of LPHN3 associated with ADHD. Some pesticides may interact with ADHD genetic risk factors to trigger or exacerbate the symptoms. We found that the common pyrethroid, deltamethrin (DLM), administered prior to weaning in rats causes long-term behavioral, neurochemical, and electrophysiological effects. We developed the first KO rats of Lphn3. Lphn3 KO rats are hyperactive, hyper-reactive to startle stimuli, and cognitively impaired. This PAR-19-386 “Environmental Risks for Psychiatric Disorders: Biological Basis of Pathophysiology” seeks models that will elucidate Gene x Environment interactions related to neuropsychiatric disorders, such as ADHD. We hypothesize that Lphn3-/- and Lphn3+/- rats will interact with DLM (Type II pyrethroid) or permethrin (PRM, Type I pyrethroid) to exacerbate an ADHD-like phenotype. Specific Aim 1: Determine the effects of DLM in Lphn3-/-, Lphn3+/-, and wildtype (WT) rats on activity, reactivity, learning and memory (L&M), dopamine (DA) and NMDA markers, and apoptosis. Aim-1a: Compare WT rats with Lphn3-/- and Lphn3+/- rats administered 0, 0.5, or 2.0 mg/kg DLM from P3-20 for changes in activity, acoustic and tactile startle (including prepulse inhibition (PPI)) egocentric, allocentric, and working L&M, and for changes in DA and NMDA-R markers in various brain regions, including markers for programmed cell death. Aim-1b, neurochemical outcomes in rats not behaviorally tested. Specific Aim 2: Determine the effects of PRM in Lphn3-/-, Lphn3+/- rats vs. WT rats on the outcomes used in Aim-1. Aim-2a: Same as Aim-1a with PRM. Aim-2b: Same as Aim-1b with PRM. Specific Aim 3: Determine the effects of DLM in adult Lphn3- /-, Lphn3+/- rats vs. WT rats. Aim-3a: same outcomes as in Aim-1a. Adults with ADHD are an understudied and a population susceptible for higher exposure to pyrethroids from occupational exposure, making Aims 3 and 4 important. Aim-3b: Same as Aim-1b in adult rats. Specific Aim 4: Determine the effects of PRM in adult Lphn3-/-, Lphn3+/- rats vs. WT rats. Aim-4a: Same outcomes used in Aim-1a. Aim-4b: Same as Aim-1b in adult rats not behaviorally tested. Impact: ADHD interferes with normal development, costs billions to treat and manage, yet we know little about environmental contributions to those with ADHD. Insecticides are suspected in ADHD but such interactions between gene and environment are not established. Lphn3-/- and Lphn3+/- rats represent a novel approach to probing the effects of exposure to pyrethroids using a known ADHD genetic susceptibility. The model will shed new light on how a gene known to be associated with ADHD affects the behavioral and biochemical effects of prototypical pyrethroids. Interaction data can be used for risk assessment and help provide safeguards against pyrethroid exposure for those with ADHD.

NIH Research Projects · FY 2024 · 2020-09

Abstract Frontonasal dysplasia (FND), also known as median cleft face syndrome, is a major class of craniofacial birth defects that profoundly impact the form and function of the face. FND patients require multiple corrective surgeries and often suffer life-long impairment. Whilst most FND cases occur sporadically with unknown etiology, loss-of-function mutations in each of the three ALX family genes, ALX1, ALX3, and ALX4, have been identified as the genetic causes for autosomal recessive FND, with disruption of ALX1 associated with severe facial clefting and extreme microphthalmia in FND3 patients while mutations in ALX3 and ALX4 resulted in milder but clinically distinctive frontonasal malformations. Little is known about how ALX transcription factors regulate craniofacial development, and the overall molecular mechanism controlling frontonasal development is poorly understood. In preliminary studies, we have generated Alx1 mutant mice using CRISPR-mediated genome editing and found that they recapitulated the FND3 phenotypes, including reduced frontonasal bones and cartilages, cleft palate, and microphthalmia. We found that Alx1-/- embryos exhibited ectopic neuroglial differentiation and reduction in ectomesenchymal gene expression in the frontonasal prominence. Moreover, Alx1-/-Alx4-/- double mutant mouse embryos exhibited increased ectopic cranial ganglia and much severer frontonasal deficiency than Alx1-/- mutants. Previous studies in multiple animal model systems revealed that the Twist1 transcription factor, whose expression is activated in cranial neural crest cells at the onset of migration, is critical for ectomesenchyme specification. Remarkably, while the molecular mechanism acting downstream of Twist1 in promoting ectomesenchymal fate is still unclear, Twist1-/- mouse embryos failed to activate the expression of all three Alx genes in cranial neural crest cells. Our finding of ectopic neuroglial differentiation in the frontonasal regions of Alx1-/- and Alx1-/-Alx4-/- embryos suggests that Twist1 and the ALX transcription factors act in the same molecular network to regulate cranial neural crest fate determination between the ectomesenchymal and neuroglial lineages. The specific aims of this research project are to determine the cellular and molecular mechanisms mediating ALX transcription factor function in frontonasal development and to unravel and reconstruct the gene regulatory network consisting of Twist1 and ALX transcription factors regulating cranial neural crest differentiation. Results from these studies will fill a longstanding critical gap in craniofacial developmental biology and lead to new improvements in molecular diagnosis and treatment/care of a large number of craniofacial disorders.

NIH Research Projects · FY 2024 · 2020-09

Patients treated with life-saving aminoglycoside (AG) antibiotics may experience adverse side effects of ototoxicity – permanent hearing loss and degraded speech communication. There are critical gaps in our understanding of individual susceptibility for ototoxicity, and access to effective tests that identify those at higher risk. The objective of this proposal is to determine the effect of AG antibiotics on auditory function in relation to individual measures of drug exposure in patients with cystic fibrosis. Our long-term goal is to design improved auditory monitoring protocols to prevent hearing deficits due to ototoxicity in patients taking AG antibiotics. This project will evaluate new methods to detect onset of ototoxicity using extended high frequency (EHF) tests of inner ear function – otoacoustic emissions (OAEs) and digits in noise (DIN), in relation to individualized pharmacokinetic/dynamic (PK/PD) measures of drug exposure. Cystic fibrosis (CF) is the most common life-threatening genetic disease and causes persistent lung infections in childhood that are frequently treated with AG antibiotics, thus is an important population to target for prevention of ototoxicity. This longitudinal observational study will include CF patients treated with AG antibiotic treatments, and control persons not treated with AGs, half of whom also have CF. Our hypothesis is that these newly developed auditory tests can detect ototoxicity early and are related to the PK/PD models. Further, we hypothesize that PK/PD models can predict risk for ototoxicity. Currently, most patients at risk are not monitored for ototoxic hearing loss, primarily due to lack of availability and awareness of early detection methods, as well as treatment alternatives that can preserve hearing. Tests that can be automated or delivered remotely via the internet or through smartphones could fundamentally improve access to ototoxicity monitoring. The proposed longitudinal observational design is impactful because it will provide highly translatable auditory data in relation to advanced measures of drug exposure. The clinically relevant aims will: (1) Assess relationships over time between cumulative doses of AGs, shifts in EHF pure tone and DIN tests, and self-reported hearing difficulty and tinnitus; (2) Compare OAE tests to hearing loss shifts and determine which OAE test is more accurate to detect presence of ototoxicity; (3) Develop a clinical PK/PD tool to predict AG ototoxicity (change in audiometry, DIN or OAEs) in relation to AG tissue accumulation in CF patients. The expected outcomes will have important positive impacts because they will provide a better understanding of ototoxicity mechanisms, timing and risk factors that can be translated into improved monitoring. Future genomic studies and clinical trials to protect the inner ear would be facilitated by this expanded knowledge and by availability of improved diagnostic and monitoring tools.

NIH Research Projects · FY 2024 · 2020-08

PROJECT SUMMARY Currently, conventional methods that have been utilized to characterize hematopoietic progenitors and their potentials including flow cytometry, in vitro colony-forming-unit assays and in vivo genetic marking are being vigorously complemented with genomics analyses such as single-cell RNA-Seq (scRNA-Seq) and scATACSeq. While these complementary analyses are defining a multitude of possible cell states, there is considerable confusion concerning the correspondence between such states and the heterogeneity/identity of cells captured within canonical flow cytometry gates, their developmental potentials, and mechanisms underlying lineage specification. To address this fundamental problem in the field we have assembled an interdisciplinary research team with deep expertise in the application of single-cell technologies, hematopoiesis, computational genomics and systems biology to develop and promote a unifying framework for the analysis of genomic states with their developmental potentials and trajectories. Specifically, we will define prevalent and rare hematopoietic intermediates as well as their developmental potencies, restrictions and trajectories, on the basis of their genomic states along with the optimal markers and flow gates necessary to isolate them. Using these genomic datasets coupled with analyses of poised or active enhancers interacting with promoters, we will infer gene regulatory networks (GRNs) that delineate the connectivity of transcription factors to their target genes thereby inferring control mechanisms underlying the distinctive genomic states. Thus, exploiting a consolidated biological, molecular and computational dissection of the hematopoietic system focusing on underlying genomic regulatory architectures, we will provide a new framework to incisively understand steady state hematopoiesis.

NIH Research Projects · FY 2024 · 2020-07

PROJECT SUMMARY/ABSTRACT Research: Contrary to children in the US with sickle cell anemia (SCA) who develop dysfunctional, atrophic spleens by 5 years old, children with SCA in sub-Saharan Africa often have splenomegaly, but its functional status and clinical consequences are unknown. The long-term goal of this research is to understand the etiology, pathophysiology, and clinical consequences of splenomegaly in children with SCA in sub-Saharan Africa. The goal of this proposal is to investigate the etiology and clinical effects of splenomegaly both before and after hydroxyurea treatment in a large cohort of children with SCA, enrolled in a prospective treatment trial (SPHERE, NCT03948867). The candidate's ancillary trial will collect serial measurements of both splenic volume (3-dimensional ultrasound) and splenic function (Howell Jolly bodies, pitted red blood cells, and specific viral serologies) in both the observation and the treatment groups of the SPHERE cohort and address these specific aims: 1) identify factors associated with splenomegaly prior to treatment and correlate anatomy (3-dimensional volume) with physiology (filtrative and immunological functions) and 2) investigate changes in splenic volume and function during hydroxyurea treatment as well as laboratory and clinical effects of hydroxyurea compared to untreated participants. These aims will test the following hypotheses: 1A) baseline splenomegaly will be present in 10-20% and associated with alpha thalassemia and previous malaria infections; 1B) pre-treatment splenic size will not correlate with function; 2A) incidence of splenomegaly will double in children receiving hydroxyurea compared to untreated children and be predicted by pre-treatment splenic volume, HbF response, and new malarial infections; 2B) splenomegaly with hydroxyurea treatment will be associated with improved splenic filtrative function and preserved immunological function. Career Development Plan: Dr. Smart's long-term goal is to become an independent investigator focused on improving outcomes for persons with sickle cell disease in the US and globally. He will pursue the following objectives during his K23 training: 1) obtain mentorship in the implementation of rigorous clinical trials in low- resource settings by conducting a prospective clinical trial among children with SCA in Tanzania; 2) understand the significance of splenic dysfunction in SCA through educational seminars and laboratory experience that includes quantitative and qualitative assessments of spleen anatomy and physiology; and 3) gain experience in clinical trial design and advanced statistical methods through coursework and data analysis. Environment: The proposed research will be conducted at Cincinnati Children's Hospital Medical Center (Cincinnati, Ohio) and Bugando Medical Centre (Mwanza, Tanzania) who have a longstanding partnership that provides a strong collaborative environment with infrastructure for clinical and translational research, outstanding mentorship, and an excellent team of collaborators with expertise in sickle cell disease, immunology, hydroxyurea therapy, biostatistics, and clinical trials in low-resource settings.

NIH Research Projects · FY 2024 · 2020-07

Acute myeloid leukemia (AML) is an aggressive hematologic malignancy that, despite being treatable with well- defined chemotherapy regimens, is ultimately fatal in over half of all cases categorized as high-risk AML. Mutations in MLL, FLT3, DNMT3A and P53 are associated with high-risk AML. Even targeted FLT3 anti kinase therapy, which constitutes 30 % of AML, failed to engender durable response in this group of AML. Co-operative oncogenic signaling” was attributed to poor therapeutic outcome, but lacks mechanistic understanding. Based on our recent publication and new preliminary data, we found that co-operative oncogenic signaling converges on c-FOS and DUSP1, which results in an increased apoptotic threshold in cancer cells and confers drug resistance. Thus, genetic or pharmacologic inhibition of c-FOS and DUSP1 sensitizes cancer cells to chemotherapy (Kesarwani, et. al. Nature Medicine 2017). We show greater expression of c-FOS and DUSP1 in high-risk AML patients, but not in low risk-AML patients. Both genetic and chemical inhibition of c-FOS and DUSP1 results in increased drug sensitivity to both TKI and conventional chemotherapeutic drugs in a model of high-risk AML (FLT3ITD+MLLAF9). Thus, we hypothesize that co-operative oncogenic signaling in AML induces the expression of c-FOS and DUSP1 resulting to drug resistance and disease relapse due to elevated apoptotic threshold. In Aim 1, we will determine whether c-FOS and DUSP1 are necessary and sufficient for transformation in a most frequent, aggressive, and fatal AML driven by FLT3ITD+DNMT3Amut+NPM1C and FLT3ITD+P53mut mutations. We will examine the cellular basis of c-FOS and DUSP1 dependency in the high- risk AML mouse models and primary patient samples by genetic deletion and pharmacological inhibition of c- FOS and DUSP1. Next, we propose experiments to understand the mechanistic basis for how co-operative oncogenic signaling via c-FOS and DUSP1 contributes to transformation and treatment failure in AML, with the goal for novel treatment strategies. Based on our preliminary data, we hypothesize that c-FOS and DUSP1 signaling converges upon oncogenically-activated enhancers mediated by specific AP-1 transcriptional complexes. In the presence of c-FOS and DUSP1, AP-1 complexes consist of c-FOS-JUN, which mediate oncogenically-active enhancers, while in the absence of c-FOS and DUSP1, Jun family homodimers (JUN- JUNB, JUNB-JUND, JUN-JUND) predominate which are unable to support the leukemic cell state. In Aim 2, we will molecularly link c-FOS-JUN AP-1 and DUSP1 activity to global enhancer chromatin dynamics. Moreover, we will exploit chromatin-embedded target-gene-reporter alleles to provide a detailed analysis of functionally-relevant downstream genes at a single-cell level in high-risk AML. The proposed work is expected to delineate the necessity of c-FOS and DUSP1 signaling in high-risk AML, as well as to provide deep molecular insight into the mechanisms underlying leukemic transformation and drug resistance. We expect that this information will be informative not only for AML, but also the broad group of treatment resistant tumors.

NIH Research Projects · FY 2026 · 2020-07

Abstract eMERGE is a national network organized and funded by the National Human Genome Research Institute (NHGRI) that combines DNA biorepositories with electronic health record (EHR) systems for large scale, high-throughput genetic research in support of implementing genomic medicine. In 2020, eMERGE IV embarked on a study of genomic risk assessment and management in 5,000 children and 20,000 adults, beginning with efforts to identify and validate published PRSs in ten common diseases with complex genetic etiologies. The study recruited and returned results to 23,840 participants (including 4,255 children) from general healthcare system populations. Enrollment was not targeted to individuals with specific conditions, although individuals with prevalent conditions were included. For this prospective, cohort study, the primary outcome being measured is the number of new healthcare actions after return of the genome-informed risk assessment. Cincinnati Children’s has been an active and engaged site in eMERGE IV. We enrolled participants, completed GIRA returns to participants and their EHRs, surveyed providers, implemented 6-month participant post return of results surveys, and reconsented pediatric participants who turned 18 and. In partnership with another site, we conducted a qualitative study to understand parents’ responses to their children’s PRS-based genomic risk results. Our site has provided Network leadership, and we have been deeply engaged with the other sites and network leadership throughout the study. In this proposal we request a one year extension of funding. This one year extension will allow the Cincinnati eMERGE IV site to quality-control and harmonize longitudinal outcome data, analyze whether returning high risk GIRA leads to new preventive and screening healthcare actions, and disseminate results through manuscripts to inform safe implementation of genomic medicine in routine care for children and adults. Altogether, we intend to work with the NHGRI leadership and other sites to continue to discover and publish the learnings from the eMERGE IV prospective, pragmatic study following the plans for an extension year that we collaboratively designed as a network.

NIH Research Projects · FY 2026 · 2020-06

PROJECT SUMMARY The current clinical standard-of-care for neurosurgical interventions for drug-resistant epilepsy (DRE) involves the use of intracranial electrodes for localization of individual cortical sites responsible for seizures and for sensorimotor and language functions. This static localizationist approach has not kept pace with modern models of the human brain as spatiotemporally dynamic multistate system of interacting networks. Moreover, the current clinical approach has not achieved satisfactory rates of post-operative freedom from seizures or cognitive impairments. The overall goal of this renewal is to achieve these key conceptual (moving from localization-based to network-based approaches) and practical (to improve seizure and language outcomes after epilepsy surgery) objectives. During the previous funding period, we developed and validated methodologies to study language and epileptogenic networks in the brain including, high-gamma modulation (HGM) language mapping, spatiotemporal propagation of HGM, functional connectivity based on coherence modulations, and effective connectivity from cortico-cortical evoked potentials (CCEPs) elicited with single pulse electrical stimulations (SPES). We generated evidence that (1) task-related HGM can localize language regions with high specificity and improved safety compared to the current clinical standard of electrical stimulation mapping (ESM) and is a better predictor of postsurgical standardized language outcomes, (2) spatiotemporal propagation of HGM and coherence modulations can delineate neuronal circuits involved in language processing and their dynamical properties on different time-scales, (3) incorporating CCEPs to define current propagation along functional pathways can reconcile and improve sensitivity of HGM language mapping compared to ESM, (4) CCEPs can delineate patient-specific epileptogenic networks which can be harnessed for precise and personalized selection of surgical targets to improve seizure outcomes after epilepsy surgery. Building upon this robust preliminary data, we propose the following specific aims: (1) to characterize neuronal language processing by combining both localization-based and network-based approaches, (2) to characterize epileptogenic networks by measuring deviations in CCEPs-defined effective connectivity, and (3) to predict, in a personalized manner, language and seizure outcomes after epilepsy surgery by quantifying interactions between neuronal circuits involved in language function and those involved in seizure generation and propagation. This project represents a transformative shift by combining both conventional localizationist and next-generation network approaches for defining patient- specific language and epileptogenic networks and their application to real-world clinical practice. We expect that this renewed project will facilitate a more precise selection of targets for neurosurgical lesioning or neuromodulation in DRE patients, resulting in better protection of language domains and improved seizure outcomes after epilepsy surgery than the current clinical standard-of-care.

NIH Research Projects · FY 2024 · 2020-06

Project Summary Mind and body approaches, specifically diaphragmatic breathing, progressive muscle relaxation, guided imagery, and biofeedback, improve outcomes for children and adolescents with chronic pain. One prevalent cause of chronic pain is migraine. Worldwide, it is the 2nd most disabling neurological disease. When youth learn and practice mind and body skills, the number of headache days and associated disability are reduced. Typically, trials have tested non-pharmacological intervention packages taught by psychologists, in face-to-face sessions, occurring over 4 to 8 weekly meetings. While efficacious, this model is not accessible to most families because of lack of trained providers, distance and travel barriers, and time commitment to sessions. Our recent pilot studies (both stakeholder engagement and health care provider skills training projects) show that youth who receive outpatient psychological care report that learning breathing, muscle relaxation, guided imagery, and biofeedback are the most useful and impactful components of the larger treatment package. Also, nurses in headache centers report that they would feel comfortable with and are interested in learning how to introduce these skills to patients; and pediatric headache specialists and primary care providers are searching for efficient and effective ways to introduce mind and body skills to their patients. Thus, we need to conduct pragmatic trials to test the delivery of these integrated approaches within the context of typical medical care to confirm if they can provide benefit or not. But, despite evidence of safety, efficacy, and successful prior trial execution, it is necessary to optimize a treatment package by evaluating which components and doses of a complex intervention are critical for changes in outcomes prior to implementing a multi-site effectiveness trial. In this NCCIH U01, we will optimize a migraine prevention treatment package focused on 4 mind and body skills that will be delivered by health care providers (for this project, nurses) in two outpatient headache centers (Cincinnati & Denver). An innovative intervention refinement approach, The Multiphase Optimization Strategy (MOST) (https://methodology.psu.edu/ra/most) will be employed to determine necessary components and doses of an efficient, effective treatment that can then be tested against standard care (patient education without any skills ≥ training) via a pragmatic trial. For this factorial experiment, we will enroll 200 youth ages 10 to 17 years with a diagnosis of migraine who are experiencing 4 headache days per month (N = 25 per each of 8 conditions). Three components will be tested: session time with nurses for introduction to the skills (dose of 20 or 40 minutes); daily home practice of skills for 8 weeks (dose of a simple handout approach or use of an active, guided eHealth application); and adherence prompt phone call at 1-month (dose of a call or no call). The endpoints are headache days and migraine-related disability (plus treatment fidelity, feasibility, drop-out rates, acceptance, & credibility; sleep; depression; anxiety; and functional disability). The most efficient combination of doses of the 3 components will be determined using the MOST approach, guided by the resource management and the optimization principles.

NIH Research Projects · FY 2026 · 2020-04

PROJECT SUMMARY Atopic dermatitis (AD) is a chronic, inflammatory skin disorder that affects up to 20% of children worldwide. AD has been highlighted as the first step in the “atopic march”, whereby AD typically predates the development of other allergic disorders. Atopic sensitization and food allergy have been reported to be precursors of AD progression to respiratory allergy, however recent data indicate that the mechanisms are far more complex. The National Institute of Allergy and Infectious Diseases recently convened a workshop titled ``Atopic dermatitis and the atopic march: mechanisms and interventions''6 and they concluded that only about 3% of children follow what has been conventionally referred to as the atopic march. They stated that a new prospective cohort study that uses multiparameter approaches to define phenotypic/endotypic subgroups of AD and to predict AD outcomes is needed. As part of our U19 Asthma and Allergic Diseases Cooperative Research Center (AADCRC) funded by the National Institute of Allergy and Infectious Diseases, we have built the first mechanistic longitudinal cohort study of pediatric atopic dermatitis (AD), the Mechanisms of Progression of Atopic Dermatitis to Asthma in Children (MPAACH). MPAACH is the first early life prospective cohort of children with AD in the US and incorporates extensive evaluations of skin, gut, airway and peripheral blood, as well as the use of multiparameter approaches to define phenotypic and endotypic subgroups of AD. Thus far, we have enrolled 537 children. The goals of the MPAACH cohort are to define AD phenotypes and endotypes, dissect the mechanisms that contribute to the progression of AD to other allergic disorders (food allergy, allergic rhinitis, asthma), and delineate the immunologic, skin, biome, genetic/epigenetic/genomic, physiologic, and environmental factors that promote the development of allergic comorbidities in children with AD. To enable mechanistic studies, extensive biospecimens are collected from lesional and non-lesional skin. We have 20 years of experience and expertise in conducting large cohort studies and are uniquely positioned to contribute to ADRN and SUNBEAM due to our current cohorts and clinical research infrastructure, as well as our experienced and diverse large staff, who are experts in recruitment, regulatory affairs, conducting visits, collection and processing of biospecimens, and execution and reporting of studies. Based on our strong preliminary data from MPAACH, we are proposing 3 CRC-specific research projects to address our overarching hypothesis is that visually normal skin may have skin barrier dysfunction that becomes clinically evident (lesional) or remains subclinical (no lesions), but in both cases the skin barrier dysfunction coupled with dysbiosis of skin microbiome triggers alarmins, which initiates an immunologic cascade that promotes the subsequent development of allergic disease including food allergy, asthma and allergic rhinitis.

NIH Research Projects · FY 2024 · 2020-04

PROJECT SUMMARY/ABSTRACT The primary objective of this K23 application is to provide the candidate with the necessary research training and mentorship to ensure her development as an independent clinical researcher. Her career goal is to investigate neurodevelopmental disorders, like Fragile X Syndrome (FXS), through the integrated use of translational biological and behavioral approaches to identify objective, quantifiable biomarkers to improve mechanistic understanding and advance treatment discovery. To achieve this goal, the candidate proposes a focused training program with an exceptional team of scientific advisors to develop her skills and knowledge in the areas of: 1) paradigm optimization and translational research, 2) advanced electrophysiology analysis and interpretation, and 3) neural systems relevant to sensorimotor and cognition and FXS. The candidate’s mentor (Dr. Sweeney) and co-mentor (Dr. Erickson) are co-project PIs on the U54 FXS Center, providing the candidate with necessary resources, recruitment pool, and scientific excellence to complete her proposed training program and research plan. This proposal is relevant to the NIH Research Plan on FXS and Associated Disorders based on overlap with goals: 3.3 develop biomarker discovery, incorporating diverse approaches to provide treatment targets, accelerate drug discovery, measure effectiveness 3.1 develop functional, objective measures to provide indicators of treatment effectiveness, 1.8 understand the relationship between behavioral phenotype in individuals with FXS and behavioral abnormalities in FXS animal models. Seminal work from the U54 FXS Center using high-density EEG has identified potential neural biomarkers of sensory hypersensitivity in FXS. Yet, electrophysiology studies of neurocognitive alterations is a remarkably under-studied area despite the devastating impact these behavioral features have on individuals with FXS and their families. The candidate proposes to use performance-based EEG to investigate the neurophysiological basis of speech production and behavioral flexibility issues—among the most functionally disabling behavioral features of FXS. The proposed research plan will consist of two phases. In Phase I, 15 adults with Fragile X Syndrome and 15 age-, sex-matched typically developing (TD) controls will complete testing in which key aspects of tasks will be parametrically varied to identify optimal testing conditions. In Phase II, 25 adults with FXS, 25 age-, and IQ-matched developmental delayed (DD) controls, and 25 matched TDC will complete testing using paradigms optimized in Phase I. To identify neural abnormalities during speech production and behavioral flexibility, event-related potentials (ERPs), phase and amplitude coupling and coherence, and gamma single-trial power (STP) in fronto-temporal and fronto-parietal regions, respectively, will be examined. Findings from the proposed studies will provide critical insight into our mechanistic understanding of FXS and assist in treatment discovery and establishment of biomarker identification/validation.

NIH Research Projects · FY 2024 · 2020-03

PROJECT SUMMARY/ABSTRACT Diploid germ cells are transformed into haploid gametes via the reductive division of meiosis. After meiotic DNA synthesis, germ cells enter meiotic prophase I, which distinguishes itself from mitotic prophase by two major characteristics. First, meiotic prophase I is dramatically longer than mitotic prophase. Second, meiotic prophase I involves an intricate series of chromosomal events that contribute to the establishment of the haploid state. The extended length of prophase I is critical for the completion of these chromosomal events, as premature exit from prophase I causes recombination defects and chromosome mis-segregation. In mammals, meiotic prophase I is prolonged by Meioc and Ythdc2. In the absence of either gene in both males and females, meiotic germ cells fail to complete meiotic prophase I and prematurely enter an abnormal metaphase before ultimately apoptosing. Several preliminary observations suggest that MEIOC and YTHDC2 function as a complex to post-transcriptionally regulate cell cycle factors within meiotic germ cells. MEIOC and YTHDC2 are first expressed in the germ line at meiotic initiation, and they interact with one another as well as with an overlapping set of transcripts, including key cell cycle regulators. These targets are enriched for the RNA modification N6-methyladenosine (m6A), which is preferentially recognized by YTHDC2's YTH domain and which is used to target and post-transcriptionally regulate RNA. In the absence of Meioc, MEIOC and YTHDC2's targets exhibit reduced stability. Changes in transcript stability are oftentimes accompanied by changes in translation, and in HeLa cells, YTHDC2 enhances translational efficiency while decreasing mRNA abundance. However, it remains unknown whether MEIOC and YTHDC2 affect translation in meiotic germ cells. This proposal will test the hypothesis that MEIOC and YTHDC2 function as a complex to recognize and translationally regulate m6A-modified mRNA in order to establish a meiosis-specific cell cycle program. This hypothesis will be tested via three specific aims. The first aim will assess MEIOC's ability to affect YTHDC2's interactions with RNA, particularly cell cycle-related transcripts, by identifying the transcripts that YTHDC2 binds to in the presence and absence of Meioc. In addition, whether m6A contributes to MEIOC and YTHDC2's ability to interact with RNA will also be assessed. The second aim will identify the translational changes that occur as germ cells transition from mitosis to meiosis, as well as between wild-type and Meioc-null samples. In particular, this aim will determine whether cell cycle factors are translationally repressed at the onset of meiosis and by the upregulation of Meioc. The third aim will determine whether MEIOC and YTHDC2 are continuously required during meiotic prophase I to prevent precocious cell cycle progression, as well as identify the mechanistic regulation behind this putative requirement. Collectively, these fundamental studies on MEIOC and YTHDC2's regulation of the length of meiotic prophase I will provide key insights into the establishment and regulation of the meiotic cell cycle program, with broader implications for fertility, development, and cancer.

NIH Research Projects · FY 2026 · 2019-12

PROJECT SUMMARY Throughout history, infectious diseases have been, and continue to be, a leading cause of morbidity and mortality throughout the world. While all ages are affected by infectious diseases, the ends of the spectrum of life (young children and elderly) are particularly vulnerable. Thus, the prevention and treatment of infectious diseases through the development of vaccines, therapeutics, devices and diagnostics is a critical global priority. As a VTEU for nearly 25 years, we have provided the scientific, clinical, administrative, and organizational structure to support implementation of clinical trials and studies for the Division of Microbiology and Infectious Diseases (DMID) including respiratory infections, enteric diseases, sexually transmitted infections and neglected tropical diseases. Also, we are recognized experts in the area of human challenge infection models (CHIMs) of enteric and respiratory pathogens. Additionally we repeatedly have demonstrated the ability to provide surge capacity to address infectious disease outbreaks as evidenced by our responses to the testing of H5N1 and novel H1N1 influenza vaccines (for which we received a personal letter from Dr Anthony Fauci). To further expand the capabilities of our Unit; we have added expertise in epidemiology and vaccine effectiveness. We consistently have met or exceed enrollment goals and routinely have over 90% of our subjects complete the study. We consistently have exceeded contractual obligations, including rapid recruitment of subjects spanning the age spectrum including pregnant women. We have provided outstanding leadership of multi-center studies and have been excellent collaborators on studies led by other VTEU sites. We have developed investigator initiated trials and have assisted in the development of trials initiated by DMID. We also have undertaken vaccine projects incorporating systems biology to more deeply understand correlates of vaccine-induced immunity. We are extremely excited to continue as a VTEU, collaborating with the IDCRC, the Leadership Group, NIAID, and other Infectious Diseases experts under this NIAID Cooperative Agreement.

NIH Research Projects · FY 2025 · 2019-10

PROJECT SUMMARY/ABSTRACT Limited data are available on the effects of antenatal opioid exposure on the brain and neurodevelopment. Most studies are limited by methodologic flaws in study design, including small sample sizes and difficulty controlling for important environmental variables. The OBOE (Outcomes of Babies with Opioid Exposure) study, an ongoing NICHD-funded longitudinal study enrolling infants with and without antenatal opioid exposure at birth and following them to 2 years of age, attempts to improve on the limitations of previous research by collecting comprehensive exposure data including infant umbilical cords, advanced neuroimaging data to evaluate brain development, and standardized and thorough information on the home environment, maternal mental health, and parenting. The OBOE consortium, comprised of 4 highly performing centers, a data coordinating center, and a neuroimaging core, has completed our goal enrollment of 200 opioid-exposed and 100 unexposed infants. In response to RFA-HD-24-014, we now propose to complete follow-up to age two in our OBOE cohort, to fulfill our main study objectives. The Cincinnati site has contributed to the OBOE study by enrolling 149 infants (94 exposed and 55 controls), completing 233 MRIs thus far, and contributing to the publication of multiple abstracts and three manuscripts using OBOE data. For this renewal grant, we will continue progress toward our aims to: 1) determine the impact of antenatal opioid exposure on brain structure and connectivity over the first two years of life; 2) define medical, developmental, and behavioral trajectories over the first two years of life in exposed infants; and 3) determine how the home environment, maternal mental health, and parenting modify trajectories of brain connectivity and neurodevelopment over the first two years of life. Our progress so far, with enrollment completed and success in following this difficult population, shows that we have the ability to successfully complete the objectives of the OBOE study.

NIH Research Projects · FY 2024 · 2019-09

PROJECT SUMMARY Children with Down syndrome (DS) have a 3-5 times greater prevalence of Attention Deficit Hyperactivity Disorder (ADHD) than typically developing children. Despite this higher risk of ADHD, rates of stimulant medication treatment are disproportionately low in children with DS+ADHD even though stimulants are the most efficacious ADHD treatment and are recommended by consensus guidelines for use in children with intellectual disability (ID) and comorbid ADHD. Possible reasons for under-utilization of stimulant treatment in DS+ADHD include: 1) diagnostic uncertainty regarding how to accurately diagnose ADHD in children with DS, making providers prone to “diagnostic overshadowing” (i.e., attributing ADHD to the ID); 2) there is not a single clinical trial examining the safety and efficacy of stimulant medication in children with DS+ADHD; and 3) concerns about cardiac safety, given the high incidence of congenital heart disease or defects (CHD) in the DS population. We propose a pilot study to define the clinical features of DS+ADHD thereby enabling more accurate diagnosis and a pilot clinical trial to inform sample size estimates for a larger clinical trial. We propose to perform the first randomized clinical trial of stimulant medication in children with DS+ADHD to provide evidence regarding the short and long-term safety and efficacy of stimulant use in children with DS+ADHD, both with and without CHD. One hundred (100) children with DS+ADHD and 70 children with DS and no ADHD (DS-ADHD), all aged 6-12 and matched on age, gender, and IQ, will participate. All 170 children enrolled in the study will complete a comprehensive assessment battery evaluating ADHD diagnostic criteria as well as behavioral, cognitive, academic, and functional impairments. The 100 children in the DS+ADHD group will also complete a multi-phased randomized, double-blind clinical trial with crossover to placebo and long-term follow- up to assess the short- and long-term efficacy and safety of stimulant medications for treating ADHD symptoms and impairment in children with DS. Study aims will focus on 1) Identifying behavioral, cognitive, academic, and functional impairments that differentiate children with DS+ADHD from children with DS-ADHD; 2) Informing sample size of larger clinical trial; 3) Assessing the short- and long-term safety of stimulant treatment in children with DS+ADHD with a specific focus on cardiac safety; 4) Determining the short- and long-term efficacy of stimulant treatment at remediating cognitive, behavioral, and functional impairments in children with DS+ADHD; and 5) Exploring moderators (e.g., IQ, ADHD subtype, executive functioning, comorbid internalizing disorders, CHD) of stimulant response and side effects. Results from this study will provide much needed diagnostic and treatment data that will directly impact the outcomes of the approximately 45,000 children with DS+ADHD nationwide.

NIH Research Projects · FY 2025 · 2019-09

SUMMARY Bronchopulmonary Dysplasia (BPD) is a chronic cardiorespiratory disease of prematurity that is responsible for the majority of neonatal intensive care unit (NICU) admissions across the nation (approximately $13B/year in the US for the NICU alone). The disease has high mortality and morbidity, and results in lifelong cardiorespiratory illnesses that are sometimes diagnosed as asthma and COPD, which themselves comprise an even larger burden of disease. Survival among extremely premature infants has significantly improved since 1990, increasing the number of severe cases and the burden of disease. This disease burden disproportionately affects patients with severe disease, and that is the focus of this renewal proposal. There is a treatment gap that exists largely because of the paucity of sensitive endpoints for testing in infancy and the justifiable exclusion of the most severe patients from studies and trials. We have successfully developed free-breathing MRI methods that even in the most severe patients can safely quantify and define image-phenotypes of disease and predict respiratory outcomes. These methods have now been translated to clinical practice. We currently follow a cohort of 257 patients (N=216 severe), who are beginning to turn age 5 in 2024, and have demonstrated very strong relationships between neonatal MRI and short-and medium-term outcomes. The overall goal of this R01 renewal is to build on our prior work in neonatal MRI to precisely characterize sequelae of severe BPD in our existing cohort of patients at school age, evaluate tomographic progression of disease for the first time from NICU to childhood, create school-age outcomes-prediction models based on neonatal phenotype, and extend functional MRI (via hyperpolarized Xe and PREFUL) to neonates. In Aim 1 we will use our well-characterized MRI phenotypes and quantitative measures at infancy to predict respiratory morbidities at school age in the entire 257-patient cohort. In Aim 2 we will precisely measure tomographic disease progression from infancy to school age, with quantitative and objective measures of regional ventilation, alveolar simplification, gas exchange, airway abnormalities, and pulmonary vascular disease, via proton and hyperpolarized Xe MRI. Accurate functional measures remain challenging in the neonatal period, and this is the focus of Aim 3: to perform Xe and functional proton MRI in neonates with BPD. Preliminary data strongly support each of these Aims. Our previous R01 led to pioneering work that innovated new MRI techniques and significantly improved patient outcomes (increased survival, decreased tracheotomy, reduced respiratory readmissions); we will continue this translation and outcomes improvement via this renewal. By understanding progression of severe BPD with precision and accuracy, that knowledge can rapidly be translated into precision treatment of individual patients and improved outcomes at all ages.

NIH Research Projects · FY 2023 · 2019-09

PROJECT SUMMARY/ABSTRACT Spina bifida is the most common complex congenital disorder and has significant impact on health and quality of life. Although life expectancy has improved for individuals with spina bifida, they continue to experience high rates of morbidity, low rates of community participation, high health care costs, and for some, lower reported quality of life. Multidisciplinary spina bifida clinics provide comprehensive, coordinated, family-centered, best quality care with the goal of promoting the highest level of health, quality of life, independence, and community participation across the lifespan. High quality evidence to guide these clinics and other providers in providing the most effective clinical care is limited and a wide variation in care practices exists among clinics. Therefore, there is a critical need to identify and disseminate evidence-based, standardized clinical care practices that result in early identification of common complications, timely delivery of cost-effective interventions, and optimal outcomes and quality of life across the lifespan. The National Spina Bifida Patient Registry (NSBPR) was established by the Centers for Disease Control and Prevention in 2008 to pinpoint and disseminate best care practices through longitudinal data collection, analysis, and dissemination of findings. However, variation in care and health outcomes still exist across multidisciplinary clinics. This proposal aims to advance the mission of the CDC’s National Center on Birth Defects and Developmental Disabilities to improve the health of children and adults by promoting health and wellness among children and adults with disabilities. The objective of this proposal is to identify and disseminate best practices in spina bifida clinical care through improved NSBPR longitudinal data collection and analysis and linkage of NSBPR with additional electronic health record (EHR) clinical and administrative data. We aim to 1) identify the clinical care practices associated with best health outcomes for people living with spina bifida by expanding NSBPR collection to adults, developing standardized data collection procedures, and increasing linkages between NSBPR and EHR data. We will 2) advance the evidence base by leveraging our experience implementing standardized care algorithms and our NSBPR/EHR data linkages to characterize the frequency of sleep disordered breathing (SDB) and the frequency of associated symptoms of SDB in individuals with spina bifida. We also aim to 3) evaluate the potential of a standardized manual muscle testing care algorithm implemented by an interdisciplinary team in the first year of life to predict ambulation at age 5. By investigating the above aims, our team is poised to improve the quality and utilization of the NSBPR data across multidisciplinary clinics with the purpose of identifying best clinical care practices that prevent complications and promote optimal health, functional independence, community participation, and quality of life for children and adults with spina bifida.