Duke University

NIH Research Projects · FY 2024 · 2022-09

1 Abstract 2 Breast cancer (BC) encompasses multiple diseases made up of different molecular subtypes that are 3 characterized by distinct oncogenic drivers and unique treatment regimens. Despite these differences, across all 4 subtypes, individuals with advanced, recurrent, or metastatic disease still have limited treatment options and 5 poor overall survival outcomes. Immunotherapies offer an opportunity to treat patients regardless of molecular 6 subtypes. This proposal leverages intratumoral (IT) immunotherapy as an alternative to ‘license’ treated lesions 7 to yield productive ratios of T cells to suppressive immune subsets while amplifying immune checkpoint axes 8 and ultimately increasing sensitivity to immune checkpoint inhibitors (ICI). Using a model of TNBC and single 9 cell RNA sequencing, we demonstrate that IT plasmid IL-12 (pIL-12) can convert poorly immunogenic/low 10 TIL tumors into highly inflamed, immunologically active lesions through the coordinated upregulation of the 11 CXCR3 axis in infiltrating immune cells that impacts the migration, differentiation, and activation of both 12 innate and adaptive immune cells. This CXCR3 signature was also significantly enhanced in patients that had 13 an increase in CD8 T cell infiltration into treated tumors post IT pIL-12 therapy and prognostic of improved 14 overall survival. We hypothesize that targeting the CXCR3 axis IT will enhance TILs and convert patients into 15 ICI responders across all molecular subtypes of BC. The proposed work will leverage this preliminary data in 16 the following 3 aims: 1.) Demonstrate increased infiltration of tumor-specific T cells following IT pIL-12-EP 17 treatment and validate the induction of a CXCR3 or trafficking-associated gene signature in ICI responders 2.) 18 Evaluate the role of trafficking-associated proteins in enhancing responsiveness to anti-PDL1 in TNBC using a 19 CRISPR based screen; 3.) Assess IT injection of plasmid CXCL9 to determine if direct targeting of the CXCR3 20 axis is sufficient to enhance T cell infiltration. Dr. Crosby’s long-term goal is to build a research program that 21 contributes to an understanding of immune cell infiltration into tumors to better design, combine, and predict 22 responses to immunotherapies, with a specific focus on BC. A critical impediment to these types of studies is 23 the lack of oncogene-driven, spontaneous BC tumor models which hampers the translational applicability of 24 many pre-clinical findings. Key resources for Dr. Crosby’s independent research are the spontaneous HER2- 25 driven and p53/BRCA1/PTEN-driven TNBC models that she has created, published, and will uniquely possess 26 to perform these and many other studies. Addressing the basic question of how to enhance T cell infiltration 27 into tumors has significant implications for changing the paradigm of treatment for BC patients, particularly 28 using an intratumoral plasmid approach that is easily altered to follow up on newly identified targets. The 29 funding provided by this K22 award will protect Dr. Crosby’s research time to develop and publish these 30 foundational, studies which will support subsequent R01 grant submissions.

NIH Research Projects · FY 2025 · 2022-09

This proposal presents a five-year research career development program focused on the study and development of a dyadic behavioral intervention to improve distress (e.g., depression and anxiety) and communication for older adults coping with cancer and pre-existing mild cognitive impairment (MCI); and for their family caregiver. While MCI in older adults does not overtly impede function, it can manifest under conditions of distress. Close to 50% of older adults with co-occurring cancer and MCI are at vulnerable risk to experience high levels of distress (e.g., depression and anxiety) which can negatively affect their sense of independence, communication of what matters most for their care, and overall quality of life. Their family caregivers may experience equal or even higher levels of distress when managing their loved one’s cancer symptoms and cognitive deficits. Surprisingly, a large gap exists in the development of dyadic behavioral interventions to treat distress and improve communication to address both patient and caregiver needs. The proposed project seeks to address a major gap in the literature and clinical practice for older adults with co-occurring cancer and MCI, and their family caregiver. The overall objective of this K08 proposal is to develop a dyadic intervention (created by Dr. Ramos, titled: COPE+), informed by her previous work in individually based interventions for oncology and palliative care populations, and pilot COPE+ as a novel patient-caregiver dyadic intervention consisting of distress coping skills, and newly include communication-skills training. The proposed mentored research activities for this K08 award are to refine and pilot test the dyadic intervention informed by Family Self-Management Theory. Mentored research training will occur in the context of a focused research project with three aims: 1) To refine the COPE+ intervention using interviews with patients, caregivers and providers. 2) To finalize the intervention and study procedures through user testing. 3) To examine the feasibility and acceptability of COPE+. This K08 application is consistent with NCI’s mission to advance scientific knowledge of the unique needs of people living with cancer and aligns with the NCI’s Division of Cancer Control and Population Sciences in helping reduce the burden of the cancer experience via use of behavioral intervention approaches to enhance quality of life. To become an independent researcher in the field of geriatric oncology and mental health, Dr. Ramos requires additional training in: 1) qualitative research and geriatric oncology; 2) recruitment, engagement, and retention of older adults with cancer and MCI, and their family caregivers; 3) design, develop, and pilot dyadic behavioral interventions; and 4) develop expertise in dissemination and implementation. Dr. Ramos’ intensive training plan coupled with a team of internationally recognized researchers in health psychology, geriatrics, health services/implementation science, and biostatistics will position her to be a geropsychology leader studying and addressing mental health in older adult cancer populations and co-occurring MCI.

NIH Research Projects · FY 2025 · 2022-09

In the United States, gastric cancer is a particularly fatal disease (survival rate of approximately 32% at 5 years) as it is generally asymptomatic until late-stage, when treatment is no longer effective. Each year in the US, 26,000 people are diagnosed with gastric cancer, and over 10,000 people die of the disease. However, gastric cancer is a preventable disease, as the predominant cause of gastric cancer is infection with the common bacterium, Helicobacter pylori (H. pylori), for which successful eradication significantly reduces the risk of developing gastric cancer. H. pylori, which greatly varies in prevalence among different populations within the US, is the world’s single leading carcinogenic infectious agent, responsible for an estimated 36.9% of the over 2.2 million infection-associated cancers diagnosed in 2018, more even than those attributed to human papillomavirus (31.5%), or the Hepatitis B and C viruses combined (23.5%). The burden of gastric cancer also falls disproportionately on different populations within the US, with incidence rates two- to three-fold higher in different groups of individuals, which is also mirrored in gastric cancer mortality rates. Moreover, these differences in gastric cancer incidence continue to grow over time. And yet, the underlying reasons for these population-based differences in gastric cancer incidence in the US are substantially understudied. Currently, little is known about whether the differences in gastric cancer incidence are a result of differences in H. pylori prevalence, host response to H. pylori, or differences in other risk factors that might affect the development of gastric cancer. These potential other risk factors include key individual and neighborhood characteristics that differ greatly within populations, such as household crowding and residential segregation, which could increase the risk of H. pylori infection, contribute to chronic stress, and induce a more severe immune response. Our goal is to fill the gap in knowledge of risk factors for H. pylori-associated gastric cancer to provide the understanding of the underlying factors that indicate who is at high risk of gastric cancer in the US. To do this, we will build a nested case-control study of approximately 800 non-cardia gastric cancer cases and 2:1 matched controls, utilizing prospective cohort data from 4 NCI-funded cohorts with pre-diagnostic specimens available: Multiethnic Cohort Study (MEC); Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO); Southern Community Cohort Study (SCCS); and Women’s Health Initiative (WHI). We will assay these biospecimens for antibody levels to H. pylori-specific proteins and for pepsinogen (a validated marker of gastric atrophy), thoroughly assess individual and neighborhood factors that are associated with gastric cancer risk, and determine what drives the population differences in H. pylori antibody levels and atrophy and resulting gastric cancer risk. Finally, we will develop an integrated “cells to society” modeling framework to assess the impact of multi-level determinants of health on the patterns of H. pylori antibody levels, gastric atrophy and resulting population differences in gastric cancer incidence. Ultimately, these findings will provide the information needed to allow for targeting of high-risk patients for the clinical trials necessary to create screening guidelines for the prevention and early detection of gastric cancer in the US, and will help clinicians with precision prevention by laying the groundwork for the building of a risk prediction tool.

NIH Research Projects · FY 2025 · 2022-09

Project summary Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the US and results in significant reduction in quality of life and functional status. Patients with COPD are 55 times more likely to fall than patients without COPD, putting these patients at high risk of fall-related injuries and further decrements in quality of life and health. This study will tackle the common and important problem of use of fall- risk increasing drugs (FRIDs) among patients with COPD. This will be achieved by implementing and evaluating a pharmacist-led deprescribing intervention to reduce FRIDs use among community-dwelling, multi- morbid adults with COPD. The central hypothesis of this proposal is that poor communication and limited shared decision making between prescribers, patients, and patient caregivers represent modifiable barriers to deprescribing. Once these barriers are addressed, prescribers, patients and caregivers will be amenable to informed deprescribing as part of this targeted intervention. In Specific Aim 1, I will use a national database to assess commonly used FRIDs among patients with COPD, identifying FRID types and combinations associated with the highest fall risk. In Specific Aim 2, I will interview patients with COPD, their family caregivers, and clinicians (primary care providers, pulmonologists, pharmacists) to elicit barriers, facilitators and key strategies to deprescribing FRIDs and enhancing shared decision making between clinicians and patients. In Specific Aim 3, I will conduct a pilot randomized trial, testing a pharmacist-led deprescribing intervention, adapted using findings from Specific Aims 1 and 2. I will evaluate the feasibility, acceptability and appropriateness of the intervention using semi-structured interviews and structured questionnaires. I will also explore the preliminary efficacy of the intervention compared to usual care for the primary outcome of FRID discontinuation. This pilot trial will provide preliminary data for a future R01-funded hybrid effectiveness- implementation trial. This research is innovative in that: 1) no prior study has evaluated an intervention to facilitate deprescribing FRIDs among patients with COPD; 2) this intervention includes family caregivers, who provide informal medication management to patients; and 3) this project uses a pulmonary clinic-based pharmacist as a conduit to improve communication and shared decision making among patients, caregivers and clinicians. My learning objectives are to learn a) advanced statistical methods to evaluate fall risk among patients with COPD, b) training on COPD therapeutics and fall risk assessment, c) behavioral intervention optimization, adaptation and assessment, and d) behavioral clinical trials design for future intervention trials. My long-term career goals are to evaluate and disseminate evidence-based interventions to improve medication management and healthcare delivery for multi-morbid adults with COPD.

NIH Research Projects · FY 2024 · 2022-09

ABSTRACT Alcohol use disorder (AUD) is a damaging and pervasive mental disorder that presents a large health and socioeconomic burden globally. Strong risk factors for AUD include early life challenges that cause inflammation, such as early life stress and early exposure to alcohol. Microglia, the brain’s resident immune cells, both respond to inflammatory challenges and organize developing circuits, lending strong support to the theory that immune signaling changes during development alter circuit maturation to increase later life drinking. Therefore, in my proposal, I will determine if there is a developmental sensitive window for increased drinking vulnerability controlled by microglia. My preliminary data suggests that microglia are responsible for increased adult alcohol consumption through a developmental mechanism: loss of pro-inflammatory signaling specifically in microglia through the ablation of MyD88, a critical toll-like receptor signaling molecule, increases voluntary adult drinking in both acute and chronic drinking paradigms. Parvalbumin interneurons (PVIs), late-maturing critical regulators of coordinated cell activity across the brain, are also altered in frontal cortex of MyD88-deficient mice, an effect that is exacerbated by early-life inflammation. This PVI change points to a potential mechanism through which microglia are impacting circuit maturation and behavior. Based on this, my central hypothesis is that MyD88- deficient microglia improperly regulate the size of the developing PVI population through reduced phagocytosis, leading to increased inhibitory frontal cortex activity in adulthood that drives excessive drinking. I propose to test this hypothesis in two aims. In Aim 1, I will determine if MyD88-deficient microglia exhibit reduced phagocytosis of PVI cells or synapses during development through immunohistochemical techniques. Then I will test the hypothesis that loss of this function in the frontal cortex during a specific developmental window is sufficient to induce the altered drinking behavior in adulthood. I will do this by administering a temporary microglial phagocytosis blocking compound to the frontal cortex during development and then measure adult drinking. In Aim 2, I will determine whether changes to frontal cortex PVI activity can drive increased adult drinking. Using a Cre-dependent chemogenetic approach, I will deliver excitatory or inhibitory designer receptors exclusively activated by designer drugs (DREADDs) to PVIs in the frontal cortex of adult mice, then deliver a designer drug across the course of an acute drinking paradigm. This will uncover whether increasing or decreasing PVI activity in the frontal cortex is driving the excessive drinking seen in MyD88-deficient animals. The proposed work will have an important positive impact not only on our understanding of AUD and its risk factors, but also will answer basic neurodevelopmental questions about the role of microglia in shaping inhibitory circuits and future behavior. The outcome of this project will be specific targets, such as microglial inflammatory signaling and PVI function in the frontal cortex, to manipulate in future studies to progress the prevention and treatment of AUD.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY For patients with advanced cardiovascular disease, implanted cardiac devices can significantly improve their survival and quality of life. While lifesaving, cardiac devices carry the added risk of developing a cardiac device infection (CDI), in which case the device has to be surgically removed. In many cases, patients with a CDI present with vague symptoms and undergo a number of inconclusive tests, resulting in a delay in their diagnosis. If left undiagnosed or untreated the mortality from a CDI is high. If identified early, CDIs can be treated swiftly, thereby reducing infection-related complications. Currently there are no reliable methods for early prevention or identification of CDI. Rapid and accurate CDI diagnosis is critical in cardiac device recipients who have a Staphylococcus aureus bloodstream infection, as the risk of CDI approaches 50%. Building on the candidate's published work, this research will use the singular resource of the Bloodstream Infection Biorepository to define the vascular biomarker signature associated with an individual's risk for a S. aureus-CDI. Second, the biological basis for why some, but not all patients, develop a CDI will be identified through the application of a novel in vitro model system of bacteremia, created by the candidate in collaboration with Biomedical Engineering. This project will: 1) define the biomarker signature associated with S. aureus-CDI, 2) determine how changes in vascular mechanics affect infection risk, and 3) apply a novel tissue engineered blood vessel system to identify critical endothelial-bacterial-device interactions that impact CDI risk. Results from this project will serve as a basis for follow-up R01 proposals, which will prospectively evaluate adjunctive CDI biomarker signatures among other etiologies of bloodstream infection and determine if a patient's endothelial phenotype is an independent risk factor for CDI. This project has direct relevance to the NHLBI's strategic goals and objectives of identifying phenotypic, biomarker, and molecular characteristics predictive of outcome, that when applied in clinical studies, can predict differential response to therapy in individuals. This project will also support the candidate's transition to an independent research career. This project will provide expertise and advanced skillsets in tissue engineering, vascular biology, and clinical research, all of which are necessary for the candidate's long-term career goal of identifying key factors that impact susceptibility to CDIs and developing effective therapeutic strategies for their prevention and treatment. The primary mentor for this award is Dr. Vance Fowler, an internationally recognized clinician-scientist in S. aureus bacteremia who has extensive experience as a mentor of junior faculty researchers. A complementary and diverse group of mentors will provide guidance in tissue engineering (Dr. Truskey) and vascular biology (Dr. Kontos). The candidate will use the outstanding resources and interdisciplinary working groups at Duke University Medical Center, the Pratt School of Engineering, the Duke Cardiovascular Research Center, and the Antibiotic Resistance Leadership Group to launch her career as an independent physician-scientist.

NIH Research Projects · FY 2025 · 2022-09

ABSTRACT Obesity is a pervasive public health problem with origins in childhood, and despite advances in treatment for obesity, primary prevention is essential to prevent morbidity and early death. There is an urgent, unmet need to predict which infants and young children are at highest risk of obesity. The first years of life provide a promising sensitive period to address excess, rapid infant weight gain and subsequent obesity and cardiometabolic risk. Previous work demonstrates associations between risk factors and rapid infant weight gain, but novel growth characteristics, such as magnitude and timing of infancy BMI peak, may provide better insight into obesity risk when combined with known risk factors. Primary care visits in the first years of life, with brief and frequent contact with parents eager for guidance, provide an ideal setting for both risk prediction and interventions. The overarching hypothesis is that childhood obesity prevention strategies in the clinical settings can be improved through predictive models and clinical decision support designed to incorporate modifiable risk factors and infancy growth patterns. The overall objectives of this proposal are to improve clinically-relevant prediction of childhood obesity and design a clinical decision support tool that incorporates real-time risk prediction. Aim 1 identifies associations between known risk factors during infancy and novel infancy growth patterns. Aim 2 develops, compares, and validates predictive models using novel infant growth characteristics, including individual and group-based patterns. Aim 3 tests implementation of a risk prediction and clinical decision support tool within the electronic health record. The outlined research aims and career development plan provides Charles Wood, MD, MPH the skills to achieve his overall career goal of becoming an independent investigator focused on obesity prevention in the primary care setting focused on the first years of life. Dr. Wood’s training plan includes experiential learning and didactic coursework to achieve the following short-term training goals: 1) master approaches to repeated measures analysis and predictive modelling construction and validation; 2) execute data linkage and harmonization using electronic health record (EHR) sources; 3) learn and practice optimal use of EHR data for research; 4) incorporate state-of-the-art approaches to designing clinical decision support tools; and 5) continue to develop career and professional skills. Dr. Wood will receive focused mentorship and consultation from a team of experts of pediatric outcomes research (Dr. Smith), primary care obesity interventions (Dr. Perrin), obesity and population health (Dr. Skinner), epidemiology of childhood growth (Dr. Woo), repeated measures analysis (Dr. Kuchibhatla), and EHR use for research (Dr. Goldstein). The rich research environment at Duke University will allow Dr. Wood to fulfill his research and career development plans and begin to address his long-term goals of comparing risk prediction strategies for childhood obesity and conducting prospective observational and interventional trials in the primary care setting.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY/ABSTRACT The care of critically ill patients with acute respiratory failure (ARF) involves life-or-death decisions. Ideally, intensive care unit (ICU) clinicians should include patients or their families in shared decision making, which promotes goal-concordant care, reduces psychological distress for both families and clinicians, and shortens ICU length of stay. However, racial disparities have been documented in all components of shared decision making and its associated outcomes. In outpatient settings, clinicians treat Black patients differently from White patients, providing fewer treatment options, less prognostic information, and less emotional support, and making assumptions about rather than eliciting patient preferences. Racial disparities in shared decision making are likely to be amplified in the ICU because clinicians often do not have long-standing relationships with families, and decisions are time-pressured and highly emotional. To promote equitable ICU care, we must fill two critical knowledge gaps: (1) we do not fully understand how or why ICU clinicians differently engage Black and White families in shared decision making about ARF, therefore (2) we do not know how to develop a shared decision making intervention to reduce racial disparities in SDM for patients with ARF. To address these evidence gaps, I propose three specific aims: (1) Compare how ICU physicians engage Black and White families of patients with ARF in decision making using mixed methods to analyze existing transcripts of ICU physician-family meetings; (2) Elicit family and ICU physician experiences with decision making about ARF through focus groups and interviews to identify ICU physician-level barriers to shared decision making with Black families; and (3) Use a human-centered design approach that is guided by feedback from families and ICU physicians to adapt and feasibility test an existing shared decision making intervention (“Jumpstart”) in order to mitigate racial disparities for patients with ARF and their families. This work addresses a key NHLBI priority to “better integrate palliative care concepts, such as respect for treatment preferences, in the management of patients” with acute respiratory failure. I will be supported by the robust research environment at Duke University and an interdisciplinary team of dedicated, nationally respected mentors: Drs. Christopher Cox, Kimberly Johnson, Sharron Docherty, and Meeta Kerlin. At the completion of the proposed project, I will have developed key scientific skills in clinical trials, health disparities research, mixed methods research, and intervention development. I will also collect preliminary data necessary for a follow-up R01 Award to conduct a clinical trial of the adapted intervention. In sum, this K23 Award is critical to my career development, and the results will have a substantial public health impact by promoting equitable shared decision making for patients with acute respiratory failure and their families.

NIH Research Projects · FY 2025 · 2022-09

Project Summary: The majority of patients with advanced stage cancers experience moderate to severe pain, and more than half of all cancer patients report insufficient pain relief by the currently available therapeutics. Head and neck squamous cell carcinomas (HNSCC) involving the oral cavity and/or oropharynx are regarded as a particularly painful cancer type which produces coincident functional impairments that lead to difficulties in feeding, swallowing, and communication. These functional impairments substantially reduce quality of life for cancer patients and are associated with increased morbidity and mortality. Thus, there is a critical need for novel therapeutics that are capable of providing safe and effective pain relief. Moreover, any newly emerging pain therapeutic must be compatible with existing and emerging standard of care cancer treatments, such as cancer immunotherapy, which has emerged as the gold-standard treatment for many cancer subtypes over the last decade. We recently discovered that pain-sensing peripheral sensory neurons (nociceptors) express the innate immune regulator STING. Strikingly, activation of STING can produce antinociception in mice and non-human primates, both in steady-state conditions and in pathological pain states. This is noteworthy, as small molecule STING agonists have shown remarkable efficacy in promoting antitumor immunity and are currently being explored as cancer therapeutics in clinical trials. The objective of this proposal is to identify the cellular and molecular mechanisms by which STING regulates nociception, both in steady-state conditions and in HNSCC pain models. We hypothesize that STING dynamically regulates nociception in steady-state and disease conditions through a mechanism dependent on nociceptor-immune cell signaling and its subcellular localization. In Specific Aim 1, we will determine how STING signaling in peripheral sensory neurons, TRPV1+ nociceptors, and classical type-1 dendritic cells (cDC1s) each contribute to STING-mediated antinociception in health and disease, using syngeneic cancer pain models, conditional genetics, behavioral phenotyping, immune profiling, and biochemical and immunohistochemical approaches. In Specific Aim 2, we will determine how the subcellular localization of STING influences its molecular and physiological properties to influence nociception and antitumor immunity. Overall, completion of these experiments will substantiate STING as a unique “neuro-immunotherapy” target capable of conferring combinatorial analgesia and antitumor properties, a finding of immediate translational relevance given the paucity of options available to patients suffering from cancer pain.

NIH Research Projects · FY 2025 · 2022-09

ABSTRACT This is a K23 resubmission application for Dr. Brian Mac Grory, a vascular neurology investigator pursuing patient-oriented clinical research focused on the identification of novel populations with underexplored cerebrovascular disorders requiring personalized secondary prevention strategies. Based on his own preliminary data and recent publications, the central hypothesis of this proposal is that central retinal artery occlusion (CRAO) – a form of ischemic stroke affecting the retina – may be an indicator of underlying cardiac disease and a sentinel of future, potentially lethal, cardioembolic stroke. CRAO is formally recognized as a form of ischemic stroke but there is an incomplete understanding of its mechanistic underpinnings, with most research to-date focused on its association with carotid artery stenosis. Testing this application’s central hypothesis will address a fundamental knowledge gap about the mechanisms of CRAO. This K23 award proposes to generate key preliminary data linking CRAO with cardioembolic substrates and set the stage for a future, multi-center, observational study that will definitively test this hypothesis. Dr. Mac Grory will leverage a very large population-based dataset (the Medicare 5% Sample) as well as both retrospective and prospective institutional cohorts. Specific Aims 1A & 1B will determine the association of each of atrial fibrillation and left ventricular failure with the development of CRAO. Specific Aims 2A & 2B will determine the association of cardiac, serum and ultrasonographic biomarkers of embolic risk with CRAO and their interplay with carotid artery stenosis. As part of this proposal, Dr. Mac Grory will undertake a linked, didactic training plan with the goal of developing as an independent investigator through acquisition of the following key skills: 1) Biostatistics in observational research including advanced causal inference methodology, 2) Data science applied to administrative claims databases, 3) Prospective, observational study design, and 4) Vascular biomarker interpretation. Advanced training in these areas will permit Dr. Mac Grory to realize his long-term career goal of becoming an independent clinical investigator who leverages interdisciplinary expertise to provide insights in to the management of understudied cerebrovascular disorders. In pursuit of this goal, Dr. Mac Grory has assembled a mentoring team with distinct though complementary skillsets in stroke medicine, comparative effectiveness research, causal inference methodology, cardiac electrophysiology, and neuro-ophthalmology. Results supportive of this application’s central hypothesis would reveal a new population who may harbor occult cardioembolic disease. Results that are neutral or negative with respect to this central hypothesis would be equally valuable as they would allow us to refine the future study of CRAO by focusing on atherothrombotic mechanisms. With the preliminary data and training obtained from the proposed research, Dr. Mac Grory will be uniquely equipped to execute future, larger-scale studies uncovering novel populations in whom evidence- based, potentially life-saving secondary prevention strategies may be deployed.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY/ABSTRACT Despite significant advances in the treatment of patients with heart failure with reduced ejection fraction (HFrEF), substantial residual morbidity and mortality continues to plague the contemporary treatment era. The cardinal clinical feature of patients with HF is reduced exercise capacity, which is associated with substantially reduced quality of life. Even with insights into diverse mechanisms of myocardial dysfunction, most current medical treatment focuses on modulating the “neurohormonal axis”, and orthogonal approaches are direly needed. Recent preclinical and clinical data from our team and others demonstrate that exogenous delivery of ketone therapy improves HF hemodynamics, suggesting potential ergogenic benefits. Our research has also highlighted the contribution of skeletal muscle abnormalities to impaired exercise tolerance in HF, and limited data suggest beneficial effects of ketones in reducing peripheral anaerobic carbohydrate metabolism in healthy volunteers. We therefore seek to understand the potential benefits of therapeutic ketosis in patients with HFrEF by performing deep phenotyping of myocardial, peripheral musculature, and metabolic contributions. Aim 1 will determine the acute effects of exogenous ketone ester administration on functional capacity and investigate potential myocardial and vascular mechanisms of benefit in a crossover, placebo-controlled trial. Aim 2 will compare whether ketone ester therapy alters systemic carbohydrate metabolism through targeted metabolomics, stable isotope infusions, and exercise measures of gas exchange. Aim 3 will investigate the effects of ketone therapy on peripheral skeletal muscle metabolism. Such studies will leverage the rich translational research environment at Duke University. If beneficial, our results would add to the burgeoning literature, demonstrating the importance of targeting the “ketone metabolic axis” as a treatment strategy to help improve exercise capacity and quality of life, and would inspire larger, randomized trials of ketone therapy. Dr. Selvaraj, an early career investigator advanced heart failure specialist, has a long-term goal of becoming an independently funded cardiovascular researcher with a focus on cardiovascular metabolic interventions in HF and using deep phenotyping techniques to define pathways of benefit. These research aims are part of a comprehensive training plan and will be supervised by a mentorship team spanning the basic science, translational, and clinic spectrum with rich experience in cardiovascular metabolism in HF, metabolomic profiling, deep phenotyping during early stage studies of HF therapeutics, and molecular metabolic imaging. This diverse and collaborative team will guide Dr. Selvaraj’s transition to an independently funded research career with extension of findings to low output HF syndromes.

NIH Research Projects · FY 2025 · 2022-08

Morbidity and mortality associated with ozone (O3) exposures are a substantial public health concern. Unlike other environmental exposures, O3-related morbidity and mortality, is largely linked to respiratory causes and associated with pre-existing respiratory conditions. However, specific mechanisms underlying this phenomenon are poorly understood. Understanding how prior lung injury drives susceptibility to subsequent O3 exposure is particularly important in the context on viral lung injury, such as pneumonia caused by seasonal influenza virus. Our overall hypothesis is that this is driven by distinct alveolar macrophage (AMØ) subsets. During the past decade, work from several groups, including ours, has demonstrated that long-living, self-maintaining, tissue-resident AMØ are the dominant immune cell type in normal mouse and human lung. Tissue-resident AMØ are essential to lung homeostasis and direct responses to pathogens and environmental exposures, including O3. We have previously reported that murine O3 exposure expands tissue-resident AMØ, and their loss exacerbates O3-induced lung injury. Conversely, monocyte-derived AMØ, recruited during lung injury (e.g. viral infection), augment inflammation. Our group previously showed that monocyte-derived AMØ recruited after lung injury persist in the lung via autocrine M-CSF/M-CSF receptor (M-CSF-R), maintain an activated phenotype, and drive chronic lung diseases. Extending this to humans, we demonstrate that the abundance and activation state of monocyte-derived AMØs negatively correlate with pulmonary function in patients with early pulmonary fibrosis. Cumulatively, our published and preliminary data support that distinct AMØ subsets direct the balance between ongoing inflammation and its resolution and suggest that AMØ composition, particularly the baseline presence and activation of monocyte-derived AMØ, prior to exposure can enhance severity and persistence of O3-induced lung injury. This baseline condition is particularly important as respiratory viral infections, including influenza, induce the recruitment of monocyte-derived AMØs. Leveraging mechanistic mouse models, state-of-the-art lineage-tracing systems, single-cell genomics, and serial sampling in controlled human O3 exposures, we will test the hypothesis that the abundance and activation state of monocyte-derived AMØs drive O3-induced lung inflammatory responses via autocrine M-CSF/M-CSF-R signaling. Our specific aims are: Aim 1: To determine the role of autocrine monocyte-derived alveolar macrophage M-CSF/M-CSF-R signaling in maintaining lung inflammation in mouse models of O3-exposure. Aim 2: To determine whether the abundance and activation status of monocyte-derived AMØ predicts lung physiological and inflammatory responses in controlled acute O3 exposures in normal human subjects and in individuals with prior respiratory viral infection. These results would support a novel translational paradigm with important public health implications, and identify a novel therapeutic strategy to revert the adverse public health effects of O3 exposure.

NIH Research Projects · FY 2025 · 2022-08

Abstract Cervical cancer is the most common cancer among women in many low- and middle-income countries, including Kenya. This is mainly due to the lack of screening, which remains the cornerstone of prevention for the over one hundred million reproductive-aged women who fall outside the target age group or live in countries where the human papillomavirus (HPV) vaccination is not available. While HPV-based screening has the potential to be incorporated into simplified protocols, the laboratory testing component requires programs to have capacity to track specimens, results and patient follow-up, which can be a challenge in settings with limited healthcare infrastructure and no electronic medical records. Further, low baseline knowledge of HPV and cervical cancer risk in the community is associated with low rates of screening and follow-up, making effective outreach and education a key component of screening programs. This work is often done by community health volunteers (CHVs) with limited content-specific training. We propose to fill these gaps through an integrated digital platform that includes a mobile app (mSaada) that supports CHVs with patient and specimen tracking and follow-up, and counseling and protocol support. In the R21 phase of this project, we will: (1) work with key stakeholders and local and international developers to finalize the mSaada platform, building on the existing prototype to add patient and specimen tracking functionality; and (2) carry out a pilot study to identify the patient, provider and health system factors necessary to design a trial to evaluate mSaada effectiveness and implementation factors. We will carry out a six-month pilot in two health facilities providing HPV-based screening, and use performance metrics including system usage rates, workflow observations and qualitative data to guide the planning of a cluster-randomized clinical trial (c-RCT) to determine effectiveness of mSaada. In the R33 phase of the project, we will use a hybrid implementation effectiveness design to: (1) conduct an 18-month c-RCT across 12 health facilities to determine the impact of mSaada on cervical cancer screening uptake, treatment acquisition and cervical cancer knowledge levels among women in the community; and (2) measure the requisite implementation factors for mSaada effectiveness, sustainability, and scale-up. The rigorous study design will allow us to determine the clinical impact of mSaada, ensure the local and regional infrastructure has the capacity necessary for sustainability and develop strategies for widespread implementation and scale-up. Collaboration with key stakeholders from the Kenya Ministry of Health will facilitate the development of a long-term sustainability plan as the country moves toward HPV-based cervical cancer screening. We anticipate the mSaada platform will play a pivotal role in facilitating the introduction of HPV-based screening programs that can reach women in settings with limited health care infrastructure.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY/ABSTRACT Sudden unexplained death in epilepsy (SUDEP) is the sudden and unexplained death of a patient with a history of seizures and epilepsy who is in a reasonable state of health. It is a major cause of death in patients with epilepsy and a common cause of neurologic death overall. Believed to be caused by a culmination of cardiac and neurologic factors, epilepsy induced bradycardia is a risk factor for SUDEP and may trigger lethal ventricular arrhythmias in susceptible myocardium. Development of a robust experimental model which recapitulates this would open the door for foundational studies to develop critical pharmacotherapies. SUDEP is a tragic outcome in patients with alternating hemiplegia of childhood (AHC) which is characterized by epilepsy, dystonia, paralysis, and, notably, sudden death in the setting of bradycardia. Among AHC patients, 90% harbor underlying pathologic genetic variants in the ATP1A3-encoded alpha-3 catalytic subunit of the Na/K ATPase pump (ATP1A3). We have identified a strong correlation between the most common AHC-associated ATP1A3 variant (D801N) and short QT on ECG and ventricular fibrillation during bradycardia. Human induced pluripotent stem cell-derived cardiac myocytes from an ATP1A3-D801N-positive child (hiPSC-CMD801N) demonstrate shortened repolarization time, disrupted calcium homeostasis, and delayed-after depolarizations, which are triggers for arrhythmias. Knock-in mice hosting the D801N variant (Atp1a3D801N) have seizures, bradycardia, and sudden death. Further, Atp1a3D801N mice have a predisposition to ventricular arrhythmias, particularly at lower heart rates, compared to controls. Collectively, these findings raise the possibility that disruption of ATP1A3 in the heart underlies SUDEP in AHC patients through bradycardia-triggered arrhythmias. We hypothesize that D801N reduces pump function leading to shortened repolarization time and predisposes to lethal ventricular arrhythmias. Our goal is to use AHC as a model to establish the role ATP1A3 in the heart, determine the mechanism of SUDEP, and explore the proarrhythmic effect of bradycardia. To approach this in an innovative and rigorous way, we will utilize patient-derived hiPSCD801N- and murine Atp1a3D801N-based models for in vitro, ex vivo, and in vivo studies to determine the mechanism of arrhythmia predisposition in the heart. Specifically, we propose to determine 1) the mechanism of action potential duration shortening induced by D801N in cardiac myocytes, 2) the mechanism of cardiac arrhythmogenesis induced by D801N in 3D tissue models and ex vivo analysis, and 3) whether bradycardia due to seizures is an arrhythmogenic trigger for a “vulnerable” myocardium in Atp1a3D801N mice. In accomplishing these aims and overall goal, we will determine the function of ATP1A3 in cardiovascular physiology and its role in cardiac repolarization, calcium signaling, and ventricular arrhythmias, thus identifying molecular targets for pharmacotherapy. Finally, this will develop robust and rigorous models to determine the mechanisms of sudden death in AHC and will provide insights into mechanisms of SUDEP more broadly.

NIH Research Projects · FY 2025 · 2022-08

Abstract The transformation of visual cues into appropriate behavior requires the collaboration of diverse neurons across distant brain areas. A fundamental gap in our knowledge about these visuomotor transformations is understanding how these neurons are functionally connected, shaping neural response dynamics that give rise to behavioral output. This gap is due to the inaccessibility of mammalian model systems, in which simultaneous in vivo observation and manipulations across the brain is impossible as well as a lack of real-time computational frameworks that can capture these dynamics. Here, we plan to investigate the brain-scale functional connectivity underlying the visually guided optomotor response (OMR) in the genetically and optically accessible larval zebrafish. Our previous computational brain-scale models generate concrete predictions for circuit composition and connectivity strength between functional cell classes and behavior but fail to capture the individual neural dynamics of this system. Therefore, to generate realistic dynamic models and test these predictions, we propose leveraging integrated methods combining streaming data analysis, volumetric two-photon microscopy, holographic optogenetic manipulation, and training of multi-regional recurrent neural networks (RNNs). Using patterned photostimulation of single and groups of functionally and molecularly identified neurons, while simultaneously recording activity from other hypothesized downstream neurons, we will infer excitability, sign, and synaptic strength from the network's response. In Aim 1, we will first define neurons both functionally and by their neurotransmitter type across the brain including the pretectum, a conserved visual processing area. In Aim 2, we will train biologically constrained RNNs to predict functional connectivity between these neurons, which we will iteratively test and validate by photostimulating automatically selected neural targets while recording resulting neural activity across the pretectum, orchestrated by our streaming analysis software (improv). Next, we will use these integrated methods to map and model the functional connectivity of pretectal neurons with specific, identifiable premotor spinal projection neurons hypothesized to orchestrate specific behavioral aspects. In Aim 3, we will develop online, gradient-based RNN training of recorded neurons to permit real-time testing and refinement of the predicted brain-wide connectivity leading to behavior in individual zebrafish. These computationally integrated experiments will generate predictive dynamic models of how signals from each eye are transformed into behavior. Together, this research will apply innovative computational and all-optical technologies to decode the temporal neural dynamics underlying complex sensorimotor processing, promising essential insights for the development of treatment strategies for neuropsychiatric disorders that are manifested in the neural connectivity across multiple brain areas.

NIH Research Projects · FY 2025 · 2022-08

ABSTRACT Globally there is a growing need to implement community-based services that support improvements in quality of life of autistic people. Early autism intervention is critical because it can significantly improve both child and family outcomes, but implementation gaps exist worldwide. These gaps are starkest in Africa, where by 2050, iven the lack of specialists in Africa, task shifting early autism intervention to non-specialists will be a key implementation strategy. Naturalistic Developmental Behavioral Interventions (NDBI), are a class of early autism intervention approaches, that can be effectively delivered by caregivers. Through a partnership between Duke University and the University of Cape Town, our team laid the groundwork for an innovative and scalable coaching intervention for young autistic children . We systematically adapted a caregiver coaching NDBI for the South African context in which coaching is effectively delivered by non-specialist Early Childhood Development practitioners employed by the Education Department. In the proposed study we will build on our foundational work by conducting a type 1 hybrid effectiveness implementation trial of the coaching intervention, delivered by non-specialists, within an existing system of care in South Africa. Our goal is to implement a feasible, scalable early autism intervention model in Africa by conducting research with culturally and linguistically diverse participants in community-based settings, that is inclusive of diverse stakeholder perspectives and incorporates task-shifting. In the proposed study, we will build on our current relationships with families, practitioners, and policy makers by formalizing these relationships and including other key stakeholder groups such as South African autistic self-advocates through a community-academic partnership, a key bridging factor in the EPIS implementation framework. The proposed project has three main objectives. First, to evaluate the real-world effectiveness of non-specialist delivered NDBI caregiver coaching for improving patterns of caregiver-child interaction and child developmental outcomes, and assess the cost- effectiveness of this approach. Second, to identify implementation determinants to inform scale-up. Third, to expand African autism research capacity to enhance scalability. This project also offers a unique opportunity to study variability in autism-related behaviors and phenomenology. We will therefore assess the degree to which response to intervention is moderated by caregiver and dimensional child characteristics. In addition, using an innovative digital assessment method, changes in dimensional quantitative measures of autism-related behaviors will be examined. Finally, cross-cultural differences in dimensional autism-related behaviors will be evaluated via comparison with existing quantitative phenotypic data gathered in U.S. studies. This study is timely and innovative and will inform scale-up of autism early intervention in Africa. Assessing the impact of a scalable intervention in an environment like South Africa which faces significant contextual challenges, increases the ecological validity and relevance of findings for many regions of the world that face with similar challenges.

NIH Research Projects · FY 2024 · 2022-08

The US opioid overdose death epidemic has continued for over 20 years. Nonmetropolitan or rural areas with low capabilities of opioid use disorder (OUD) treatment are associated with significantly elevated rates of opioid overdose deaths. Many countries have increased OUD treatment access to reduce opioid morbidity by allowing community pharmacy dispensing of methadone for methadone maintenance treatment (MMT). MMT has been the most studied and longest utilized OUD treatment for about 55+ years. Federal regulations require MMT to be provided through one of about 1,860 SAMHSA certified opioid treatment programs (OTPs). MMT is considered less expensive (more affordable) and has higher treatment retention rates than buprenorphine treatment for OUD. Thus, MMT is a preferred treatment option for many individuals with OUD. However, the limited number of OPTs, limited capabilities of existing OTPs, and a long travel distance to an OTP are major barriers to accessing MMT, especially for persons with OUD in rural and suburban areas. Pharmacists are among the most trusted healthcare professionals. About 90% of Americans live within 5 miles of a community pharmacy. Federal regulations allow OTPs to obtain approvals to establish methadone medication units (MUs) at pharmacies (pharmacy MUs) to allow pharmacy administration and dispensing of methadone for MMT to expand treatment. MUs are managed by OTP directors of the parent OTP who have oversight of patient care at both the main OTP and MU location. MUs have been infrequently utilized in the US. Given the serious shortage of OUD providers in the US to address the escalating opioid overdose death epidemic, there is an urgent need to identify useful strategies of establishing MUs and to disseminate useful strategies of establishing MUs nationally to OTP directors and community pharmacists in the US. Built on the successful experience of the PI’s (Dr. Wu) research on developing physician-community pharmacist collaborative care models to engage community pharmacists in providing buprenorphine treatment care to patients with OUD (Wu et al., 2021a) and administration and dispensing of methadone for MMT (Wu et al., 2021b), we will conduct a survey of OTP directors (n=586) and community pharmacists (n=586) to identify OTP and community pharmacy facility/practice, individual, and contextual factors that are related to intentions to establish a MU. Guided by a mixed methods explanatory sequential design, we will also conduct follow-up qualitative interviews of a subsample of participants from each survey to further obtain in-depth data on MU implementation barriers and facilitators in the US. Due to the serious shortage of OUD providers and escalating rates of opioid deaths, this study is time-sensitive. This study will be the first effort in the US to identify MU implementation barriers and facilitators from both OTP directors and pharmacists. We will produce multiple peer-reviewed publications and an electronic toolkit for establishing MUs to quickly disseminate the toolkit and publications to OTP directors and pharmacists nationally.

NIH Research Projects · FY 2025 · 2022-08

ABSTRACT Lung transplantation is an effective and life-extending treatment for patients with advanced lung diseases. However, improvements are needed in donor management, candidate selection, and recipient care to prevent early postoperative complications and improve the long-term success of lung transplantation. To address these unmet needs, the NHLBI is creating the multisite Lung Transplant Consortium (LTC) to conduct clinical and mechanistic observational research across up to 8 clinical centers (CCs) and up to 24 individual sites. Central to the success of the LTC is a single Data Coordinating Center (DCC) that will oversee consortium wide activities including the development and implementation of a common protocol that will enroll approximately 3200 lung transplant subjects prospectively collecting clinical data and serial biosamples to create a unique resource for future research. With this application, the Duke Clinical Research Institute (DCRI), proposes to serve as the administrative and operational home for the LTC DCC, partnering with the biorepository expertise and resources of the University of Pennsylvania (Penn). The DCRI-Penn DCC brings unparalleled clinical lung transplant subject matter expertise, longstanding prior experience coordinating multicenter research studies in lung transplantation, and operational rigor in research oversight and biosample collection that will fully support and enhance the LTC committee structure, common protocol design and implementation, and CC studies. The DCC will be led by the Multiple Principal Investigator team of Drs. Palmer, Christie, and Neely, who together bring considerable and complementary expertise in clinical and research aspects of lung transplant, data and statistical methodology, leadership experience in the design, coordination, and publication of multicenter research studies in lung transplant and lung diseases. The DCRI-Penn DCC team comprises additional experts in transplant surgery, data management, regulatory affairs, site-based research oversight and monitoring, digital health, patient engagement, web design and communication. Thus, the DCC team is optimally poised to collaboratively partner with the NHLBI and CCs to complete the following Aims: 1) create LTC administrative infrastructure that facilities efficient team communication, timely dissemination of study results and data, and public engagement, including creation and maintenance of the LTC website that serves as a focal point for protected consortium communication and engagement of the broader lung transplant community and key stakeholders 2) provide thought leadership and operational input that ensures the efficient development of high-impact, operationally feasible, and scientifically rigorous common protocol and CC studies, 3) oversee common protocol conduct including use of a single IRB, site operations, robust collection of serial subject data and biosamples, monitoring of data quality, and safety reporting in a manner that results in timely subject enrollment and ensures the rigor, quality, and completeness of clinical data and biosamples.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY/ABSTRACT While lung transplantation is the only treatment option for end-stage lung disease, early post-operative complications are common and limit long-term patient survival while concomitantly increasing the economic burden of an already expensive therapy. Successful surgical outcomes can be defined by an ideal or “textbook outcome” (TO) where the patient does not have significant early post-operative complications, which for lung transplant can include primary graft dysfunction, acute lung allograft dysfunction, renal failure or infection. Our group recently published the first lung transplant TO definition based on single-center data and found failure to achieve TO was strongly associated with worse patient survival and significantly higher cost to the health system. A subsequent registry analysis of 62 US lung transplant centers found the rate of achieving TO ranged from 27% to 72%, emphasizing wide variability in outcomes and potential for intervention and improvement. The Lung Transplant Clinical Center in this proposal include Duke University, University of Louisville, University of Minnesota and University of Pennsylvania. These centers are four of the oldest and most respected lung transplant centers in the country with geographic and size diversity, including small, medium, and large volumes. Our proposal aims to understand the critical pretransplant clinical characteristics, as well as novel underlying biologic aging differences, that contribute to worse early outcomes, or failure to achieve a TO. We hypothesize that specific clinical variables and biological aging measures can predict early complications. Biological age in the pretransplant patient may be driven by organ specific advanced lung disease and therefore ameliorated with lung transplant. Alternatively, biological age may be a systemic process across organs systems and does not resolve with transplant. To determine the significance of organ specific versus systemic aging, we will evaluate pretransplant biological aging in the recipient's pretransplant immune system and explanted lung. Using iterative machine learning we will develop and validate a TO prediction model based on the identified clinical variables and biological measurements to determine a personalized perioperative risk of lung transplantation for individual candidates. More than just a predictive tool, this proposal will allow for identification of potentially modifiable clinical and biologic variables that can be leveraged to improve outcomes. As part of the larger Lung Transplant Consortium, we will enroll participants and contribute data and biospecimens through a common research protocol under the auspices of the Lung Transplant Consortium Data Coordinating Center and Steering Committee.

NIH Research Projects · FY 2025 · 2022-08

Abstract Laparoscopic surgery is the standard of care in high-income countries for many cancer operations in the chest and abdomen. Laparoscopic surgery avoids large incisions by using a tiny camera and fine instruments manipulated through keyhole incisions, but it is generally unavailable in low- and middle-income countries (LMICs) due to high cost of installment, lack of qualified maintenance personnel, unreliable electricity and shortage of consumable items. Patients in LMICs would benefit from laparoscopic surgery, as advantages include: decreased pain, improved recovery time, fewer wound infections, and shorter hospital stays. Laparoscopic surgery would reduce recovery time, enabling patients to return to home and work more quickly, thereby mitigating impoverishing health expenditure. KeyScope and KeyLoop (collectively called KeySuite) are laparoscopic prototypes that we have designed for the resources, needs and challenges of LMICs. KeyScope is a laparoscope that can be made for $150 (cost of goods), plugs into a laptop computer to display images during surgery, exists as a single unit without complicated assembly and is sterilizable by immersion in Cidex. It links to a tele-mentoring application so that experienced surgeons can mentor surgeons in capacity-building partnerships. KeyLoop is a laparoscopic retractor that lifts the abdominal wall during surgery, obviating the need for a constant power supply and medical-grade carbon dioxide. This would enable laparoscopic surgery to be performed in rural hospitals, where most patients live in LMICs, and increase access in tertiary centers where laparoscopic equipment is rare and expensive. We describe a multi-disciplinary collaboration between surgeons, engineers, oncologists, attorneys, global health experts and business executives to take this technology to the next stage. We will perform a clinical First-in-Human study at the Uganda Cancer Institute. Ugandan surgeons will use the KeySuite devices to perform biopsies of intra-abdominal tumors. Primary outcome will be the ability to perform biopsies laparoscopically without conversion to open surgery. Secondary outcomes include: 1) device feasibility and safety data and 2) patient satisfaction. We will demonstrate that KeySuite devices can be constructed in Uganda, through the Duke-MUK Shipping Container Makerspace. We will create a bill of materials, manufacturing process instructions, training videos, and measures of quality control. Once we have achieved exceptional construction quality, we will transfer this work to the Uganda Industrial Research Institute (UIRI) which will move the KeySuite to a product for commercialization. Using the WHO Good Manufacturing Practices (GMP) we will establish quality assurance protocols for sustainable local manufacturing and regulatory approval of the KeyScope and KeyLoop through the Uganda National Drug Authority and CE mark.

NIH Research Projects · FY 2024 · 2022-08

PROJECT SUMMARY / ABSTRACT Older adults living in disadvantaged neighborhoods, marked by poor physical, social, and economic conditions, are at elevated risk for dementia regardless of their personal sociodemographic characteristics. It is not yet clear when in the lifespan such risk emerges or through which putative causal mechanisms, if it is indeed causal. The activities proposed in this application will fill key research gaps in environmental health and geroscience through first-ever longitudinal studies of neighborhood characteristics and brain aging in midlife, when it is still possible to intervene to prevent dementia. They will inform the identification of at-risk individuals and significantly advance the evidence base needed for potential neighborhood-level dementia interventions, which could leverage public resources outside the healthcare sector and operate without requiring individual behavior change. Proposed projects will integrate diverse geospatial neighborhood data (housed at Michigan State University) into the four-decade archives of the Dunedin Study of psychosocial health, development, and aging among a population-representative New Zealand-based cohort born in 1972 and followed to midlife. The Dunedin cohort is the only one in the world with fine-grained measures of brain integrity from infancy to midlife, with the latest assessment (age 45) including brain structural and functional antecedents of dementia. Studies will determine: (1) whether individuals living in disadvantaged neighborhoods demonstrate signs of accelerated brain aging by midlife; (2) if specific neighborhood characteristics are uniquely associated with midlife brain- health deficits; and (3) whether pro-degenerative health behaviors and conditions (e.g., low physical activity, hypertension, etc.) and are more common in disadvantaged settings and thus may act as causal meditators. The applicant’s career goal is to become a clinical neuropsychologist and independent academic researcher who conducts public health-oriented research on the degenerative consequences of environmental exposures in the hopes of identifying modifiable risk factors and unique interventions to lower the global burden of brain disease. This fellowship will leverage a multi-university training plan to significantly advance the applicant’s career by allowing him to: (1) enter a PI-role in the Dunedin Study; (2) gain additional training to advance his unique research goals, including in established and cutting-edge methods in geospatial analysis, neurotoxicant assessment, and premorbid modeling of brain aging and dementia; and (3) prepare for an innovative career bridging environmental health and psychology with job-readiness skills in teaching, mentoring, and grant writing and management. Mentored training will occur in psychiatric, geospatial, and environmental epidemiology labs at Duke, Michigan State, and Harvard, supplemented by coursework, workshops, and conferences. The fellowship will ensure the applicant's move to independence for a unique body of work investigating environmental contributions to pathological brain aging, with future steps involving additional data linkage and assessment in older and younger cohorts and at the next assessment phase of the Dunedin Study.

NIH Research Projects · FY 2025 · 2022-08

Project Summary/Abstract Delirium is a syndrome of fluctuating changes in alertness and attention that occurs in up to 40% of older surgical patients (i.e. age >65. Delirium is associated with an increased risk of developing dementia, a progressive loss of thinking and memory skills that eventually results in an inability to care for oneself and to live independently. The most common cause of dementia in older Americans is Alzheimer’s disease (AD) which is associated with a progressive buildup of abnormal deposits in the brain of two proteins, tau and amyloid beta. Amyloid beta deposits typically develop in the brain for years if not decades before the start of memory deficits and other AD symptoms. Patients with these early or “pre-clinical” amyloid beta deposits, even if they appear mentally normal, are often at increased risk of developing delirium after surgery. Here, we will examine whether these amyloid beta deposits, or other “pre-clinical” changes in brain structure and activity, predispose patients to show larger than normal brain activity changes in response to anesthetic drugs given during surgery. The central idea of this proposal is that an altered (or exaggerated) brain activity responses to anesthetic drugs is a marker of an unhealthy brain, i.e. a brain with signs of “pre-clinical” AD and which is at increased risk of postoperative delirium. First we will examine whether patients with evidence of brain amyloid beta pathology (as measured by spinal fluid amyloid beta levels) have altered brain activity responses to anesthetic drugs. Second, we will use brain imaging to determine whether changes early AD-like changes in brain structure and connections are associated with altered brain activity responses to anesthetic drugs. Third, we will determine whether altered brain activity responses to anesthetic drugs are associated with increased postoperative delirium occurrence and severity. This work will help us understand mechanisms underlying postoperative delirium and AD and related dementias, and the links between them. Further, this work will provide a way for anesthesiologists (and surgeons) to use brain activity recording data already in wide use in American operating rooms to predict which patients are likely to develop postoperative delirium and/or AD, which could allow these patients to be selected for interventions to prevent these disorders.

NIH Research Projects · FY 2026 · 2022-08

PROJECT SUMMARY Heart failure (HF) is the leading cause of hospitalization in adults aged 65 and older. More than 3 million hospitalizations occur each year in older adults with HF and recurrent hospitalizations after discharge are common, costly, and often preventable. For more than a decade, 30-day hospital readmissions have received considerable attention as an actionable target to improve quality of care and reduce costs in the older-adult (Medicare) population. Despite these investments, high rates of (re)hospitalization continue to put enormous strain on the U.S. healthcare system and on those suffering from the disease. We argue that these strategies have been largely ineffective because they focus on a single snapshot of a patient’s risk of hospitalization (30- day readmission) and do not consider the majority of hospitalizations that occur over the course of the illness. Therefore, efforts to predict and ultimately lower hospital readmissions in older adults will continue to fall short until the full progession of hospitalizations are recognized and addressed. In response to this urgent need, our study will address three critically unanswered questions: What are the most common patterns of hospitalization that occur in older adults diagnosed with HF? Who are the patients most likely to follow these patterns of hospitalization? And what are the factors that can help prevent hospitalizations during the course of treatment? Drawing from a life course perspective and using data from a nationally-representative longitudinal study of older adults, Medicare claims, and electronic health records, our proposed aims are threefold: First, we will classify the major trajectories of hospitalization that occur in older adults diagnosed with HF. This aim will provide evidence of how the number and timing of hospitalizations vary among HF patients over the course of their illness. Second, we will examine how a wide array of demographic, socioeconomic, psychosocial, behavioral, health-, and hospital-related factors are associated with patterns of hospitalization in HF patients. This aim will allow us to determine key patient characteristics that can be assessed at the time of diagnosis to predict a person’s probability of having a given trajectory of admissions over the course of their illness. Third, we will identify factors that may reduce hospitalizations during the course of HF treatment. Our final aim will examine a similarly wide range of factors that may alter the course of a trajectory (i.e., timing and/or number) of hospitalizations, particularly among patients who experience high numbers of hospitalizations and/or face critical periods of risk. Bringing together a strong team of interdisciplinary investigators, the results from this project will have enormous potential to inform the design, targeting, and timing of interventions that are most likely to succeed in reducing the significant burden of hospitalizations in older adults.

NIH Research Projects · FY 2025 · 2022-08

Enhancing the efficacy of radiation therapy for brainstem glioma by targeting ATM Project Summary/Abstract Brainstem gliomas are devastating pediatric brain tumors. Brainstem gliomas include “diffuse midline gliomas with H3K27M mutation” in the 2016 World Health Organization Classification of Tumors of the CNS, and includie tumors previously referred to as “diffuse intrinsic pontine gliomas” or DIPG. Brainstem gliomas are uniformly lethal to the patients. Radiation therapy is thought to be the only effective treatment for these tumors, providing temporary relief from symptoms and from tumor progression. However, brainstem gliomas inevitably progress after radiation therapy and result in death of the patient resulting in a median survival of less than one year. New strategies are needed to improve the efficacy of radiation therapy to improve patient survival. One promising investigational therapeutic strategy is to radiosensitize tumors by inactivating the serine/threonine kinase Ataxia Telangiactasia Mutated (ATM). ATM is the master sensor for DNA damage, and orchestrates the DNA damage response after cells are damaged by ionizing radiation or other DNA damaging agents. ATM inactivation dramatically radiosensitizes a genetically engineered mouse model of brainstem glioma. When ATM is inactivated in the tumor cells of our mouse model of brainstem glioma, radiation therapy is particularly effective and extends median overall survival of the mice by approximately threefold compared to mice bearing tumors with intact ATM. However, the specific cell populations that are radiosensitized by ATM inactivation, and the mechanisms by which ATM inactivation radiosensitizes brainstem gliomas, is unknown. A deeper understanding of the molecular mechansisms by which ATM inactivation can radiosensitize brainstem gliomas is needed to enable the rational design of combination therapies that combine ATM inhibition, radiation therapy, and other novel epigenetic and immunologic therapies to maximize survival of patients with brainstem gliomas. Here, I will test the hypothesis that ATM inactivation specifically radiosensitizes a population of progenitor-like tumor cells in our genetically engineered mouse model of brainstem glioma. In parallel with this work, I will dissect type I interferon signaling pathways that are contribute to radiosensitivity when ATM is inactivated. These experiments will map the tumor microenvironment of a mouse model of brainstem glioma at single cell resolution for the first time. They will also credential a genetically-engineered mouse model of brainstem glioma with an intact immune system for preclinical investigations of immunotherapeutic approaches. Additionally, the proposed work will provide me with critical expertise in genetically engineered mouse models and in immunologic investigations that will help me transition to a productive independent investigator.

NIH Research Projects · FY 2025 · 2022-08

Superoxide and other derivative reactive oxygen species (ROS) promote atherosclerosis (athero) as well as vascular smooth muscle cell (SMC) and macrophage inflammatory signaling. Anti-atherogenic strategies targeting O2--producing NADPH oxidases, however, increase susceptibility to infection. This project’s goal is to discern novel mechanisms for constraining ROS-promoted atherogenesis while minimizing adverse effects on immunity. One such mechanism may involve the ubiquitously expressed noncoding small nucleolar (sno) RNAs from the ribosomal protein L13a (Rpl13a) locus: SNORD32A, SNORD33, SNORD34, and SNORD35A. We found that these snoRNAs augment ROS levels and oxidative stress in vitro and in vivo. Our Preliminary Studies with Rpl13a-snoRNA-/- (snoKO) mice and SMCs derived from them show: (1) snoKO SMCs have lower levels of ROS, cell proliferation and migration than congenic WT SMCs. (2) Compared with WT SMCs, snoKO SMCs express 5.7-fold more cytochrome C oxidase subunit 4 isoform 2 (COX4I2), which reduces mitochondrial O2- production. (3) SnoKO carotid arteries develop less athero than WT carotids when transplanted orthotopically into Apoe-/- mice. (4) Compared with Apoe-/- mice, snoKO/Apoe-/- mice develop 40% less brachiocephalic athero. (5) Compared with snoRNA+/+ brachiocephalic arteries or carotid grafts, snoKO arteries demonstrate less SMC-to-foam-cell transdifferentiation, a process potentiated by ROS. SnoRNAs bind to their target RNAs via an antisense domain, then recruit the enzyme fibrillarin, which effects RNA 2’-O-methylation. SnoRNAs canonically modify ribosomal RNA; however, we discovered that at least one of the Rpl13a snoRNAs can target mRNA for 2’-O-methylation—a process that alters mRNA abundance and translation. Nonetheless, specific mRNAs that constitute targets for pro-oxidant effects of Rpl13a-snoRNAs remain obscure. This project will therefore test the hypotheses that Rpl13a snoRNAs promote athero, particularly by potentiating SMC-to-foam cell transdifferentiation, and that that Rpl13a-snoRNA-guided mRNA 2’-O-methylation affects protein expression of key ROS-regulating enzyme(s) in SMCs and Mφs, including COX4I2. To do so, this project will compare athero in Rpl13a-snoRNA-/-/Apoe-/- versus Apoe-/- mice, and use bone marrow transplantation to discern the roles of Rpl13a-snoRNAs in bone marrow-derived cells versus arterial wall-derived cells. We will investigate how Rpl13a-snoRNAs affect foam cell formation in macrophages and SMCs, and determine whether COX4I2 engenders lower ROS levels and inflammation in snoKO SMCs. Finally, we will identify mRNA targets of Rpl13a-snoRNAs in SMCs and macrophages, by performing transcriptome-wide mapping of 2’-O-methylation sites on mRNA from WT and Rpl13a-snoRNA-/- SMCs and macrophages, by using the RibOxi-seq and crosslinking, ligation, and sequencing of hybrids (CLASH) approach. By elucidating mechanisms by which snoRNAs regulate ROS in SMCs and macrophages, this project should identify new therapeutic targets for athero.