Vanderbilt University Medical Center

NIH Research Projects · FY 2025 · 2021-09

Project Summary Human Immunodeficiency Virus (HIV) infection remains a significant public health problem in the United States (US). It is estimated that almost 15% of the 1.17 million people living with HIV (PLWH) in the US are unaware of their HIV status. And despite the existence of highly effective HIV treatment (antiretroviral therapy, ART), only 65% of people living with diagnosed HIV have achieved viral suppression. Similarly, among HIV-negative people eligible for PrEP, only 18% have used PrEP. These gaps between evidence and practice are deepened in the US South, where the opioid crisis has further increased the risk for acquiring HIV in this region. In order to achieve US Ending the HIV Epidemic (EHE) goals, implementation research, particularly in the US South, is needed to close the gap between evidence-based interventions and practice in the HIV neutral continuum of care. Thus, our overarching goal is to support and evaluate the implementation of a sustainable HIV health service model for rapid HIV testing and linkage to HIV treatment (ART) or prevention (PrEP) in Tennessee (TN), a state located in the US South. Our Core Project will focus on implementation and evaluation of rapid HIV testing and linkage to ART from the Shelby County Health Department, the highest volume HIV testing facility in Memphis, TN (a southern US city which ranks 4th among all US Metropolitan Statistical Areas for HIV incidence) to several nearby Ryan White-funded HIV care clinics. Our Collaborative Project will focus on implementation and evaluation of rapid HIV testing and linkage to local PrEP providers from: 1) Street Works, a Community Based Organization (CBO) providing a Syringe Service Program (SSP) to the Nashville community and 2) A Betor Way, a CBO providing a SSP to the Memphis community. We are uniquely positioned to perform the work we propose for three important reasons. First, we plan to leverage an established collaboration with implementation and community partners in Memphis and Nashville including colleagues from St. Jude Children’s Research Hospital, University of Memphis, Shelby County Health Department, Street Works, and A Betor Way. Second, we will leverage resources available at the TN Center for AIDS Research, Vanderbilt Center for Health Services Research, and the Meharry-Vanderbilt Alliance/Community Engaged Research Core. Thirdly, the investigators involved in this proposal possess the expertise in HIV clinical care and prevention, implementation science, and public health practice necessary to complete the proposed work. The proposed study will support the implementation of a contextually appropriate rapid HIV testing and linkage to HIV treatment (ART) or prevention (PrEP) in Memphis and Nashville, TN. The results will inform future scaling of these models to additional HIV testing, care, prevention sites across TN, a geographic area at the epicenter of important US HIV disparities. Importantly, our work will support the Memphis and Nashville communities in reaching their local EHE goals through leveraging of our unique academic, public health, and community-based partnerships.

NIH Research Projects · FY 2025 · 2021-09

Most cases of atrial fibrillation (AF) arise from a combination of clinical risk factors and genetic susceptibility. Moreover, it has recently become clear that AF can be the earliest manifestation of rare high effect size variants associated with potentially fatal cardiac channelopathies or cardiomyopathies (CM). When inherited arrhythmia/CM syndromes are suspected, current guidelines recommend genetic testing to enable early detection and reduce the risk of sudden cardiac death. However, current guidelines specifically state that genetic testing should not ordinarily be performed in patients presenting with AF alone. Thus, major knowledge gaps are how to identify those patients in whom AF is the first sign that they possess a potentially serious underlying genetic disease and what is the cardiac phenotype and clinical significance of those rare genetic variants. We are now in a position to address these issues using the NHLBI’s Trans-omics for Precision Medicine (TOPMed) and NHGRI’s Centers for Common Disease Genomics (CCDG) resources. TOPMed has performed whole genome sequencing (WGS) and CCDG has performed whole exome sequencing (WES) in large numbers of subjects with common cardiovascular diseases. Currently, this includes 2,852 participants with early onset AF (age <60 years, a group in which genetic factors may play an especially important role) from Vanderbilt (Vanderbilt TOPMed AF Cohort=1,161, Vanderbilt CCDG AF Cohort=1,691). These participants were recruited from Vanderbilt AF registries and have consented for potential recontact. Using these resources, Aim 1 will perform deep phenotyping to define the cardiac phenotype of AF patients with a pathogenic or likely pathogenic (P/LP) rare variant associated with an inherited cardiomyopathy (CM) syndrome (e.g. arrhythmogenic CM, hypertrophic CM, dilated CM; Aim 1A) or inherited arrhythmia syndrome (e.g. Brugada Syndrome, Long QT Syndrome; Aim 1B) and compared to controls. Participants from these defined genetic subgroups and controls will be recruited for an outpatient research visit to undergo a cardiac MRI, rest/stress/signal-averaged ECGs, and cardiac monitoring. If an inherited arrhythmia/CM syndrome is diagnosed, guideline-directed changes to medical care will be recommended. Aim 2 will create a prediction tool using clinical risk factors ± an AF polygenic risk score to identify patients with AF who have a P/LP rare genetic variant and therefore should undergo genetic testing. While advances in sequencing technology have improved the understanding of how rare and common genetic variation contributes to AF susceptibility, the phenotype of AF genetic subgroups remains incompletely defined. If genetic testing for AF is to add therapeutic value, our work to identify who should be tested and define the clinical implications of these results in a broad AF population is needed.

NIH Research Projects · FY 2025 · 2021-09

Abstract Of the one million emergency department (ED) patients hospitalized with acute heart failure (AHF), loop diuretics are the only IV treatment used over 80% of the time, although only with level of evidence C. Prior studies have focused on the initial dose of IV diuretic and failed to find one strategy with maximal efficacy. Diuretic dosing and response vary widely, leaving many patients inadequately treated. Some have a clinical response to diuretic therapy resulting in symptom improvement and discharge from the hospital within 3-5 days. However, despite apparent symptom improvement, 50% of these patients experience no weight loss and up to 50% leave the hospital with residual congestion. Patients with residual congestion and minimal weight loss at hospital discharge experience a disproportionately high number of readmissions. Up to 20% of hospitalized patients have a poor initial response to IV loop diuretics, and are considered diuretic “non- responsive”. As a result of untreated fluid and sodium retention, worsening heart failure (WHF) occurs frequently during their inpatient stay. Patients who develop WHF experience prolonged hospital lengths of stay (LOS), increased mortality, and consume significantly more resources. There is an unmet need to individualize diuretic therapy to improve decongestion and subsequently reduce adverse events. Yet, even knowing the fundamental role of congestion in AHF, there is little consensus among clinicians about how to optimize diuretic responsiveness. Despite multiple clinical trials aiming to clarify the ideal approach to loop diuretics in the management of congestion, the appropriate selection of dose and route, as well as determination of effectiveness of diuretic therapy remains largely empirical. A standardized, protocol-driven treatment pathway for hospitalized patients started in the first two hours of ED evaluation and utilizing objective measures of diuretic response is needed. This would maximize diuretic efficiency, facilitate quicker resolution of congestion, avoid WHF and prolonged LOS, and reduce AHF readmissions. Our strong preliminary data suggests low urine sodium predicts length of stay and outcomes after initial diuretic dosing in the outpatient and inpatient setting, and can be used to titrate diuretics. Our preliminary use of spot urine sodium to titrate loop diuretic doses and maximize response in inpatients with AHF has shown compelling improvements in congestion and weight loss. We propose to begin this protocol in the ED and hypothesize it will improve AHF outcomes relative to structured guideline-based usual care. Specifically, we hypothesize use of spot urine guided diuretic therapy will: 1) result in significant improvement in global clinical status at 5 days relative to structured guideline-based usual care, and 2) result in significant improvement in congestion at 5 days and in global rank at 30 days relative to structured guideline-based usual care. Early protocolized treatment of patients with AHF will more rapidly improve dyspnea, avoid development of in-hospital WHF, result in greater decongestion at hospital discharge, and therefore prevent HF-related readmissions and CV death.

NIH Research Projects · FY 2024 · 2021-09

ABSTRACT Sepsis-induced acute respiratory distress syndrome (ARDS) is a leading cause of acute respiratory failure in critical illness. Morbidity and mortality are high and there are no proven pharmacologic therapies other than antimicrobials. Sepsis-associated ARDS is characterized by pathologic degradation of the pulmonary endothelial glycocalyx—a glycosaminoglycan-enriched endovascular layer necessary for pulmonary vascular homeostasis. There is a vital need to identify early triggers of endothelial glycocalyx degradation in sepsis, both to enhance our understanding of pathophysiology, and critically, to identify new therapeutic targets for prevention and early treatment of sepsis-induced ARDS. Our published and preliminary data suggest that (1) cell-free hemoglobin (CFH) is released into the circulation in sepsis and contributes to oxidant-mediated organ dysfunction and death; (2) CFH can directly injure the lung endothelial glycocalyx, causing degradation and shedding; (3) haptoglobin, an endogenous scavenger for cell-free hemoglobin that limits its ability to cause oxidative injury has a common genetic variant, HP-2, that increases the risk of ARDS in both humans and mice with sepsis; and (4) patients and mice with sepsis and the HP-2 variant have increased degradation of the endothelial glycocalyx and evidence of increased oxidative stress. The studies in this proposal will build on these preliminary findings to characterize the mechanisms by which CFH-mediated endothelial glycocalyx degradation is modified by the HP-2 genotype. Our primary goal is to translate these findings to new targeted therapies that will be tested in our novel isolated human lung model as preparation for rapid translation to targeted clinical trials in sepsis. In Aim 1, we will use state-of-the-art mass spectrometry analyses of circulating glycosaminoglycan fragments to determine the extent and signature of endothelial glycocalyx shedding in patients with the HP-2 variant, study the association with ARDS and determine downstream mechanisms of endothelial injury. In Aim 2 we will use genetically manipulated mouse models to determine the contribution of heparanase and oxidative injury to glycocalyx degradation in mice with the HP-2 genotype. In Aim 3, we will test the therapeutic potential of targeting oxidant mediated injury in the HP-2 genotype to preserve the endothelial glycocalyx in the isolated perfused human lung as a translational bridge to future patient studies. The studies proposed in these aims have the potential for major and sustained scientific impact. Since HP-2 is the most common allele of the HP gene and over 40% of people of European or African ancestry are homozygous for this allele, targeting patients with the HP2 genotype with therapies to prevent endothelial glycocalyx degradation is a new approach that could have a major impact on clinical outcomes.

NIH Research Projects · FY 2025 · 2021-09

Abstract: Research addressing the causes, diagnosis, and treatment of epilepsy and childhood neurological disorders, as well as implementation of diagnostic and treatment services, is urgently needed in Africa. The burden of epilepsy and child neurological disorders in Africa is very high. Neurological syndromes unique to sub-Saharan Africa have been described, with many more likely awaiting discovery. Currently most children with treatable neurological disorders in sub-Saharan Africa (e.g., epilepsy) are neither diagnosed nor treated. Most of the knowledge base childhood neurological disorders is based upon research from North America, Europe and the Pacific Rim, where the population genomics and environmental causal factors are different from Africa. Large-scale epidemiology studies, clinical trials, development of diagnostic technologies, and implementation science research in Africa are required to close this knowledge gap. There are no well- developed collaboratives of child neurology and epilepsy researchers that cover a large relatively homogenous population of children in Africa. This project, Aminu Kano Teaching Hospital (AKTH)-Bayero University Kano (BUK)-Vanderbilt: Developing Future Leaders in Child Neurology and Epilepsy Research (ABV), will build upon a solid foundation of successful NIH-funded collaborations between Vanderbilt, BUK and AKTH in child neurology and epilepsy to develop a cadre of physician-scientists in northern Nigeria- a region with a population of over 100 million people, half of whom are children. Based in Kano, the hub of northern Nigeria, ABV will over five years provide research training and mentoring for three groups of future research leaders in northern Nigeria: (1) five ABV Faculty Fellows selected to develop and teach new courses at BUK targeting the needs of future research leaders in child neurology and epilepsy, under the mentorship of Vanderbilt faculty; (2) eight ABV Scholars who will complete the MScPH degree at BUK, launching their own research projects co-mentored by Vanderbilt and AKTH/BUK faculty, and attending the Vanderbilt Institute for Research Development and Ethics, where they will learn to write, submit and administer their own grants; and, (3) eight ABV Executive Scholars, mid-career physician-investigators who will devote half-time for up to two years to enhance their skills in an area of child neurology or epilepsy research, working under a mentor and taking selected courses at BUK . ABV Scholars and ABV Executive Scholars will be recruited from not only Kano, but also from sister institutions in the other major cities within northern Nigeria – Zaria, Kaduna, Maiduguri, Katsina, and Sokoto. A yearly Child Neurology and Epilepsy Congress will be launched in Year 3 as a regional conference highlighting the work of the ABV Fellows, Scholars, and Executive Scholars, with plans to expand to an Africa-wide conference by Year 5. The ABV alumni will form a collaborative network across northern Nigeria to address critical research needs in child neurology and epilepsy. Throughout the first five years of the ABV program future principal investigators of ABV will be mentored as they prepare to renew the ABV D43 funding with all Nigerian principal investigators.

NIH Research Projects · FY 2025 · 2021-08

Project Summary Persons with HIV (PWH) have an approximate 2-fold higher risk of cardiovascular disease (CVD) compared to HIV-negative individuals, which is not explained by traditional risk factors and persists despite effective antiretroviral therapy. Some evidence suggests that cytomegalovirus (CMV), an almost universal co-infection in many subgroups of PWH, may be linked to increased CVD risk. However, CMV seropositivity alone (i.e., the presence of anti-CMV antibodies) has been insufficient as a predictor of CVD, potentially due to the greater importance of cellular immunity in the CMV-CVD pathway. Cardiovascular events are the leading cause of death in PWH and although CMV is thought to be important, its specific contribution to CVD in PWH is unclear. Current knowledge on the contribution of CMV to CVD is limited in several ways: 1) Few human studies have assessed peripheral blood circulating anti-CMV T cells and prevalent atherosclerosis. 2) There is a paucity of data on whether CMV-specific T cells are present within human atherosclerotic plaque. 3) At present there is not a reliable animal model to investigate the infiltration of virus-specific T cells into plaque. We have shown that CD4+ T cells co-expressing the surface markers CX3CR1, GPR56 and CD57 (i.e. `C-G-C') are largely CMV- specific. We also showed that C-G-C+ CD4+ T cells are increased in the blood of PWH with metabolic disease and subclinical atherosclerosis. As the chemokine receptor CX3CR1 is highly expressed on CMV-specific T cells and traffics cells to activated endothelium, we hypothesize that inflated anti-CMV C-G-C+ CD4+ T cells recruited to inflamed endothelium via CX3CR1 are a major driver of subclinical atherosclerosis in PWH. I am a physician scientist skilled in immunology and microbial pathogenesis with training in infectious diseases. My tailored career development plan will advance my skills through experiential, didactic and professional training in: (1) tissue immunology; (2) atherosclerosis-pathogenesis; (3) clinical and translational research; (4) human-mouse chimera models; and (5) responsible conduct of research. With a transdisciplinary mentoring panel with expertise in HIV clinical research, epidemiology, single cell immunology, CVD, and atherosclerosis, I will accomplish the following aims. In Aim 1, we will test the hypothesis that peripheral C-G-C+ CD4+ T cells are CMV-specific and associated with subclinical atherosclerosis in PWH. In Aim 2, we will test the hypothesis that plaque-infiltrating C-G-C+ CD4+ T cells are CMV-specific. In Aim 3, we will use a mouse model to test the hypothesis that recruitment of circulating CMV-specific C-G-C+ CD4+ T cells to inflamed atheroma is CX3CR1-dependent. Completion of these specific aims will increase our understanding of whether CMV has an important role in CVD in PWH. With the completion of my career development plan, I will gain expertise in clinical and translational research, vascular biology, and cutting-edge immunology. The completion of this K23 award will allow me to transition to become an independent physician scientist in the cardio-immunology space with concentration on virus-specific immune responses.

NIH Research Projects · FY 2025 · 2021-08

Lung cancer is the leading cause of cancer death in both men and women. African Americans (AAs) have a higher risk of lung cancer than European Americans (EAs) and any other racial group in the U.S. In addition, socioeconomically disadvantaged populations suffer a higher burden of lung cancer than more We recently found that AA males living in deprived neighborhoods had up to a 1.5-fold increased risk of lung cancer than those living in better neighborhoods. We also found that healthy eating was associated with a lower risk of lung cancer. However, the biological mechanisms linking the DNA methylation, one of the most frequent and important epigenetic modifications, plays a crucial role in regulating gene expression and cell function. Lifestyle and socioeconomic status (SES) factors may affect health through methylation modifications AAs and affluent populations. socioeconomic factors with lung cancer is not clear. . In addition, SES disadvantaged populations endure a greater acceleration of biological aging. However, how the individual and social SES and lifestyle factors affect DNA methylation, biological aging, and lung cancer risk in AAs and socioeconomically disadvantaged populations is largely unknown. The ongoing NCI-funded Southern Community Cohort Study (SCCS), a landmark investigation tracking a cohort of ~86,000 adults, two-thirds AAs and one-third non-Hispanic EAs, shows a similar low SES among AAs and EAs. Building on these unique resources, we will conduct the first well-powered prospective social epigenomics study in a cohort at an elevated lung cancer risk. We will perform genome-wide methylation assays for pre-diagnostic blood samples from 1,250 incident lung cancer cases (800 AAs and 450 EAs) and 1,700 individually-matched controls (800 AAs and 900 EAs). Using these methylation data, along with rich epidemiological data collected in the SCCS, we will: identify methylation markers and patterns in association with race (self-reported and genetically determined), individual and social SES, and lifestyle factors (Aim 1) and further investigate whether DNA methylation markers and patterns identified in Aim 1 are associated with lung cancer risk (Aim 2); investigate the associations between lifestyle and SES factors with biological aging (methylation-based age and age acceleration) (Aim 3) and investigate whether biological aging is associated with lung cancer risk (Aim 4). We will further investigate the potential effect of SES and lifestyle factor changes on DNA methylation and biological aging. We will also conduct in vitro functional investigation of promising methylation sites and their regulated genes. Because detailed epidemiological data and biological samples have already been collected in the parent study, this proposed project is both highly feasible and extremely cost-efficient. Findings from this study may provide insights into how individual and social contextual factors affect DNA methylation and help us to better understand the mechanistic relationships between SES/lifestyle factors and lung cancer risk. The findings may also provide useful information which could be used to ameliorate the lung cancer disparities.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY/ABSTRACT Despite marked declines, atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide. Fatal or non-fatal acute myocardial infarction (MI) remains the initial presentation in at least half of these patients. In recent years, reflective of the greater understanding of the many diverse causes of myocardial injury, international consensus definition now includes non-ischemic causes of myocardial injury and several etiologically distinct subtypes of myocardial injury, including subtypes of MI. However, the basic epidemiology of MI subtypes and non-ischemic myocardial injury and how risk factors differ between these categories is conspicuously lacking and critically needed. A fundamental understanding of the epidemiology of myocardial injury events, including differential relationship of traditional and nontraditional risk factors to the different MI subtypes, is needed to advance the prediction, prevention, and treatment of these leading causes of death. The Multi-Ethnic Study of Atherosclerosis (MESA) is a gender balanced contemporary NHLBI cardiovascular cohort with extensive baseline participant phenotyping and event surveillance. In this proposal, we aim to systematically re-adjudicate more than 18,000 clinical events collected in MESA over 14 years. We have developed innovative tools to enhance accuracy and efficiency of the adjudication process. We will use this data to ascertain the incidence of specific acute MI subtypes. We will delineate the size and strength of association between baseline traditional and novel cardiovascular risk factors with individual acute MI subtypes and acute non-ischemic myocardial injury. In addition to analyzing the impact of individual risk factors on specific myocardial injury subtypes, we will utilize factor analyses to leverage information gained from how multiple risk factors within a domain (e.g., thrombogenicity, atherosclerosis and myocardial damage) interact with each other to impact specific myocardial injury subtype. Successful completion of the proposed study will define the type and frequency of acute MI events in a cohort representative of the US target prevention population. By first characterizing and quantifying the risk factor profile, we expect the findings of this project to enable development of more specific individual patient risk prediction and effective tailoring of prevention efforts (precision medicine). Such knowledge will result in the evaluation of more judicious application of current therapies—e.g., limiting aggressive anti-thrombotic therapy for those at greatest risk for Type 1 versus Type 2 MI to maximize benefit and limit risk while more efficiently utilizing healthcare resources. Furthermore, identification of new risk factors will support exploration of novel therapeutic avenues that specifically target individual myocardial injury subtypes.

NIH Research Projects · FY 2025 · 2021-08

Modified Project Summary/Abstract Section This K23 award will support the candidate’s growth toward an independent clinical research career focused on developing and testing psychosocially-oriented mind-body interventions to improve the quality-of-life and treatment outcomes of chronic pain and postsurgical pain populations. Lumbar spine pain affects over 50 million individuals in the United States (US). The rate of spine surgeries performed in the US is the highest in the world. Yet, up to 40% of patients experience poor pain-related, functional, or quality of life outcomes after surgery. Despite the limited efficacy and high risks associated with long term opioid use, up to 50% of patients are prescribed opioids for up to 12 months following lumbar spine surgery. Nonpharmacological approaches addressing psychosocial risk factors for poor post-surgical outcomes are understudied and underutilized during postsurgical recovery. The proposed project aims to 1) adapt and refine a mindfulness-based intervention (MBI) for one-on-one telehealth delivery (live videoconference) to patients recovering from lumbar spine surgery by conducting a preliminary test of the MBI and collecting patient feedback using mixed methods; 2) conduct a two-arm pilot randomized controlled trial (RCT) of the postsurgical telehealth MBI vs. an education control to evaluate the feasibility and acceptability of the interventions and research procedures; and 3) summarize trajectories of pain-related outcomes (pain interference, opioid usage) and treatment targets (pain-related beliefs, mindfulness, psychophysical measures), within intervention groups and within key patient subgroups (levels of preoperative negative affect and opioid use status). The proposal targets career development in several areas: 1) developing and testing mind-body interventions utilizing mixed methods and longitudinal data collection and analysis; 2) randomized clinical trial design and methodology; 3) psychophysical testing of pain modulatory systems; 4) content knowledge in postoperative orthopaedic pain and opioid use; and 5) grant-writing skills. The candidate’s training goals will be achieved with the support of a multidisciplinary team of accomplished mentors and contributors, through targeted course work and seminars, culminating in completion of the proposed research project and dissemination of results. Training will take place in a resource-rich academic medical center with a top-performing surgical center and existing infrastructure for the prospective study of patients undergoing lumbar spine surgery. The findings will help tailor a telehealth MBI for an orthopaedic postsurgical population and provide preliminary data to optimize a well-powered RCT. This K23 award will promote the early career candidate in establishing an independent research program focused on optimizing telehealth mindfulness interventions in postsurgical and pain populations to inform the science and delivery of personalized pain management practices. The goals of this project are strongly aligned with NCCIH scientific priorities to address the widespread burden of chronic pain and the ongoing opioid epidemic.

NIH Research Projects · FY 2025 · 2021-08

Project Summary / Abstract This study will investigate the epidemiology, clinical implications, and immunologic and infectious determinants of aging-related diseases and outcomes in older people with HIV (PWH) in Brazil. In part a result of the long- term effects of HIV infection and ongoing inflammation, older PWH experience high rates of non-communicable diseases (NCDs) and early onset of geriatric syndromes including frailty, disability, and cognitive decline. However, HIV is not alone as a chronic infection that can cause inflammation and other immunological changes associated with these outcomes. Our knowledge of how other chronic infections endemic to low-and middle-income countries affect the pathogenesis and epidemiology of geriatric syndromes in is lacking. A middle-income country with a large population of older PWH, Brazil has a history of comprehensive HIV care as well as endemic chronic infections. This diverse, longitudinal study will recruit PWH on antiretroviral therapy ≥50 years of age in three Brazilian cities (n=360 ages 50-64years and n=340 ages ≥65 years) to evaluate the ways coinfections such as TB, HTLV-1, Chagas disease, toxoplasmosis, and others affect the epidemiology and immunologic pathways of aging-related morbidity. We will examine the association of syndemics of coinfections and social determinants of health with validated NCDs. We will prospectively evaluate how individual and cumulative burden of coinfections predict incident geriatric syndromes. We will evaluate a novel screening tool to assess vulnerability of older PWH for adverse clinical outcomes including death, hospitalization, and new disability. This study will also investigate how coinfections affect biologic pathways of inflammation which contribute to development of NDCs and geriatric syndromes Building upon established and productive collaborations in HIV observational research in Latin America, this study is uniquely positioned to provide urgently needed, high-quality data to understand aging with HIV in a global context. It will offer novel insights into a diversity of infectious contributions to cellular mechanisms of aging experienced by PWH around the globe.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY Although there is evidence that autism spectrum disorder (ASD) can be accurately identified during the second year of life, and that early intervention can improve developmental outcomes, many children in the United States are not diagnosed with ASD until much later. Families seeking ASD evaluation often face barriers such as low availability of specialists, lengthy waitlists, and long distances to tertiary care diagnostic centers. This is especially true for children from traditionally underserved groups and communities. Without an innovative approach for prompt identification of ASD in young children, families and clinicians will continue to struggle with accessing and providing care. Telemedicine offers tremendous potential for addressing this need. However, there are few psychometrically sound, validated tools that can be administered remotely, via telehealth platforms, in order to guide service and action. We recently developed and evaluated a novel parent-administered/clinician- guided tele-assessment tool, the TAP (previously the TELE-ASD-PEDS; R21 MH118539). Initial successful studies within a controlled laboratory context yielded very high levels of family satisfaction with the experience, perceived utility by clinicians, and agreement regarding ASD risk classification with blinded comprehensive evaluation. Although promising, this work was limited by its reliance on controlled laboratory settings, a relatively small homogeneous sample, and use within a single research group. We have not yet validated the TAP for in- home use in a broader community sample, with novel groups of diagnostic clinicians, nor have we adequately demonstrated its value and impact for families representing traditionally underserved populations and areas. The current proposal represents the first rigorous evaluation of a tele-assessment tool for ASD with a large, diverse sample of children within their homes. In the current study, across two sites, we will recruit 360 toddlers (18-42 months) to participate in a home-based telemedicine evaluation using an ASD assessment tool explicitly developed for this purpose (i.e., the TAP). The sample will include children from the community who have screened positive on an ASD screener, as well as those referred from primary care and state early intervention systems. We will randomize families to receive assessment based on telemedicine alone or telemedicine plus an in-person evaluation, and then follow families over a 6-month time interval. This methodology will allow us to conduct rigorous psychometric evaluation of the TAP and comparison to widely used diagnostic tests, longitudinally evaluate service access and family engagement, and examine factors that affect diagnostic decision-making and family outcomes. This work has potential to transform the ASD evaluation process and dramatically improve access for traditionally underserved groups.

NIH Research Projects · FY 2024 · 2021-08

PROJECT SUMMARY/ABSTRACT Coronary artery disease (CAD) is a leading cause of death among adults in the United States. Its prevalence is highest in individuals of African ancestry. It has been estimated that genetic factors account for 26% to 69% of interindividual variation in CAD risk. Large-scale genome-wide association studies (GWAS) of CAD have mainly been conducted in populations of European and East-Asian ancestries and identified 207 independent loci so far. Few of the identified loci have been replicated in populations of African ancestries. Large-scale genetic study of CAD in African-ancestry populations are lacking. This proposal will efficiently leverage the existing resources of the Population Architecture using Genomics and Epidemiology Consortium, Million Veteran Program and other established cohorts to create the largest-ever sample size for a genetic study of African-ancestry populations comprehensively phenotyped for CAD and related cardiometabolic traits. We propose to address the following Specific Aims. Aim 1 will interrogate the genome using admixture mapping, univariate GWAS, multi-variate GWAS and trans-ethnic GWAS approaches to identify loci associated with CAD in African-ancestry populations. Aim 2 will use phenome-wide association studies, variant-trait hierarchical clustering and integrative genomic analyses to characterize CAD loci and gain insights into phenotypic, physiologic, and mechanistic impacts that underlie the pathophysiology of CAD. Aim 3 will explore the public health impact and clinical relevance of CAD risk variants by constructing polygenic CAD risk scores and identifying pathogenic variants in Mendelian syndromes of CAD genes that are relevant to African-ancestry populations. The construction of population- specific polygenic risk scores and identification of rare and low-frequency pathogenic variants of large effect in Mendelian syndromes of CAD genes will facilitate quantification of CAD risk in individuals of African ancestry and potentially narrow the translational gap towards clinical use of genetic information across diverse populations. The comprehensive cross-trait associations of identified CAD risk loci will facilitate the discovery of subtypes of CAD. Both improved genetic CAD risk classifications and refined CAD sub-phenotyping would help with the implementation of precision medicine in CAD. The new biological insights elucidated from novel loci identified in African-ancestry populations may also be generalized to other populations for the diagnosis, prevention, and treatment of CAD.

NIH Research Projects · FY 2025 · 2021-08

Project Summary/Abstract: Acquired hearing loss is becoming increasingly common, especially with the growth of the aging population. For many individuals, hearing loss is severe enough to warrant cochlear implantation. While many adults with cochlear implants (CIs) understand speech well through their devices, enormous unexplained variability exists in speech recognition outcomes, as well as in the trajectory of speech recognition improvement (i.e., perceptual learning) after implantation. Unfortunately, because of this unexplained variability, clinicians are unable to predict how an individual will perform with a CI, to explain why someone has poor speech recognition with a CI, or to design appropriate rehabilitation strategies to help an individual with poor performance. Currently, only half of this outcome variability can be explained by traditional clinical measures. Recent studies have suggested that individual differences in speech recognition among CI users reflect variability in more basic sensory (“bottom-up”) and cognitive-linguistic (“top-down”) factors. These factors should explain additional variability in CI outcomes, and a comprehensive integrative model incorporating traditional clinical measures along with bottom-up and top-down factors is needed. The overall objective of the proposed project is to fill the gap in knowledge regarding the sources of unexplained variability in CI speech recognition outcomes and perceptual learning. Aim 1 will determine the degree to which pre- operative measures of bottom-up sensory functions and top-down cognitive-linguistic processes predict CI speech recognition outcomes. Aim 2 will investigate the degree to which additional objective bottom-up sensory processes, and especially their interactions with top-down factors, explain sentence recognition. Aim 3 will investigate the trajectories of perceptual learning in speech recognition that occur during the first two years of CI use. The findings from this research project will have important theoretical and clinical implications by comprehensively delineating the contributions and interactions of bottom-up and top-down factors as they relate to variability in recognition of speech, as well as helping clinicians to better predict pre-operatively and understand post-operatively the outcomes and time course of perceptual learning that occurs after implantation.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY While reductions in medial temporal lobe (MTL) white matter tract microstructure have been suggested to have a central role in longitudinal cognitive decline in aging and Alzheimer’s disease (AD), it is unknown what genetic factors drive these reductions. The objective of this proposal is to use MTL white matter tract templates in conjunction with genome-wide analyses to identify the genetic drivers of white matter tract microstructure. This proposal will leverage several aging datasets, including the Alzheimer’s Disease Neuroimaging Initiative (n=525), Baltimore Longitudinal Study of Aging (n=295), Religious Orders Study/Memory and Aging Project/Minority Aging Research Study (n=414), Vanderbilt Memory & Aging Project (n=319), Wisconsin Alzheimer’s Disease Research Center (n=488), and Wisconsin Registry for Alzheimer’s Prevention (n=468) to conduct all analyses, totaling in 2,509 participants. Moreover, validation of all results will be conducted using data from a well-established lifespan study (UK Biobank (n=14,701)) and data from the AD Genetics Consortium. The central hypothesis is that MTL white matter tract microstructure is driven by genes and pathways related to myelination, axonal transport, and neuroinflammation in aging and AD. Based on this hypothesis, the primary aims of this proposal will take a multi-level approach to understand which genes and pathways lead to MTL white matter microstructure by using: (1) a candidate gene approach to determine with AD-risk genes are associated with MTL white matter microstructure, (2) a genome-wide approach to identify novel variants which contribute to MTL white matter microstructure and quantify genetic overlap with other traits, and (3) a genome-wide approach to identify how gene expression is associated with MTL white matter tract microstructure and localize signals to relevant biologic pathways. The complementary training plan will equip me with the skills necessary to transition to an independent career focused on imaging genetics by emphasizing the following training objectives: (a) expand expertise in computational genetics, (b) acquire a practical understanding of the pathophysiology and clinical manifestation of AD, and (c) enhance my skillset in data harmonization and big data analytical techniques. The mentoring team is made up of experts in each of these areas, and their training will be augmented through formal coursework, interdisciplinary training at the Vanderbilt Memory & Alzheimer’s Center, and cutting-edge computational and genomic resources available at the Vanderbilt University Medical Center. Together, these practical and intellectual resources provide the ideal training environment, and my primary mentor, Dr. Timothy Hohman, has a well-funded laboratory which will provide all the necessary resources for career transition. These resources will allow me to dedicate 100% protected effort as an Assistant Professor to focus on research and career development. This will ensure that I can competitively compete for independent funding (R01) over the course of the proposed award period.

NIH Research Projects · FY 2024 · 2021-07

Summary HIV-1 infection results in destruction of T helper cells, leading to immunodeficiency and the disease known as AIDS. Most currently available antiretroviral drugs target the viral reverse transcriptase, integrase, and protease enzymes. These medicines are effective but not curative, and therapy must be adhered to rigorously and permanently. Moreover, HIV-1 constantly evolves and acquires mutations rendering it resistant to therapies. Therefore, ongoing research is needed to develop drugs against new viral and cellular targets. Owing to its multiple functions in infection, the HIV-1 capsid represents an attractive therapeutic target, and potent inhibitors targeting this structure have shown promising results in clinical trials. The capsid, which is an assembled lattice composed of a single viral protein, forms a shell around the viral genome and associated proteins and is essential for efficient reverse transcription, a key early step in HIV-1 infection. Perturbations to the stability of the capsid result in abortive infection, yet the mechanism by which the capsid ensures efficient reverse transcription is unknown. This project will fill this gap by defining the effects of capsid perturbations on HIV-1 reverse transcription in vitro, and vice-versa. Using native viral cores purified from infectious HIV-1 particles, we will employ cutting-edge biophysical techniques together with computational and molecular virology approaches to precisely define the role of the viral capsid in HIV-1 reverse transcription. The project will accomplish the following goals: (1) define the biochemical requirements for reverse transcription in HIV-1 cores; (2) define the structural transitions in the core during reverse transcription; (3) determine the role of capsid pores in nucleotide uptake during reverse transcription; and (4) precisely define the protein-nucleic acid interactions within the core during specific stages of reverse transcription. Collectively, this project will yield a greater understanding of capsid function in HIV-1 infection, thereby informing the mechanism of action of an emerging class of antiviral drugs. Relevance The results of this project will be a greater understanding of the functions of the viral capsid that are critical for HIV-1 infection. This information will inform the development of capsid-targeting antiviral drugs and improve the treatment of HIV-infected persons, thereby improving public health and reducing the spread of HIV-1.

NIH Research Projects · FY 2025 · 2021-07

Acute kidney injury (AKI) is an enormous public health problem that affects up to 20% of hospitalized patients, is strongly associated with morbidity and mortality, and carries a high financial toll. Nowhere is this more apparent than in the Southeastern US, which is disproportionately affected by kidney disease and its complications. In addition to the clustering of known risk factors (obesity, diabetes) for AKI In this region, AKI has also emerged as a risk factor for chronic kidney disease (CKD), cardiovascular disease, poor health-related quality of life (HRQoL), rehospitalizations, and death. Improving the quality of care following hospitalization has been recognized by the National Institute of Diabetes and Digestive and Kidney Diseases and other stakeholders as a critical opportunity to reduce the risk for these long-term complications. Despite this emphasis, optimum care for care of AKI survivors is often poor and fragmented, particularly among the disadvantaged who face both systemic and individual-level barriers to post-AKI care that can contribute to CKD. These barriers include poor access to nephrology-specific care elements such as monitoring of kidney function for recovery or recurrent AKI, risk factor modification for kidney disease progression, medication reconciliation and nephrotoxin avoidance, use of kidney and cardioprotective medications, and appropriate in-person nephrology referral. In addition, many patients also experience a heavy symptom burden, limited mobility and motivation, fatigue, and reduced access to transportation or ability to miss work that can reduce engagement in the care. The overarching goal of this proposal is to demonstrate that a nephrologist-guided, multi-faceted intervention with the capability of remote application can bridge these disparities to provide clinical and patient-centered care effectively and efficiently. Specifically, we will apply a specific ‘post-hospitalization AKI care bundle’ following hospital discharge to improve adherence to clinical guidelines and provide other critical elements of care. Simultaneously, we will offer patients cognitive- behavioral based physical therapy (CBPT), a novel home-based intervention that couples self-directed exercise with cognitive-behavioral strategies that can reduce patient’s perception of symptoms and improve engagement and functional status. We will test the ability of these interventions to improve process and clinical outcomes after AKI as well as HRQoL and symptom burden. We will also leverage the tele-health platform to improve accessibility and engagement based on feedback from patient consultant feedback. The study will be performed at Vanderbilt University Medical Center and University of Alabama Birmingham, two major academic medical centers in the Southeast that serve a large catchment of underserved patients and have a robust infrastructure to support the proposed work and the objectives of the Caring for Outpatients after Acute Kidney Injury (COPE-AKI) Consortium.

NIH Research Projects · FY 2025 · 2021-07

PROJECT SUMMARY Dementia is a major cause of death and disability and has emerged as one of the major public health issues of today. Hypertension is a leading risk factor for dementia, both Alzheimer disease (AD) but also Alzheimer disease related dementias (ADRD). Hypertension disrupts the function of the neurovascular unit and promotes vascular insufficiency, leading to neuronal dysfunction and cognitive impairment. Salt-sensitivity is a critical factor in essential hypertension, affecting approximately 50% of hypertensive individuals, but it is unknown how it leads to cognitive impairment. Dietary salt activates signaling pathways which promote production of interleukin-17 (IL17), and increasing circulating levels of the cytokine IL17 have been identified in patients with hypertension, raising the possibility that this cytokine may be involved. Here we will test the hypothesis that the harmful effects of salt-sensitive HTN are mediated by IL17 acting on IL17 receptors on both endothelial cells and perivascular macrophages (PVM), free radical-producing immune cells located in the perivascular space closely apposed to cerebral microvessels, via two distinct mechanisms: (1) circulating IL17 acts on endothelial cells to induce a loss of the beneficial effects of nitric oxide (NO), while (2) T-cells infiltrating the meninges increase IL17 in the cerebrospinal fluid which acts on PVM to induce oxidative stress and proinflammatory signaling. Together, these actions lead to cerebrovascular dysfunction and cognitive impairment in salt-sensitive HTN. To this end, we will first establish the temporal relationship between neurovascular and cognitive dysfunction in a mouse model of salt-sensitive hypertension. Then, we will use pharmacological and cell-specific genetic approaches to determine the contribution of IL17 to the neurovascular and cognitive dysfunction in this model, and establish what are the cellular targets of IL17 in the neurovascular unit. Finally, we will determine the role of peripheral versus central T-cells in mediating the dysfunction, focusing on the relative contribution of meningeal IL17gdT-cells. To achieve these goals, we will use state-of-the-art approaches to study neurovascular regulation, including genetic models for specific conditional knockdown of the IL17 receptor subunit A. In addition to providing me with a unique training opportunity, these studies will fill an obvious gap in the understanding of the mechanisms by which HTN and excessive dietary salt lead to cognitive impairment and may provide new therapeutic approaches to mitigate the damaging effects of HTN on cognitive health.

NIH Research Projects · FY 2025 · 2021-07

PROJECT SUMMARY (ABSTRACT) Sensorineural hearing loss and vestibular dysfunction are most common sensory disorders affecting millions worldwide 1–3. Auditory and vestibular functions require mechanosensitive hair cells, with hair cell loss leading to permanent hearing loss and disabling vestibular dysfunction/hypofunction. Recently, the neonatal mouse utricle, one of five vestibular organs that relies on hair cells to detect linear acceleration, was shown to harbor robust numbers of progenitor cells 6,7. However, while the existence of both mitotic and non-mitotic mechanisms in mammals is now clear, we currently lack understanding of the timing, location, and mechanisms of cell fate decisions. In other systems, like the skin, it is known that fate decisions are made downstream of stem cells and their transit amplifying populations, but we do not yet know the fates of these putative populations in the inner ear 39. A central regulator of tissue homeostasis and stem cell maintenance across many organs is the Wnt pathway 8, and this signaling cascade is upregulated in the inner ear 12. I hypothesize that following injury, mitotic regeneration leads to different cell lineages in the neonatal utricular sensory epithelium, and that Wnt activation directs more supporting cells to adopt the mitotic cell lineage. Gaining an in-depth understanding of the sequence of events that drive mitotic regeneration post injury will reveal potential approaches to regenerate hair cells and supporting cells, with the ultimate goal of restoring hearing and balance functions. As a surgeon-scientist with a passion for treating patients with hearing and balance disorders, I am well equipped to tackle the scientific questions outlined. My interests in the basic sciences stem from my undergraduate years working on the genetics and development of the somatosensory cortex and studying the olfactory system. During medical school, I saw the lack of therapies of patients with permanent hearing loss as an opportunity, working on hair cell regeneration under the tutelage of renowned scientists, including Dr. Stefan Heller and Dr. Roel Nusse (Jan et al., 2013, Development). As a resident in otolaryngology, I focused on gaining the clinical and surgical expertise to treat patients and had the opportunity to continue basic science research with a focus on hearing loss under Dr. Konstantina Stankovic. In order to gain advanced surgical skills and learn state of the art techniques to study inner ear regeneration, I completed the T32 funded Clinician Scientist Training Program in Otology & Neurotology. This program further allowed me to collect preliminary data and chart my goals for this proposal as a new faculty member at UCSF. While I have extensive training in inner ear biology, my knowledge is lacking in advanced mouse genetics, new single cell RNAseq technologies, and advanced bioinformatics. Under the guidance of renowned stem cell physician-scientist Dr. Ophir Klein as my mentor at UCSF, and expert inner ear surgeon-scientist, Dr. Alan Cheng as my co-mentor at Stanford, I am confident this award will prepare me for scientific independence through the R01 grant mechanism.

NIH Research Projects · FY 2025 · 2021-07

PROJECT SUMMARY Despite major medical advances, cardiovascular disease remains the major cause of morbidity and mortality worldwide. Even with aggressive risk factor control, nearly 50% of patients suffer recurrent cardiac events and this “residual risk” has been attributed to excessive inflammation. Recent work has demonstrated that atherosclerosis is also characterized by the failure of inflammation resolution. The resolution program is regulated by the production of specialized pro-resolving lipid mediators (SPMs) and the efficient clearance of apoptotic cells (efferocytosis) from tissue. Advanced atherosclerotic plaques have higher numbers of apoptotic cells, larger necrotic cores, and an imbalance of pro-inflammatory:pro-resolving mediators compared with early lesions, all of which are suggestive of failed resolution. Strategies that boost resolution and break the cycle of chronic inflammation promote plaque stability. Therefore, the identification of novel targets that mediate this process is of critical importance. Our preliminary data have identified Ca2+/Calmodulin-Dependent Protein Kinase IV (CaMK4) as a central regulator of both inflammation and resolution. Uniquely, CaMK4 appears to play an important role in the development of innate immune memory in macrophages, which enhances their pro- inflammatory responses to atherogenic stimuli. Therefore, we hypothesize that CaMK4 is a critical mediator of immune memory and that immune training impairs resolution through a CaMK4-dependent mechanism. We will test our hypothesis through the following aims: Specific Aim 1 will test the hypothesis that myeloid-CaMK4 impairs resolution as a mechanism by which it promotes atheroprogression. Specific Aim 2 will explore the mechanism by which CaMK4 promotes oxLDL training of myeloid progenitors and macrophages in order to augment their inflammatory cytokine production. Specific Aim 3 will test the hypothesis that targeting CaMK4 in advanced atherosclerosis can promote regression of plaque.

NIH Research Projects · FY 2025 · 2021-07

Schizophrenia is a severe and heterogeneous mental disorder that impacts most domains of function including behavior, cognition, and emotion. Recent models have highlighted important alterations of the emotion brain networks in schizophrenia that contribute to schizophrenia symptoms, like paranoia and delusions. To date, the studies of emotion in schizophrenia have primarily focused on fear processing and have shown heightened amygdala responses to neutral stimuli and altered amygdala-prefrontal cortex connectivity. However, recent research suggests that another brain region—the bed nucleus of the stria terminalis (BNST)—may play a critical role in anxiety and that BNST-mediated anxiety is distinct from amygdala-mediated fear. The RDoC’s Negative Valence System recognizes this fear-anxiety distinction and has separate constructs for Response to Acute Threat (amygdala) and Response to Potential Harm (BNST). To our knowledge, the BNST has yet to be examined in individuals with schizophrenia. Using methods pioneered by our lab to study the human BNST, we have collected preliminary data in schizophrenia. Our pilot data provides initial evidence for BNST connectivity differences in both response to unpredictable threat, a measure of the response to potential harm construct, and during a resting state in individuals with schizophrenia compared to healthy controls. Further, we found evidence that BNST alterations in schizophrenia differ for those who do or do not have comorbid anxiety. Individuals with schizophrenia and anxiety disorders demonstrated stronger connectivity between BNST and multiple brain regions involved in threat detection, uncertainty, and anxiety relative to those with schizophrenia and no anxiety disorder. The current study will investigate BNST connectivity in three groups: individuals with schizophrenia with a comorbid anxiety disorder (SZ+ANX), individuals with schizophrenia without a comorbid anxiety disorder (SZ-ANX), and healthy controls (HC). We hypothesize that individuals with schizophrenia will have altered BNST connectivity in response to unpredictable threat and altered BNST intrinsic connectivity relative to HC. In addition we predict that SZ+ANX group will show BNST hyperconnectivity relative to SZ- ANX. We will test these hypotheses with three specific aims. (1) Investigate BNST connectivity in response to unpredictable threat in individuals with schizophrenia; (2) Determine whether there are differences in BNST intrinsic connectivity in individuals with schizophrenia; (3) Test for relationships among BNST connectivity, stress responses (skin conductance and cortisol), and clinical symptoms in schizophrenia. Given the prevalence of anxiety in schizophrenia, BNST alterations within schizophrenia are likely and may shed new light on the neurobiological mechanisms underlying emotion alterations in schizophrenia. The results from the proposed study can provide a foundation for future studies of emotion in schizophrenia, determine whether there are neurobiological differences in anxiety subgroups, and guide the development of novel neuroscientifically-informed treatments.

NIH Research Projects · FY 2025 · 2021-07

Black African multiple sclerosis (BA-MS) patients exhibit double the neurodegeneration rates of Caucasian patients (CA-MS). Socioeconomic factors do not completely account for this disparity, pointing to biological mediators. Antibody-secreting cells (ASC)s are associated with MS disease activity and production of neurotoxic demyelinating and axopathic antibodies. Intrathecal antibody levels strongly correlate with neurodegeneration among Black African but not Caucasian MS patients. This suggests that ethnicity-associated differences in neurotoxic antibody function may promote the heightened clinical severity reported for BA-MS patients. However, no study has examined whether the prevalence or quality of neurotoxic antibodies differs according to ethnicity. Determining how neurotoxic antibody responses in MS vary by ethnicity will improve our understanding of antibody-mediated CNS degeneration. This will better position us to address inordinate CNS disease burden faced by MS patients from underserved backgrounds. The mentored phase (Aim 1) includes: generating recombinant human antibodies (rhAb) derived from individually sorted ASCs; culturing these rhAbs with myelinating central nervous system tissue; and, measuring rhAb-mediated demyelination and axon loss through immunohistochemical analysis. Sequencing data collected as a byproduct of single cell rhAb generation will provide the candidate opportunity to gain high-level knowledge of antibody genetic repertoire analysis. During the independent phase, the above approaches will be applied to other B cell subsets that feature in MS disease activity; double negative 2 (DN2) B cells in Aim2, and repopulating B cells after depletion therapy in Aim3. Each of the three aims employs subject cohorts that correspond to different stages of MS: early MS patients experiencing their first symptoms (Aim1); established clinically- managed MS patients (Aim2); and established clinically-managed MS patients after B cell depletion therapy (Aim3). For each cohort we will determine the quality, quantity and cellular sources of neurotoxic antibodies in relation to self-identified ethnicity and genetic ancestry. Employing similar technical approaches across all aims establishes complementary phenotypic, functional and genetic antibody repertoire datasets for different B cell subsets and stages of MS. This facilitates future research avenues for the candidate. The proposed work will provide competencies for an independent research career. The mentoring team: Drs Vartanian, Monson, Elemento, & Pascual, will supervise the candidate in experimental methodology. Through regular meetings, they will advise the candidate in securing a faculty position and developing a research program. Advisor team members: Drs. Bennett, Nussenzweig, Davis, Kittles, Sanz & Kister will provide additional technical & professional guidance through their extensive experience with methods & approaches outlined in the Research Strategy; such as, neuroimmunologic assays, molecular genetic approaches, as well as with studying differential ethnicity or ancestry-associated clinical disparities.

NIH Research Projects · FY 2025 · 2021-07

Reoviridae viruses, which include important human and animal pathogens, assort and package nine to twelve positive-sense RNA segments that are converted to genomic double-stranded RNA during virus assembly in cytoplasmic inclusions. Reoviridae genetic diversity contributes to host range and vaccine responses. To infect and adapt, Reoviridae viruses have evolved mechanisms to promote genetic diversity and complement defective particles. These mechanisms include segment reassortment and transmission of multiple particles as collective infectious units. Evolutionary benefits of diversity are countered by a need to maintain interactions mediating multipartite genome packaging, assembly, egress, and transmission. Thus, the replication strategy also may inherently constrain diversity. The goal of the proposed research is to understand how Reoviridae assembly and transmission processes regulate unique aspects of viral genetic diversity. To accomplish this goal, we will use reovirus, a genetically tractable Reoviridae virus with established tissue culture and mouse models. The termini of Reoviridae RNA segments are important for packaging, but RNA elements that mediate assortment of a specific collection of segments are poorly defined. In Specific Aim 1, we will sequence defective viral gene segments using long-read and short-read approaches to identify minimal reovirus RNA packaging and assortment determinants. We will determine the capacity of RNA recognition elements to interchangeably mediate segment packaging and assortment using reverse genetics and functional assays. Physical sequestration of viral RNA in cytoplasmic inclusions may influence segment reassortment during coinfection, and innate cellular responses may influence reassortment by inhibiting superinfection. In Specific Aim 2, we will determine the localization of viral RNA during coinfection using sensitive RNA imaging probes and effects of infection timing on replication and reassortment in vitro and in vivo using viruses encoding silent genetic polymorphisms. Transmission of Reoviridae viruses in extracellular vesicles may promote simultaneous multi-particle infection of target cells. In Specific Aim 3, we will elucidate contributions of vesicle- mediated virus transmission to genetic diversity and virulence. The proposed studies will provide insight into mechanisms of viral genetic diversity that are mediated by the assembly and transmission processes of viruses in the Reoviridae family. Many principles derived from this work will apply broadly to viruses that replicate in compartmentalized subcellular regions, induce innate antiviral responses, or travel in extracellular vesicles. Together, these findings will promote rational engineering of Reoviridae-based preventives and therapeutics and identification of factors that predict outcomes of natural virus coinfection and transmission.

NIH Research Projects · FY 2024 · 2021-07

PROJECT SUMMARY/ABSTRACT The use of benzodiazepines, an addictive yet commonly prescribed class of drugs in the US, is independently linked to serious health outcomes, including falls and fractures. Benzodiazepines are also frequently involved in opioid-related overdoses, underscoring their relevance in the ongoing US opioid epidemic. Benzodiazepine coverage restrictions and other regulatory actions have been implemented in the past to reduce benzodiazepine use and related harms, though the intended and unintended impact of these actions remains unclear. One such restriction with national implications was the exclusion of benzodiazepines coverage for Medicare enrollees during the implementation of Medicare Part D in 2006. At the same time, the Tennessee Medicaid (TennCare) program instituted a restriction on benzodiazepine coverage for all enrollees. TennCare was the only State Medicaid program in the country to do so. Thus, TennCare enrollees (including dual- eligibles) did not have benzodiazepine coverage from either Medicaid or Medicare from 2006 through 2013, when the restriction was partially removed, and then completely removed in 2014. This intermittent restriction and subsequent reintroduction of benzodiazepine coverage is unique to TennCare enrollees and provides the setting for a natural experiment to determine the impact of benzodiazepine restrictions on benzodiazepine- related harms and the use of other psychotropic medications. The proposed work will use retrospective longitudinal TennCare data linked to Medicare Part D, Vital Records, and State hospitalization data to examine three specific aims: Aim 1: To test the hypothesis that benzodiazepine restrictions in 2006 led to a lower rate of falls, fractures and opioid-related overdoses among TennCare patients with indications for benzodiazepines use compared to patients without indications for benzodiazepines. Aim 2: To test the hypothesis that the implementation and subsequent removal of benzodiazepine restrictions in 2006 and 2014 led to compensatory changes in the rates of filled prescriptions for other similarly indicated psychotropic medications among TennCare patients with indications for benzodiazepine use. Aim 3: To test the hypothesis that the removal of benzodiazepine restrictions in 2014 led to a higher rate of falls, fractures and opioid-related overdoses among patients with indications for benzodiazepine use compared to patients without indications for benzodiazepine use. To inform the proposed work and the development of an independent research program focused on drug safety research, the candidate has identified mentors with relevant expertise to oversee additional training opportunities in (1) the application of advanced difference-in-difference designs for the evaluation of state policy changes, (2) the clinical needs and barriers to care among patients that use benzodiazepines and other psychotropic drugs, and (3) the large-scale linkage of claims data with other clinical and administrative data sources. Findings from this study will inform future strategies to reduce benzodiazepine- and opioid- related harms, including benzodiazepine and opioid-related overdoses and death.

NIH Research Projects · FY 2025 · 2021-07

Project Summary Over 25 million people per year are treated emergently for injuries and more than 5 million people are admitted annually for critical illness. This Interdisciplinary Training in Injury and Critical Illness will help contribute to the next generation of trauma surgeon-scientists who can tackle the basic, translational, and clinical aspects of research spanning the bench to bedside. This research will center on the broad-expertise of our 16 Scientific Mentors covering the domains 1) Injury and 2) Critical Illness. Interdisciplinary participating faculty have extensive collaborations with each other and hail from the 6 Departments (Surgery, Orthopedics, Plastics, Medicine, Anesthesiology, and Engineering). Vanderbilt is at the nexus of 70,000 miles of injured and critically ill patients with annual trauma evaluations exceeding 6,000/year, offering robust opportunities for primary and secondary analysis of prospective clinical cohort and multicenter clinical trial data, as well as translational approaches to important aspects of injury and critical illness (e.g., lung injury, peripheral nerve injury, orthopedic trauma, sepsis, burns, cognitive impairment). Dr. Mayur B. Patel, a previous post-doctoral T32 trainee, now established academic trauma surgeon-scientist, will lead this T32 program as Program Director to develop the next generation of future surgeon-scientists. Scientific Mentors who serve as primary mentors for T32-funded trainees hold secondary appointments in multiple basic science and clinical departments and associated research centers. The proposed T32 training program will commence after a national search for high-performing candidates, who have completed a minimal of two years of surgical training (or equivalent clinical or post-doctoral experience), and ultimately support up to one new post-doctoral trainees per year. Two years of dedicated research training will be required for all trainees. To maximize scientific career development potential, our training program offers the rigorous opportunity to earn additional graduate training (e.g., Master of Public Health, Master of Clinical Investigation).

NIH Research Projects · FY 2025 · 2021-06

PROJECT SUMMARY There is a fundamental gap in our understanding of how host mitochondrial health and homeostasis modulate infectious disease outcomes. The overall objective of this application is to define the molecular contributions of pathogen-induced mitochondrial damage and host mitochondrial mutations to innate immune outcomes during Mycobacterium tuberculosis (Mtb) infection in macrophages ex vivo and in mouse models of human disease. Because mitochondria are of bacterial ancestral origin, they release many of the same damage-associated mo- lecular patterns (DAMPs) that activate innate immune pathways during bacterial infection. In spite of their clear potential to regulate innate immunity, the ability of mitochondrial DAMPs to skew innate immune responses during infection remains understudied. Several lines of evidence strongly argue that mitochondrial homeostasis is crucial for controlling mycobacterial infection outcomes. First, genome-wide association studies frequently identify SNPs in mitochondrial-associated genes (e.g. LRRK2, TFAM, POLG) that confer susceptibility to myco- bacterial infection. Second, mycobacterial infection itself has been shown to damage mitochondria and release mitochondrial DAMPs that are associated with potent innate immune responses, including type I interferon ex- pression, inflammasome activation, and inflammatory cell death. The central hypotheses of this application pre- dict that (1) Mtb has evolved to damage mitochondria directly in order to enhance type I IFN expression and induce pro-bacterial immune reprogramming and (2) mutations in leucine rich repeat kinase 2 (LRRK2) confer mycobacterial susceptibility because they compromise mitochondria network stability and trigger excessive cell death in Mtb-infected macrophages, which leads to hyperinflammation during Mtb infection in vivo. To fully ap- preciate the biology at the mitochondrial-Mtb interface, one needs to consider both the host and the pathogen. To this end, pathogen-focused Aim 1 of this proposal is designed to identify novel Mtb virulence factors that disrupt mitochondrial homeostasis and link the release of mitochondrial DAMPs to type I interferon production in Mtb-infected macrophages. Aim 2 shifts focus to the host and investigates the molecular mechanisms that drive mitochondrial damage and inflammatory cell death pathways in macrophages that harbor a common human mutation, Lrrk2G2019S. Lastly, Aim 3 will link these macrophage phenotypes to the hyperinflammatory phenotype observed in Mtb-infected Lrrk2G2019S mice and determine whether drugging mitochondrial-associated factors like LRRK2 can alter the outcome of Mtb infection. This project is significant because elucidating the role mitochon- drial dysfunction plays in exacerbating tuberculosis disease enables the design of therapeutic interventions that correct mitochondrial defects and balance skewed immune responses to improve patient outcomes. This ap- proach is innovative because it challenges existing conceptual paradigms, employs sophisticated technologies at the cutting-edge of Mtb research, and leverages the unique expertise of PIs on each side of the host-pathogen interface.