Vanderbilt University Medical Center

NIH Research Projects · FY 2025 · 2021-06

PROJECT SUMMARY AND CAREER DEVELOPMENT ABSTRACT There is no therapy that slows the progression of any symptom of Parkinson’s disease (PD), a progressive, age-related neurodegenerative disorder that affects more than one million Americans. Although reserved for later PD stages as an alternative when medications fail, deep brain stimulation (DBS) therapy has strong evidence that it protects nigral neurons when applied in animal models of early-stage PD. Those promising preclinical studies motivated the first randomized clinical trial evaluating DBS in early-stage PD. Recent findings from that pilot trial provided class II evidence that early DBS slows the progression of rest tremor, a common and often distressing cardinal motor symptom for early-stage patients. This landmark finding must now be prospectively tested, and a multicenter, randomized phase 3 trial is approved by the FDA. Similar to the pilot, the phase 3 trial will evaluate underlying motor symptom progression using week-long therapeutic washouts. Since the original investigation completed, new objective measures to evaluate PD have emerged, including PD-specific metabolic networks identified from 18F-fluorodeoxyglucose (FDG) positron electron tomography (PET) scans and wearable biosensors that evaluate motor symptoms and dyskinesia. Including these unbiased measures alongside standard clinical assessments after a week-long therapeutic washout offers the opportunity to objectively evaluate whether early DBS slows PD progression compared to standard medical therapy. Additionally, there were no safety issues during 147 washout experiences in the pilot, and early-stage PD patients preserved their independence in activities of daily living throughout the washouts. Given the mild symptomology of early-stage PD, conducting the washouts in the ambulatory setting may offer a less burdensome and more cost-effective alternative. Before proceeding to a phase 3 trial, the feasibility of making changes to the week-long washout protocol to add objective FDG-PET neuroimaging (Aim 1) and wearable biosensors (Aim 2) while being conducted in the ambulatory setting (Aim 3) must first be tested. This study will fill critical knowledge gaps concerning use of new objective measures during an outpatient washout in 20 early-stage PD patients. This new information will be used to finalize the protocol of a phase 3 trial to determine if early DBS slows Parkinson’s disease motor symptom progression compared to standard care. My career goal is to become an independent scientist who investigates new therapies for early-stage Parkinson’s disease. I have identified four gaps in my training that, once filled, will accelerate my progress toward that goal. These four areas are: 1) PD neural networks, 2) objective PD measurements, 3) health care needs for older adults with neurological disorders, and 4) leading multidisciplinary clinical trials teams. I have developed a training plan to overcome these barriers that integrates formal didactic training with one-on-one, multidisciplinary mentorship in an outstanding research environment at Vanderbilt University. Completing the proposed research and training plan will help me successfully compete for R01-level funding.

NIH Research Projects · FY 2025 · 2021-06

ABSTRACT: Antisocial behavior is common in patients with frontotemporal dementia (FTD). These behaviors result in significant morbidity and can lead to crimes in extreme cases. Yet despite being one of the most challenging and problematic symptoms to manage clinically, the mechanisms leading to antisocial behavior in FTD are unknown, and treatments remain limited. The goal of the current proposal is to determine the cognitive and neural mechanisms leading to antisocial behavior in FTD. Understanding these mechanisms will have a major impact on FTD patients by improving clinical evaluations to monitor the onset and progression of antisocial behaviors, helping to develop novel pharmacologic and neuromodulatory treatment strategies, and informing legal and ethical treatment of FTD patients who commit crimes. In Aim 1 I will examine the neural mechanisms and the hypothesis that FTD patients with antisocial behavior will have atrophy in a pre-defined network of brain regions I identified in patients with antisocial behaviors caused by focal brain lesions. I will test this hypothesis using a new neuroimaging method I recently developed and validated called atrophy network mapping that uses the human connectome and single-subject atrophy maps to localize neurological symptoms to brain networks rather than an isolated region. In Aim 2 I will examine the cognitive mechanisms and the hypothesis that FTD patients with antisocial behavior have specific impairments in moral decision-making. My long-term goal is to use multimodal neuroimaging and decision-making tasks to better understand the mechanisms leading to antisocial behavior and other behavioral problems in dementia patients. To achieve this goal, a training plan is proposed to learn additional research skills in functional neuroimaging methods (Training goal 1) and the neuropsychology of social decision-making (Training Goal 2). Additional training in leadership, biostatistics, and grant-writing will prepare me to achieve independence (Training goal 3). A mentorship team of experts has been assembled to help me achieve these training goals, consisting of Dr. Daniel Claassen (primary mentor), a behavioral neurologists who studies reward-based decision-making and functional neuroimaging in patients with neurodegenerative disorders; Dr. David Zald (co- primary mentor), a neuropsychologist and cognitive neuroscientist who uses functional neuroimaging to study decision-making in aging and antisocial behavior; and Dr. Bennett Landman (co-mentor), a neuroimager who develops computational methods to study neuroimaging changes in aging. The team will also include Dr. Hakmook Kang (collaborator), a biostatistician with expertise in neuroimaging, Dr. Catherine Chang, a neuroimager with expertise in functional connectivity, and Dr. Katherine Rankin (external consultant), a neuropsychologist with expertise in psychometric assessments of social and emotional processing in FTD.

NIH Research Projects · FY 2025 · 2021-05

PROJECT SUMMARY / ABSTRACT This proposal is for a mentored patient-oriented research career development award for Dr. Shawniqua Williams Roberson, Assistant Professor of Neurology and Bioengineering at Vanderbilt University Medical Center. Dr. Williams Roberson's long-term goal is to establish an independent research career using EEG signal processing techniques to study the neurobiology and neurophysiological indicators of ICU delirium and post-ICU cognitive impairment and dementia, a potentially devastating disorder recognized and funded under the Alzheimer's Disease and related dementias (ADRD) for which older adults are at highest risk. To accomplish this, her objectives during the period of this award are: (1) to develop expertise in the design and implementation of patient-oriented clinical research studies in ICU delirium and post-ICU dementia; (2) to gain experience in the assessment of cognitive function as an outcome measure; and (3) to develop the scientific communication, grant writing and leadership skills to support a successful career as an independent researcher. The central hypothesis of this proposal is that there are objective EEG-based signatures of ICU delirium that predict patterns of post-ICU cognitive impairment and dementia. The specific aims are (1) to characterize quantitatively the resting-state EEG signatures associated with ICU delirium in older adults and (2) to determine the relationship between EEG signatures during recovery from critical illness and post-ICU cognitive performance in this population. The proposed studies will yield critical information to advance our understanding of the neurobiology underlying delirium and its evolution to post-ICU ADRD by informing development of a novel delirium monitoring tool for the ICU and identifying EEG predictors of ADRD in survivors. The results will be used to inform a subsequent R01 validating an EEG-based index of ICU delirium and a prediction model for post-ICU ADRD. The project will be conducted in the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center and will allow the PI to capitalize on guidance from a world-class mentoring team. Dr. E. Wesley Ely, a renowned expert in clinical research in aging and critical care populations will be primary mentor and supervise the clinical research methodology. Dr. James C. Jackson, a world leader in neurocognitive outcomes research, will guide the conduct, analysis and interpretation of cognitive assessments. Dr. Mayur Patel, PI of multiple ongoing NIH-funded studies investigating long-term outcomes after critical care, will oversee professional development in scientific communication, grant writing and leadership. This project will thus provide a platform for Dr. Williams Roberson to establish preliminary data and clinical research skills to launch an independent research career at the intersection of critical illness, cognitive neuroscience, engineering and clinical neurophysiology, where she is uniquely poised to make a durable impact for ICU survivors.

NIH Research Projects · FY 2025 · 2021-05

ABSTRACT: Background: EGF receptor (EGFR) is a receptor tyrosine kinase (RTK) that is overexpressed in over 50% of colorectal cancer (CRC) cases where it is linked to metastasis and poor prognosis. Cetuximab, an EGFR-targeting monoclonal antibody is approved by US-FDA to treat advanced wild-type KRAS CRC. However, cetuximab, as monotherapy, is effective in only about 10% of CRCs and resistance frequently emerges. Thus, there is a pressing need 1) to identify those patients most likely to respond (or not respond) to cetuximab and 2) to devise treatment strategies that would prevent resistance and/or enhance cetuximab response. We propose to address these needs by aggressively pursuing our observations that enhanced activity of multiple RTKs (e.g. MET and RON) confers de novo and acquired cetuximab resistance, which may be overcome by addition of the dual MET/RON inhibitor, crizotinib. Our central hypothesis is that upregulation of RTK activity confers cetuximab resistance in CRC and that it may be a viable therapeutic target. In Aim 1 we will identify the mechanism of RTK cooperation during CRC progression and cetuximab resistance using genetic and chemical modifications in CRC cell lines and patient- derived xenografts (PDXs) and organoids (PDOs). In Aim 2 we will assess the impact of disrupting RTK cooperation in overcoming resistance to EGFR-directed antibodies. In Aim 3 we will identify rational drug combinations and stratify patient populations to overcome resistance to EGFR- directed mAbs. Study design: We will employ our in vitro 3D culture system for CRC cell lines and PDOs and in vivo nude mice xenografts, PDXs, and immune-competent syngeneic mouse CRC models in this grant. We will also employ complementary approaches (Transwell cultures, tumor tissue microarrays, phospho-RTK arrays, and human CRC samples) in relevant sections. Key proteins (EGFR, MET, RON, ERBB3, HGF, HGFL, NRG1 and other positive and negative RTK and ligand regulators) will be manipulated (overexpression, CRISPR-mediated knockout, ligand stimulation, and chemical and antibody-based inhibition) to characterize individual contribution. These experiments will be recorded at subcellular localization, morphological, and phenotypic levels to tease out key differences. These studies will identify and characterize new modes of cetuximab resistance and its prevalence in CRC, while devising means to prevent or overcoming the resistance. This research will help optimize precision medicine and stratify individuals based on their response/resistance profile for better CRC treatment and management.

NIH Research Projects · FY 2025 · 2021-05

Project Summary: Salt-sensitivity of blood pressure (SSBP) is an independent risk factor for cardiovascular mortality not only in hypertensive, but also in normotensive adults. The diagnosis for SSBP is not feasible in the clinic due to lack of a simple diagnostic test, making it difficult to investigate therapeutic strategies. Most research efforts to understand the mechanisms of SSBP have focused on renal regulation of sodium (Na+). However, salt retention or plasma volume expansion are not enhanced in salt sensitive (SS) versus salt resistant (SR) individuals. In addition, over 70% of extracellular fluid is interstitial and therefore not directly controlled by renal salt and water excretion. Thus, further research is needed to understand the extrarenal mechanisms contributing to SSBP. We recently found that Na+ enters monocyte-derived dendritic cells through the amiloride sensitive epithelial Na+ channel (ENaC) and activates the NADPH oxidase leading to formation of highly reactive products of lipid oxidation known as isolevuglandins (IsoLGs). IsoLGs adduct to self-proteins and act as neoantigens, which activate T cells to produce cytokines that promote Na+ retention and blood pressure (BP) elevation. Interestingly, analogous to SSBP, we found considerable variability in the response of human monocytes to in vitro exposure to elevated Na+ which correlated with known cardiovascular risk factors. It is not known if this variability in the responsiveness of monocytes to elevated Na+ happens in vivo and if it contributes to the SSBP. Recent studies found that Na+ accumulates in the interstitium electrostatically bound to glycosaminoglycans but can be mobilized. This is relevant to circulating monocytes as they enter and re-emerge from the interstitium with increased ability to present antigens. Our data indicate that monocytes from humans with high skin Na+ are activated and have increased IsoLGs. This R01 proposal presents an opportunity to study how immune activation and interstitial Na+ interact to impact SSBP in well phenotyped SS and SR individuals. We hypothesize that circulating monocytes transmigrate into regions of elevated Na+ including the skin, muscle and kidney, and are activated via IsoLG-adduct formation leading to SSBP. In Aim 1, we will employ an inpatient Weinberger protocol to classify participants as SS or SR and measure tissue Na+ using 23NaMRI to determine if tissue Na+ and monocyte activation contribute to SSBP. In Aim 2, we will adoptively transfer monocytes with T cells from SS and SR people into immunodeficient NSG-(KbDb)null (IA)null mice and determine if monocytes from humans with SSBP induce T cell activation, endothelial dysfunction, end-organ damage and SSBP in the humanized mice. These translational studies will advance the field and reveal more feasible and cost-effective diagnostic and therapeutic strategies for SSBP. Our exciting preliminary data indicating that changes in monocyte IsoLGs mirror changes in BP in response to salt provide promise for not only a simple diagnostic tool, but also mechanistic insight into the pathogenesis of SSBP. Alongside efforts to develop therapies for SSBP by focusing on the kidney, we propose that interstitial Na+ and monocyte activation via IsoLGs are important targets.

NIH Research Projects · FY 2025 · 2021-05

PROJECT SUMMARY The acute respiratory distress syndrome (ARDS) affects more than 200,000 adults each year in the United States and carries a high mortality risk. Heterogeneity in susceptibility and outcomes are prominent features of ARDS, and improved understanding of the genetic underpinnings of ARDS would advance our ability to define ARDS subphenotypes, predict disease risk, and identify new therapeutic targets: a critical challenge identified in the NHLBI’s most recent Strategic Vision plan. This K01 proposal will provide Dr. V. Eric Kerchberger, MD with critical training for his long-term career goal of bringing precision medicine to critical care by applying his expertise in biomedical informatics and genetic analysis to leverage the power of large-scale electronic health record (EHR) databases and DNA biobanks. The project will be completed under the guidance of primary mentor Lorraine B. Ware, MD and co-mentor Wei-Qi Wei, MD, PhD, and a research advisory committee of experts in precision medicine, biomedical informatics, and functional genomics. By integrating existing GWAS- level genotyping with PrediXcan, an advanced functional genomics framework, this project will quantify tissue- specific gene expression levels for lung tissue and immune cells in 3,100 critically ill adults enrolled in the Validating Acute Lung Injury Markers for Diagnosis (VALID) Study cohort. Then, leveraging Dr. Kerchberger’s expertise in EHR phenotyping, we will validate the genetic findings from VALID in an independent sample of ARDS patients from BioVU, Vanderbilt University Medical Center’s large de-identified DNA biobank. This mentored research project has three specific aims: Aim 1: Test the association between genetic regulation of gene expression and ARDS susceptibility in at-risk adults. Aim 2: Test the association between genetic regulation of gene expression and patient-centered outcomes in ARDS. Aim 3: Use advanced phenotyping methods to identify ARDS patients and at-risk controls in BioVU, and replicate gene expression associations identified in VALID. Completion of these studies will yield novel methods to identify ARDS patients and at-risk controls from large EHR databases, and advance our understanding of tissue-specific gene expression in ARDS, bridging the gap between genetics and biology. The knowledge gained from this proposal will provide vital preliminary data for Dr. Kerchberger to design and execute future R01 proposals to study functional genomics in ARDS using NIH- supported EHR biobanks such as the Electronic Medical Records and Genomics Network and the NIH All of Us Project. Furthermore, Dr. Kerchberger will gain new skills in the clinical translation of functional genomics and advanced EHR phenotyping, forming the foundation for Dr. Kerchberger to independently lead collaborative teams of clinicians, geneticists, and data scientists to conduct large EHR-based studies of critical illness syndromes that will improve risk prediction, identify novel disease subtypes using genetic risk, and ultimately bring precision medicine to the critically ill patient.

NIH Research Projects · FY 2026 · 2021-05

PROJECT SUMMARY The goal of this application is to test the clinical utility of a biomarker-informed approach to the evaluation and management of indeterminate pulmonary nodules (IPNs). The study is designed to address this major and growing unmet need given the adoption of lung cancer screening in the US and abroad and the common occurrence of incidentally identified IPNs. We have developed and validated in external cohorts a high sensitivity hs-CYFRA 21-1 biomarker assay and quantitative imaging features that together improve the current non- invasive assessment of IPNs. In this proposal we hypothesize that a prediction model that integrates clinical variables, hs-CYFRA 21-1 serum concentration, and quantitative imaging signature will show clinical utility by reducing costly and invasive procedures while shortening time to diagnosis. To test this hypothesis, we propose the following specific aims: First, we will test the clinical utility of a biomarker-informed strategy in a first of its kind randomized clinical trial of IPN management. We will enroll 440 individuals with intermediate risk IPNs (10- 70% risk for cancer) at four institutions with the goal of reducing the number of invasive procedures and time to diagnosis. In the control arm, participants will follow the standard of care and in the intervention arm the biomarker results, expressed as a post-test probability for lung cancer, will be given to providers and participants to inform nodule management. Second, to further our work in identifying new candidate biomarkers for better risk stratification, we will apply a workflow for evaluation of candidates and validate the best candidates for entry into a similar future trial to that proposed in Aim 1. In a set of prospectively collected specimens, evaluated retrospectively in a blinded fashion (ProBE design), we will test the improvement in diagnostic accuracy of candidate biomarkers in patients with IPNs of intermediate risk for lung cancer based on the Mayo risk model. A blood biomarker signature from Abbott laboratories will be tested alone and in combination with a validated radiomics score to determine if together they reclassify at least 20% of those at intermediate risk (10-70%) based on the Mayo risk model alone into either a lower risk (<10%) or higher risk (>70%) group. We will determine the optimal and most cost-effective Mayo model + biomarker combination or sequence needed to achieve the critical decision thresholds in the management of IPNs. At the end of this project, we will have: a) demonstrated for the first time the clinical utility of a biomarker informed approach to IPN management and acquired additional outcomes data for a larger follow-on randomized multicenter trial, b) validated the incremental diagnostic accuracy of new candidate biomarkers for the management of IPNs, and c) opened a new avenue for rapid testing of the most effective combination(s) of candidates.

NIH Research Projects · FY 2025 · 2021-05

Abstract Indiscriminate prescribing of opioids for chronic pain management has contributed to the current opioid crisis. While opioids work well at stable doses for some patients, others experience poor pain relief with significant risks of developing iatrogenic opioid use disorder (OUD). Similar risks may occur in the context of extended postoperative pain management using opioids following major surgery. Ability to predict this risk/benefit balance for individual patients is limited by inadequate understanding of mechanisms influencing opioid responses and risks. To address this gap, our prior funded work has systematically evaluated mechanisms contributing to differential opioid responses. We have shown that: 1) chronic pain patients at increased risk of opioid misuse experience greater analgesia and subjective reinforcing effects of opioid analgesics (e.g., drug liking, desire to take the drug again), 2) low endogenous opioid (EO) function predicts greater analgesic responses to opioid analgesics (replicated across two studies), and 3) that low EO function and endocannabinoid (EC) levels together predict greater subjective opioid reinforcing effects. Our data are consistent with a reinforcement model in which differential opioid responding related to low EO and EC function may enhance risk of OUD. Stress is a known predictor of risk for OUD, but mechanisms are not well understood. EO and EC activity are however both known to inhibit stress responses. This project integrates diverse literatures and will test in 120 chronic low back pain patients a novel mechanistic model in which elevated stress, via links to low EO and EC activity, contributes to patterns of differential opioid responding that will enhance OUD risk via elevated opioid reinforcing properties. Primary aims are: 1) to determine whether stress-related measures are associated with analgesic and misuse-relevant subjective responses to placebo- controlled oxycodone administration, and 2) evaluate associations between stress-related measures and both EO function and EC levels, and test whether EO and EC mechanisms mediate associations between stress- related measures and oxycodone responses. This project will assess stress at multiple levels (subjective, cardiovascular reactivity to two controlled stressors, and pain-relevant heart rate variability [HRV] stress markers) with quantitative assessment of EC levels, and assessment of EO function and opioid agonist subjective and analgesic responses based on randomized, placebo-controlled crossover administration of naloxone (for EO) and oxycodone (opioid responses). Laboratory stress measures will be validated using EMA electronic diary assessment of stress. Results will provide unique mechanistic knowledge of mechanisms contributing to known associations between stress and OUD risk, in line with the goals of PAS- 18-624, and highlight a novel and clinically-pragmatic HRV measure that might predict risk-enhancing differential opioid responses before initiating opioid therapy.

NIH Research Projects · FY 2026 · 2021-05

Project Summary/Abstract Diabetic retinopathy (DR) is the principal cause of blindness among working-age adults in the United States. In individuals with diabetes mellitus, the duration and the severity of hyperglycemia correlate with the risk of developing retinopathy, and have long been considered the main factors leading to DR onset. However the mechanism by which hyperglycemia leads to DR pathology is not known. Photoreceptors are both the most abundant and the most metabolically active cells in the retina, and they have been shown to contribute to the pathogenesis of DR, but the photoreceptor response to hyperglycemia remains poorly understood. Our preliminary data suggests that the c2 isoform of nuclear factor of activated T-cells (NFAT) is significantly induced in photoreceptors exposed to hyperglycemia in vivo, and is activated and translocates to the nucleus of photoreceptors treated with high glucose in vitro. NFATc2 target genes include cytokines that have been shown to regulate inflammation and related processes driving the progression of DR. However the functional implications of NFATc2 induction in photoreceptors exposed to high glucose are not known. The hypothesis of this project is that specific inhibition of NFATc2 in photoreceptors under hyperglycemic conditions can reduce the induction of pro-inflammatory proteins and decrease the downstream effects of photoreceptors on other retinal cell types, including Müller glia and retinal microvascular endothelial cells. Under the mentorship of Dr. John Penn, this hypothesis will be tested using a stepwise approach, complementing primary cell culture- based assays (Aim 1) with in vivo mouse models of DR-relevant pathologic processes (Aim 2). Confirming the ability of NFAT inhibitors and NFATc2 loss of function in photoreceptors to reduce the progression of DR will affirm the potential of NFATc2 as a treatment target for this condition. The principal investigator is an M.D. Ph.D. physician-scientist with scientific training in neuroscience and clinical training as a vitreoretinal surgeon. The K08 award will leverage her prior training under the mentorship of a world-class team with extensive experience in retinal vascular disease, retinal cell biology, and animal models of diabetes, and that includes, in addition to Dr. John Penn, Dr. Sabine Fuhrmann an expert in the neural retina and the retinal pigment epithelium, and Dr. Maureen Gannon, an expert in systemic diabetes. The work will take place within the outstanding scientific and collaborative environment of the Vanderbilt University School of Medicine and Vanderbilt University Medical Center, which have an excellent track record of producing successful clinician- scientists. Dr. De la Huerta will develop the necessary skills to become an independent investigator in the field of diabetic retinopathy, while generating pilot data to successfully compete for independent NIH funding, to advance the understanding of DR pathophysiology and to accelerate the development of new DR therapies.

NIH Research Projects · FY 2026 · 2021-05

PROJECT SUMMARY Severe burn injuries result in immune and metabolic dysfunction, leaving patients vulnerable to life-threatening infections, which remain a leading cause of morbidity and mortality. These vulnerabilities arise from immune exhaustion, metabolic impairments, and disrupted leukocyte function, leading to prolonged immunosuppression. Despite advancements in wound care and antimicrobial therapies, effective strategies to address these systemic dysfunctions are lacking. This MIRA renewal application aims to investigate the mechanisms of burn-induced immune dysfunction and evaluate Toll-like receptor (TLR) agonist- mediated “trained immunity” as a therapeutic approach. Trained immunity involves long-term functional reprogramming of innate immune cells, enabling enhanced antimicrobial and metabolic responses to subsequent infections. Our prior studies demonstrate that TLR agonists, such as monophosphoryl lipid A (MPLA) and CpG, induce trained immunity and provide broad protection against infections, including in burn and other immunocompromised models. These agonists reverse markers of immune exhaustion, enhance metabolic reprogramming, and strengthen antimicrobial defenses in macrophages, monocytes, and neutrophils through MyD88- and mTOR-dependent pathways. These pathways promote glycolysis, mitochondrial biogenesis, and immune activation. Building on these findings, we propose to: 1) investigate the cellular and molecular mechanisms of burn-induced immune exhaustion and metabolic dysfunction, focusing on innate leukocyte reprogramming; 2) evaluate the effects of TLR agonists on infection resistance in clinically relevant murine burn models, including bacterial clearance, immune activation, and myeloid cell recruitment; and 3) extend these findings to human studies by analyzing PBMC samples from burn patients to explore immune and metabolic adaptations post-burn. This research will leverage advanced methodologies such as Single Cell ENergetIc metabolism by profiling Translation inHibition (SCENITH), single-cell RNA sequencing, and infection models with pathogens relevant to burn patients (e.g., P. aeruginosa, S. aureus, K. pneumoniae), to assess the functional outcomes of trained immunity. Findings from this work will provide a mechanistic framework for targeting burn-induced immune dysfunction and guide the development of tailored immunotherapies to reduce infection-related mortality in immunocompromised populations. The flexibility of the MIRA award will support the exploration of emerging hypotheses, ensuring the program remains innovative, impactful, and clinically relevant.

NIH Research Projects · FY 2025 · 2021-05

Project Summary/Abstract This proposal brings together Dr. Javid Moslehi, a cardio-oncologist and myocyte biologist, and Dr. Justin Balko, a cancer biologist and immunologist, to define the immunologic and antigenic drivers of myocarditis associated with cancer immunotherapies. Specifically, immune checkpoint inhibitors (ICI), which block the activity of immune ‘brakes’, such as CTLA-4 or PD-1, have revolutionized treatment for many cancer types but by activating the immune system, they can lead to autoimmune phenomena, called immune-related adverse events. Our group has defined the clinical features of ICI-associated myocarditis, characterized by T cell and macrophage infiltration into the myocardium, fulminant arrhythmias, concurrent myositis, and high fatality rate. To study this entity in more depth, we have generated pre-clinical mouse models that recapitulate ICI-associated myocarditis: specifically, a genetic mouse model, where the genes for PD-1 (Pdcd1) and CTLA-4 (Ctla4) are deleted, leads to early death due to myocarditis which recapitulates human ICI-myocarditis clinically and pathologically. Surprisingly, the mice do not have systemic autoimmunity; rather the T cell infiltration is limited to the cardiovascular system and specifically the heart. Similarly, the infiltration seen in patients is often limited to T cell and macrophage infiltration into striated muscle, namely the heart and skeletal muscle. In this grant, we hypothesize that specific CD8+ T cell infiltrates restricted to one or more myocardial antigens are the drivers of pathogenesis in ICI-myocarditis. We seek to define the T cells responsible for the etiology and pathogenesis of ICI-myocarditis and to demonstrate that specific T cell populations are both necessary and sufficient to drive pathogenesis (Aim 1). Additionally, we seek to define the antigen targets of ICI-myocarditis in mice and in patients (Aim 2). We leverage a team of experts in cardiology, oncology and immunology to test our hypothesis through conduction of these studies. In addition, we have leveraged a large international network of collaborators to collect cases of ICI-associated myocarditis. The overwhelming success of ICI is hampered in some patients by the development of fulminant toxicities, including ICI-myocarditis. This proposal will allow us to generate insights into the mechanisms of this entity, which we feel can translate into more effective treatment and prevention strategies. In addition, the unique team of clinicians and scientists we have assembled for this proposal allows incorporation of new technology which will allow better interrogation of the interactions between the cardiovascular and immune systems translating into better insights in other forms of inflammatory cardiovascular diseases.

NIH Research Projects · FY 2025 · 2021-05

Project Summary Obesity is clearly detrimental in asthma, yet we lack tools to treat the unique obese asthma phenotype. Comorbid obesity impacts >40% of adult asthmatics1 and increases asthma severity, symptoms and exacerbations while simultaneously reducing the efficacy of conventional therapies.2-5 Our long-term goal is to develop novel treatments for airway inflammation in the obese asthma phenotype. Our overall objective, which is the next step in translating our preclinical and preliminary clinical findings, is to determine the impact of glucagon-like peptide-1 receptor agonists (GLP-1RA) on asthma control and airway and adipose inflammation in adults with obese asthma. Our central hypothesis is that GLP-1RA improve asthma control and reduce airway inflammation due to direct effects on the respiratory tract in obese asthma. To generate the proof-of- concept data to support definitive phase 3 clinical trials of GLP-1RA in the obese asthma phenotype and test our central hypothesis, we propose the following specific aims: 1) Determine the efficacy of GLP-1RA on asthma control and assess tolerability in obese asthma and 2) Determine the tissue-specific impact of GLP- 1RA on inflammation in the airway and adipose in obese asthma. In a 12-week double-blind, randomized, placebo-controlled trial of oral semaglutide 7 mg once daily in adult subjects with obesity-related, symptomatic asthma without DMII, we will test the hypotheses that semaglutide improves asthma control (aim 1a), is tolerated (aim 1b) and reduces type-2 and non-type 2 airway inflammation independent of weight loss (aim 2). The primary clinical outcome will be change from baseline in ACQ-7. The primary mechanistic outcome will be change from baseline in serum periostin. Because insulin resistance is variable in obesity and baseline blood eosinophil counts are often predictive of response to asthma therapeutics, these markers will be used for prespecified subgroup analyses. Subcutaneous abdominal adipose and respiratory tract samples at baseline and 5 and 12 weeks of therapy will be compared using RNA sequencing to test the hypothesis that GLP-1RA reduce inflammation to restore homeostasis in the respiratory tract opposite to changes in adipose tissue in obese asthma. This proposal facilitates the collection of the necessary clinical, mechanistic, and tolerability data to inform the design of a definitive phase III clinical trial of a GLP-1RA in asthma. It thereby supports the rapid development of a novel therapeutic class for asthma and represents a paradigm shift in the approach to therapeutic intervention in asthma through the targeting of a metabolic pathway which regulates upstream inflammation across multiple organ systems, may be disease modifying, and ultimately glucocorticoid sparing.

NIH Research Projects · FY 2025 · 2021-05

Abstract: Opioid analgesics are commonly used to manage children’s postoperative pain. Under-medication of children’s postsurgical pain can have significant consequences including reduced quality of life, respiratory issues, dehydration, and nausea, which can increase health care costs due to emergency department visits, provider phone calls, and readmissions. In contrast, a proportion of parents may over-medicate children’s postsurgical pain, potentially leading to greater respiratory depression and other opioid side effects. Given (a) the potential repercussions of under- or over-medicating postsurgical pain in children, (b) uncertainty regarding level of opioid analgesics needed for optimal postsurgical pain management, and (c) increasing societal focus on the negative consequences of opioid medications, further understanding the patterns and predictors of home opioid use and pain management following surgical procedures in children is necessary to guide development of interventions to enhance appropriate analgesic use for pediatric postsurgical pain. The proposed project is designed to address this gap in understanding by prospectively examining parent and child predictors of the extent of opioid analgesic use following tonsillectomy and adenoidectomy (T&A) procedures in pediatric patients aged 7 to 12 years. Parents and youth will complete preoperative measures regarding opioid medication beliefs, pain-related beliefs and emotional responses, and history of painful experiences and opioid use. At the time of IV placement for surgery, blood will be collected to assess children’s circulating endocannabinoid levels. Following surgery, parents and youth will complete electronic diaries regarding pain, emotions, medication use, and side-effects 3 times a day for 7 days and a 3-month follow-up survey assessing additional opioid use and opioid disposal. The central aims of this proposal are to understand parent and child factors that may predict opioid analgesic use following T&A procedures in order to inform predictive models for opioid-related outcomes following pediatric surgeries more broadly. A key innovation of this project is the examination of joint influences of parent and child factors on postoperative opioid use patterns. We hypothesize that parents and children who tend to catastrophize more about painful experiences, have positive beliefs regarding opioid efficacy, and less negative beliefs regarding opioid side effects will be more likely to use opioid medications and be less likely to dispose of opioid medications. Identifying these parent and child predictors could allow for the development of targeted screening and patient education in order to identify potentially modifiable targets for interventions to improve pediatric postsurgical pain management and reduce opioid-related risks. Further, this project provides critical career development support for a young investigator focused on developing expertise in pediatric acute pain, opioid guidelines and clinical opioid use patterns, advanced statistical modeling skill, leadership skills, and biological mechanisms related to pain and opioid use which will inform an overall program of research focused on improving pain management practices for children.

NIH Research Projects · FY 2025 · 2021-04

PROJECT SUMMARY/ABSTRACT Screening promotes early detection of cancer to decrease mortality. Unfortunately, significant racial disparities exist in lung cancer screening. Recently published findings by our team show that under current national screening guidelines African Americans have reduced eligibility for lung cancer screening compared to whites. These screening guidelines are based on a combination of age and smoking pack-year criteria derived from a national lung screening trial that was primarily (91%) white. Importantly, smoking behaviors and baseline risks for lung cancer differ greatly between African Americans and whites. Because of this, a risk-based screening strategy may provide a more equitable assessment of eligibility than current screening guidelines. However, the development of personalized risk prediction models for lung cancer in African Americans has been limited. To address this gap and to improve equity in screening eligibility, we propose building a personalized prediction tool using the combined data from three large-scale population-based prospective cohorts with substantial African American representation. The combined cohorts have over 336,000 individuals (44% African American) and 9,132 incident lung cancer cases from across the United States. We propose the following three aims: 1) construct a well-calibrated natural-history model of lung cancer risk for screening in African Americans, 2) evaluate lung cancer screening strategies by simulation and identify sub-populations who would benefit from screening, accounting for comorbidities and false-positives, and 3) develop a web-based decision aid for screening that is culturally appropriate. We will employ innovative machine learning techniques and state-of-the- art statistical methods to build a well-calibrated lung cancer prediction model for African Americans. Careful examination will identify sub-populations (such as women, low socioeconomic status, rural, age groups, etc.) that will benefit from screening. A key innovative aspect of this proposal is its community-engaged approach and partnership with a Community Advisory Board, both of which will help translate our empirical findings into the design of a patient-oriented decision aid. This project is relevant to the mission of the National Cancer Institute since it focuses on establishing equity in lung cancer screening eligibility. Our findings will have sustained impact on precision health and motivate improved clinical strategies for the early detection of lung cancer for African Americans.

NIH Research Projects · FY 2025 · 2021-04

PROJECT SUMMARY Genome-wide association studies (GWAS) have identified common variants in ~200 genetic loci associated with breast cancer risk. However, it is difficult to translate these findings to disease prevention and treatment because causal genes and underlying mechanisms in these loci are largely unknown. Increasing evidence suggests that epigenetic regulation may be on the causal pathway between genetic variants and diseases. DNA methylation, one of the most frequent and important epigenetic modifications, plays a crucial role in cancer development. However, it is almost impossible to collect pre-diagnostic breast tissues to profile the methylome from a large number of participants. Herein, we propose a novel -omics approach: a methylation- wide association study (MeWAS) using genetic instruments. In Aim 1, we will build race-specific prediction models using genome wide methylation and genetic data in fresh-frozen breast samples from 600 cancer-free women of African-, Asian- and European- ancestry (200 per race). These models will then be applied to the GWAS data from three large consortia, including ~123,000 cases and ~106,000 controls of European, ~25,000 cases and ~25,000 controls of Asian-, ~20,000 cases and ~20,000 controls of African- ancestry to impute methylation levels. The genetically predicted methylation levels will be tested in association with breast cancer overall and by estrogen receptor and HER2 status. In Aim 2, we will perform a series of integrative functional analyses to evaluate the functions of promising methylation sites and the potential target genes regulated by these methylation sites. In Aim 3, we will select the top 20 methylation sites and their target genes for in vitro functional assays to assess their influence on major cell functions related to cancer biology. Given the strong pilot data, unique resources from three large genetic consortia, and our team's extensive expertise and experience, we are uniquely positioned to conduct this project. The findings will greatly improve our understanding of the genetic and biological basis of breast cancer pathogenesis and facilitate the translation of genetic findings to prevention and treatment.

NIH Research Projects · FY 2025 · 2021-04

Project Summary Resistance to anti-tuberculosis drugs complicates the care and worsens the outcomes of individuals with tuberculosis, the leading infectious cause of death worldwide. South Africa is using the new anti-tuberculosis drug bedaquiline as part of both shorter and longer all-oral treatment regimens for patients with rifampicin- resistant tuberculosis (RR-TB). While clinical trials and observational studies demonstrate improved treatment outcomes with bedaquiline-based treatment, the predictors of poor treatment response (defined as positive cultures two, four, or six months after diagnosis) and poor treatment outcomes are not well-characterized in programmatic settings. Alarmingly, resistance to bedaquiline has been detected in clinical Mycobacterium tuberculosis isolates. The background resistance to both new and old drugs that compose treatment regimens, combined with observed variation in pretreatment phenotypic susceptibility to bedaquiline, raise concerns that the risks of poor treatment response and outcomes may be higher than anticipated. To address these concerns, we will use the robust infrastructure of the South African National Health Laboratory system and the electronic drug-resistant tuberculosis register to assess programmatic poor treatment response among patients with RR-TB in South Africa. We will perform minimum inhibitory concentration testing of bedaquiline and companion drugs on routinely collected specimens in the Gauteng Province of South Africa to determine whether elevated minimum inhibitory concentrations of bedaquiline in phenotypically bedaquiline-susceptible pretreatment isolates are associated with poor treatment response or outcomes. Whole genome sequencing on routinely collected specimens will allow simultaneous characterization of the underlying molecular epidemiology of RR-TB. We will also use a novel approach of using the concentration of drugs with different half-lives determined programmatically and pharmacokinetic modeling to evaluate association with time to culture positivity and treatment outcomes. We will combine mycobacteriologic factors, drug concentration data, and clinical data to develop a prediction model for poor treatment response and outcomes. Our findings will guide targeted intervention strategies for individuals at high risk for poor treatment response, inform rapid drug susceptibility tests that incorporate genotypic data for bedaquiline and companion drugs in new treatment regimens of RR-TB, and explore the potential importance of measuring drug concentrations early in the course of RR-TB treatment. The insights gained about genotypic and phenotypic variation in relation to treatment outcomes of RR-TB will be highly valuable not only for South African tuberculosis programs, but also for high- burden and under-resourced settings worldwide. Our study team includes globally recognized content experts from South Africa and the US and will allow critical progress in drug-resistant TB research in South Africa.

NIH Research Projects · FY 2025 · 2021-03

Summary Our primary objective is initiating a personalized approach to curative therapies in children and adults with sickle cell disease (SCD) to maximize benefits and limit adverse outcomes. Limited systematic efforts exist to elucidate long-term health outcomes following curative therapies for SCD. The paradigm of focusing only on the initial cure is analogous to what occurred in pediatric oncology in the 1980s with successful curative therapies. Subsequently, curative therapies were associated with increased risk for organ dysfunction and malignancies, leading to a new field, survivorship in pediatric oncology. With emerging curative therapies for SCD (allogeneic [allo] hematopoietic stem cell transplant [HSCT], gene therapy/editing), long-term health outcomes studies are time-sensitive and critical to inform personalized choices. Unfortunately, adverse outcomes have started to emerge after SCD curative therapy. Specifically, 10% of the deaths following HSCT occur more than 5 years after HSCT. Further, our group has demonstrated therapy-related myeloid neoplasms and clonal hematopoiesis of indeterminate potential (CHIP) may occur when graft rejection/mixed chimerism is present (seen in 5 of 76 patients with SCD after HSCT). Thus, risks of cure in SCD must be measured against the benefits of cure, including stabilization of lung function (FEV1) and improved tricuspid regurgitant jet velocity [TRJV]. Ultimately, the shortened lifespan of individuals with SCD, attributable to declining heart (elevated TRJV), lung (decreased FEV1), and kidney (decreased eGFR) function, for which curative therapies were designed to ameliorate, must be measured against favorable and unfavorable late outcomes. In our multicenter retrospective-prospective cohort, we will test the following hypotheses: 1a): myeloablative curative therapies for children with SCD will result in progressive pulmonary and renal dysfunction when compared to children with SCD receiving standard therapy; 1b): nonmyeloablative HSCT for adults with SCD will result in no significant change in FEV1% predicted, but will lead to accelerated decline in eGFR when compared to adults receiving standard therapy; 2) nonmyeloablative HSCT for adults with SCD will be associated with a clinically significant improvement in TRJV following HSCT; and 3) in adults with SCD, proliferative and genotoxic stress uniformly related to nonmyeloablative allo-HSCT and myeloablative gene editing will lead to post-HSCT therapy-related myeloid neoplasm of recipient origin. We will address these hypotheses with the following aims: 1) evaluate the incidence of pulmonary and renal function in 1a: children with SCD receiving myeloablative curative therapies; and 1b: adults with SCD receiving nonmyeloablative allo-HSCT, compared to a pre-existing cohort of children and adults with SCD; 2) determine whether there is a clinically significant improvement in TRJV in adults with SCD, at least half having TRJV > 2.5 m/s, following nonmyeloablative allo-HSCT, and 3) evaluate the prevalence, incidence and evolution of CHIP following non-myeloablative HSCT or myeloablative gene editing in adults with SCD.

NIH Research Projects · FY 2025 · 2021-03

PROJECT SUMMARY Delusions are psychotic symptoms that contribute to significant emotional distress, poorer quality of life, functional impairment, hospitalization and violence. Delusions are treatment-resistant in many patients. Mechanistic understanding of delusion severity remains elusive, limiting treatment advancement. Abnormal belief updating is a proposed mechanistic framework of delusions with accumulating evidentiary support. Prior cross-sectional work has demonstrated altered belief updating ability and associated neurobiological abnormalities in psychotic disorder patients during cognitive tasks. However, it is unknown whether belief updating abnormalities are state-markers of delusional thinking that change over time, or represent stable cognitive traits that contribute to delusion-proneness. Answering this question can not only inform mechanistic models of delusions, but will guide targeted treatment development. This K23 mentored patient- oriented career development award proposes a longitudinal examination of delusion severity and belief updating in psychotic disorder patients recovering from an acute episode of psychosis. This project will use computational and functional neuroimaging (fMRI) approaches to 1) determine how belief updating parameters change throughout six months of recovery from an acute delusional state, and 2) characterize neurobiological correlates of belief updating parameters as symptom severity changes. The applicant is a licensed clinical psychologist with a background in using neuropsychological tasks and neuroimaging techniques to understand cognitive deficits across the psychosis spectrum. Her long-term career goal is to build an independent research program that employs sophisticated cognitive neuroscience techniques to test mechanistic models of psychosis, and then use that knowledge to develop and test novel interventions. In order to accomplish these short and long-term goals, the applicant requires additional training, as outlined in this proposal. Training areas include: 1) the computational and cognitive neuroscience of delusions, 2) longitudinal research design and statistics, and 3) intervention research to prepare the applicant for a translational research career. Training will include formal coursework, didactics, and on-site trainings, guided under a mentorship team of experts in the longitudinal cognitive neuroimaging of psychotic disorders, computational modeling of psychotic symptoms, and treatment of delusions. Mentored training and completion of the proposed project will provide the applicant the skills and experience necessary to launch a successful independent research career.

NIH Research Projects · FY 2025 · 2021-02

Project Summary We propose to optimize and validate two novel diffusion MRI models/methods that have direct clinical relevance for cervical spinal cord evaluation in health and multiple sclerosis (MS): Neurite Orientation Dispersion and Density Imaging (NODDI) and Spherical Means Technique (SMT). While diffusion tensor imaging (DTI) has existed for 20 years, advanced biophysical models for evaluating neurological disease in the CSC are lacking. Advanced diffusion MRI can extract indices related to neural architecture and axonal loss, yet evaluating the pathological substrates of MS (specifically axonal loss) in the CSC is undertested and questions remain if the models as-developed are relevant for pathology. Lastly, it is not clear if advanced diffusion MRI offers greater clinical value over DTI. We address the current knowledge gap in human CSC diffusion MRI by optimizing and evaluating two clinically-approachable diffusion techniques: NODDI and SMT in healthy volunteers and patients with relapsing-remitting MS (RRMS) to 1) study lesion and normal appearing white matter (NAWM) in comparison with conventional DTI (assessing value), lesion burden, and atrophy (reflecting axonal loss) and 2) to assess the sensitivity of diffusion MRI to tissue change over time. In MS, spinal cord health is integral to neurological function, yet current studies rely on identifying lesions and/or tissue atrophy; the biological substrates of CSC tissue damage are poorly characterized, and their relationship to neurological function is weak. Advanced diffusion MRI provides estimates of axonal volume, cellular inflammation, and neurite dispersion and may provide greater specificity than DTI for microstructural changes in the CSC throughout MS evolution. However, advanced diffusion MRI has only recently been explored due to lack of CSC-optimized acquisitions and models that account for pathology, which we show are surmountable. We will test the hypotheses that NODDI and SMT diffusion MRI, can 1) detect sub-radiological axonal pathology in MS (CSC areas devoid of lesions), 2) offer improved value and specificity over conventional DTI, and 3) characterize axonal-sensitive indices longitudinally concomitant with neurological deterioration. We optimize, and acquire NODDI and SMT data in addition to DTI, T2-, T2*-, T1 MRI in the CSC of patients with RRMS. We published NODDI and SMT in the CSC in a small cohort of RRMS patients, but now evaluate the value that advanced diffusion modeling in the CSC can add to the clinical assessment of MS patients. As in the brain, NODDI and SMT can be acquired in a reasonable exam time, but are untested for spinal cord pathology in MS. If successful, we will offer clinically-relevant, optimized acquisition and analysis tools for the application of advanced diffusion MRI in CSC pathology in comparison with clinical radiological standards. Alternatively, we will solidify the importance (and provide optimized CSC sequences) for rapid, conventional CSC DTI for clinical deployment. A byproduct is the evaluation of alternative models in pathology, which has not been tested before and have direct benefit to understanding other spinal cord diseases.

NIH Research Projects · FY 2025 · 2021-02

PROJECT SUMMARY Metabolic and bariatric surgery is an emerging option to treat obesity-related metabolic diseases, e.g., type 2 diabetes, and prevent atherosclerotic cardiovascular disease (ASCVD). Metabolic surgery can profoundly alter the gut microbiota; meanwhile, gut microbiota and their metabolites may affect cardiometabolic outcomes after the surgery. Investigation of these “host-microbiota interactions” will offer novel mechanistic understanding of metabolic surgery and evidence for developing potential microbiota-based models/therapies to achieve better cardiometabolic health. Yet, longitudinal patient studies that examined pre- to post-surgery gut microbiota and their metabolites in relation to cardiometabolic outcomes are scarce. Existing studies are limited by small sample sizes XVXDOO\ Q” , non-prospective design, no evaluation of microbial functionality nor activity (e.g., via multi-omics), and little consideration of diet or medication use. Of note, no studies have evaluated gut microbiota in relation to estimated 10-year ASCVD risk, which reflects the overall cardiometabolic benefit of metabolic surgery and is widely used in clinical practice per ACC/AHA guideline. Furthermore, no studies have included African Americans (AAs), a population with high rates of cardiometabolic diseases. We aim to fill these research gaps by establishing a longitudinal, multi-ethnic cohort of metabolic surgery patients and applying multi-omics to identify microbial features (e.g., species, pathways, and metabolites) associated with estimated 10-year ASCVD risk and/or improvements in A1C, blood pressure, and blood lipids. In a pilot study, we enrolled 20 patients (including AAs), collected longitudinal stool/blood samples, conducted surveys, and found significant changes in microbiome and microbial metabolites after surgery, demonstrating the feasibility and our ability to carry out the proposed full-scale study. Specifically, we will enroll and follow 200 patients to collect biospecimen and conduct surveys at pre-surgery and 3-month and 1-year post-surgery visits. We will evaluate pre- to post-surgery changes in gut microbiome and fecal and circulating levels of metabolites, especially microbiota-derived metabolites, and the prospective associations of pre-surgery and 3-month microbiome and metabolites with ASCVD risk and metabolic outcomes at 1-year post-surgery. We will also explore potential effect modifications by diet and medication, focusing on fiber intake and metformin use. Our proposed research will provide substantial novel data to advance our understanding of the role of gut microbiota in cardiometabolic improvements after metabolic surgery, which may translate into novel microbial approaches to identify and treat patients for better cardiometabolic health. Our team has extensive expertise in cardiometabolic diseases, diet-microbiota-host interactions, metagenomics and metabolomics in longitudinal cohorts, as well as in metabolic surgery with experiences as patients, care providers, and/or researchers, and thus, is uniquely positioned to accomplish the proposed research.

NIH Research Projects · FY 2025 · 2021-02

The applicant, Aaron W. Aday, MD, is an Instructor of Medicine in the Division of Cardiovascular Medicine at Vanderbilt University Medical Center. The applicant's goal is to become an independent cardiovascular investigator studying the thrombotic mechanisms underlying peripheral artery disease (PAD) development. This application for a K23 Mentored Patient-Oriented Research Career Development Award describes a focused plan for the applicant to acquire the research skills and expertise required to transition into an independent investigator under the primary mentorship of Joshua A. Beckman, MD. The proposal centers on the study of thrombosis and antithrombotic therapy in PAD. PAD is a highly prevalent atherosclerotic disease associated with significant cardiovascular morbidity and mortality. However, there remain notable gaps in our knowledge of the biologic pathways involved in PAD development. Recent data suggest important contributions of thrombosis, through both coagulation cascade activation and platelet activation, to the development of PAD. However, the mechanisms of thrombosis and platelet activation contributing to PAD in humans are not fully known. The specific aims of the proposed research are: (Aim 1) to quantify the risk conferred by activation of thrombotic pathways, in addition to traditional cardiovascular risk factors, on PAD using Mendelian randomization; (Aim 2a) to test the hypothesis that low-dose rivaroxaban, a clotting factor Xa inhibitor, improves macro- and microvascular endothelial function in humans with PAD; and (Aim 2b) to test the hypothesis that low-dose rivaroxaban reduces PAR-1- mediated platelet activation while also facilitating thrombolysis and reducing inflammation via downstream signaling. The candidate has a strong background in both clinical vascular genetics as well as epidemiology of PAD. The proposed project will afford him new expertise in several key domains, including (1) genetic epidemiology and Mendelian randomization methods, (2) design and implementation of clinical trials, (3) patient-oriented vascular physiologic studies, and (4) translational investigations of thrombosis and platelet function. Vanderbilt University Medical Center has an ideal environment to support the candidate's investigational career. He will be supported by an outstanding mentorship team with extensive experience in clinical and translational cardiovascular research. However, the proposal will also provide Dr. Aday the opportunity to develop into a leading investigator with unique expertise in genetic epidemiology as well as mechanistic clinical trials focusing on PAD. Data from the proposed studies will also serve as the basis for future mechanistic and interventional studies (i.e. R01) of thrombosis in PAD. The support of this Career Development Award will provide Dr. Aday with the tools necessary to lead his own independent clinical and translational research program.

NIH Research Projects · FY 2025 · 2021-02

ABSTRACT Obesity is characterized by an excess of white adipose tissue (WAT), which has low metabolic activity. Recent studies demonstrate that cells in WAT can be driven toward a metabolically active brown adipose phenotype (termed “beiging”), which is causally associated with weight loss and improved insulin sensitivity. Pharmacologic therapies to stimulate beiging of WAT and activation of brown adipose tissue (BAT) may reduce cardiovascular and diabetes risk in obesity. Cyclic guanylate monophosphate (cGMP) signaling may positively influence adipose tissue metabolism. cGMP serves as the second messenger for the natriuretic peptides, which are reduced in obesity. Wild type mice exposed to exogenous natriuretic peptide have increased expression of brown adipocyte-associated genes in WAT and BAT, providing evidence for beiging of WAT and activation of BAT. A safe and inexpensive strategy to enhance cGMP signaling in humans is inhibition of an enzyme involved in its breakdown, phosphodiesterase type 5A (PDE5). Data on the effects of PDE5 inhibition on WAT and BAT function in humans are limited. One barrier to human studies has been the lack of a non-invasive method to detect both activated BAT and beiging of WAT. We have developed and published a magnetic resonance imaging technique to quantify the full spectrum of lipid metabolism in WAT and BAT using fat signal fraction (FSF). In preliminary data, we show that 1) cold exposure (a cGMP stimulus) causes beiging of WAT in humans, 2) chronic PDE5 exposure improves insulin sensitivity in obese adults and, 3) mice treated with PDE5 inhibitors exhibit increased energy expenditure and resistance to weight gain. We hypothesize that PDE5 inhibition in obese adults will result in beiging of WAT and activation of BAT. We will perform non-invasive imaging and subcutaneous fat aspiration to link changes in adipose imaging and gene expression at the same anatomic site for the first time. We will randomize participants to tadalafil (20mg/day) or placebo for 3 months. Endpoints will be measured at room temperature and after a cold exposure protocol, which will allow us to determine whether a chronic increase in cGMP tone through PDE5 inhibition “primes” BAT and WAT for activation in the setting of a natriuretic peptide stimulus. Aim 1 will examine the effect of PDE5 inhibition on adipose metabolism. We will randomize 100 obese individuals to tadalafil or placebo for 3 months. The primary endpoint is WAT FSF at room temperature. Aim 2 will examine the effect of PDE5 inhibition on subcutaneous WAT gene expression. The primary endpoint will be change in WAT UCP1 expression at 3 months. A secondary aim will link data from Aims 1 and 2 to examine the association between change in FSF and WAT gene expression after PDE5 inhibition and cold exposure. The importance of this aim is to establish for the first time in humans the relationship between imaging and molecular markers of adipose metabolism. Repurposing PDE5 inhibitors could be an important adjunct to lifestyle interventions in an effort to counter cardiovascular and diabetes risk in obese individuals.

NIH Research Projects · FY 2024 · 2021-02

PROJECT SUMMARY/ABSTRACT Arachidonic acid, a long-chain ω-6 polyunsaturated fatty acid (PUFA), has been demonstrated to affect carcinogenesis in animal and in vitro studies. The effect of arachidonic acid is believed to be largely due to overproduction of the eicosanoid, prostaglandin E2 (PGE2). The other class of PUFAs, ω-3, also bind to the same enzymes involved in arachidonic acid metabolism; however, the resulting set of eicosanoids are anti- inflammatory. Thus, ω-3 PUFA metabolism could indirectly inhibit PGE2 production and reduce cancer risk. Over the past few years, multiple genetic variants have been identified to be associated with PUFAs. The goal of the proposed K99/R00 award is to elucidate the potential causal association between long-chain PUFAs and colorectal tumor risk using Mendelian randomization (MR), an approach that may avoid potential pitfalls of conventional observational epidemiologic research. Using fine-mapping, the proposed study will identify additional variants in key loci (11q12.2 and 6p24.2) that are involved in the conversion from short- to long- chain PUFAs to improve the PUFA genetic instruments. The proposed study will utilize individual-level data from the ColoRectal Transdisciplinary Study (CORECT) consortium; blood and tissue samples from the Tennessee Colorectal Polyp Study (TCPS); and genotype and phenotype information from Vanderbilt University's de-identified electronic medical record DNA bio-repository (BioVU). Specifically, we propose the following aims: (1) to conduct a MR study for the association between long-chain PUFAs and colorectal cancer risk; (2) to conduct fine-mapping to identify additional variants in key PUFA metabolism loci to improve the genetic instruments for MR; (3) to evaluate potential interactions of genetically predicted long-chain PUFAs (using the improved genetic instrument) and use of aspirin and non-steroidal anti-inflammatory drugs (NSAID) with the risk of colorectal tumors; (4) to investigate associations between genetically predicted long-chain PUFAs and selected tumor biomarkers; and (5) to conduct a mediation analysis to determine whether PGE2 is a mediator on the causal pathway between long-chain PUFAs and colorectal adenoma risk. This innovative study will be the first to develop an instrumental variable using a polygenic risk score in order to identify potential causal association between long-chain PUFAs and colorectal cancer tumor risk, and will be cost- efficient. The proposed study will help elucidate associations between long-chain PUFAs and colorectal tumors, which could lead to potential risk reduction strategies. Lastly, the proposed career development award will equip the candidate with the additional didactic and research training necessary for building an independent research program in the areas of nutrition, genetics and molecular epidemiology, and cancer.

NIH Research Projects · FY 2025 · 2021-01

Project Summary Lung cancer is the leading cause of cancer death in the United States and many other countries. Genome-wide association studies (GWAS) have identified ~55 genetic loci associated with lung cancer risk. However, causal genes (and their underlying biological mechanisms) for most of these loci remain unknown. Gene expression is an intermediate phenotype between genetic variants and disease. DNA methylation plays a critical role in regulating gene expression. Directly integrating genomic, transcriptomic, and methylomic data with disease risk can uncover novel disease susceptibility genes and potential mechanisms. However, it is extremely difficult, if at all possible, and costly to directly profile the transcriptome and methylome in lung tissues from a large number of cases and controls for evaluating these associations. Herein, we propose a novel approach: transcriptome-wide association study (TWAS) and methylation-wide association study (MeWAS) to identify novel genes and methylation loci related to lung cancer risk using genetic instruments. These novel approaches have been shown to be very powerful in identifying novel genes and methylation sites in both GWAS-reported loci and regions not yet revealed in GWAS in multiple recent studies, including our pilot study in lung cancer. We propose to conduct a well-powered TWAS and MeWAS to discover novel genes and methylation loci (both potential targeted genes/methylation sites in GWAS-identified loci and genes/methylation sites in loci not yet uncovered by GWAS) for lung cancer risk (Aim 1). We will evaluate the differences in the expression levels of TWAS-identified genes and the methylation levels of MeWAS-identified loci between lung cancer tissues and normal tissues to prioritize genes and methylation loci that may contribute to lung cancer risk (Aim 2). We will investigate the regulating effects of methylation sites on the expression of promising genes and evaluate the functions of genes and methylation loci by functional genomics analyses (Aim 3). Finally, we will perform a serial of functional analyses to evaluate the potential functions of identified genes and methylation loci (Aim 4). We anticipate that this proposed study will identify a large number of novel genes and methylation loci for lung cancer risk and provide functional data to improve understanding of biological mechanisms. The proposed study is highly innovative and cost efficient. Our results will help us to better understand the mechanistic relationship between genetic and epigenetic variations and how those variations relate to lung cancer risk, and may lead to the discovery of biomarkers that would facilitate early detection of lung cancer and the development of targeted gene therapies for personalized treatment.

NIH Research Projects · FY 2025 · 2021-01

PROJECT SUMMARY Early detection of lung cancer among asymptomatic individuals is a priority for reducing mortality of the number one cancer killer worldwide. Most lung cancers are first detected as indeterminate pulmonary nodules (IPNs). While the vast majority of IPNs are benign, those malignant ones present with specific features that should allow for the early discrimination and intervention. We have recently completed a study demonstrating the value of structural imaging features analysis in providing improved accuracy in detection of cancers among IPNs with accuracy of over 90% trained in the NLST and validated in two independent cohorts. The AUC increased from baseline risk estimate of disease using clinical parameters (Mayo model) 0.78 to 0.84 and from 0.82 to 0.92 in two independent validation cohorts. Similarly, we tested the added value of our high sensitivity hsCYFRA 21-1 assay in three populations of lung nodules and obtained similar added value to the MAYO model. Finally, we identified signatures predictive of lung cancer using large scale data mining in the electronic health record (EHR). The performance of the performance of the established imaging predictor, hsCYFRA concentrations and EHR trajectories will be validated in a prospective cohort. In an innovative partnership between pulmonary oncology, radiology, machine learning, and data science experts at Vanderbilt, we propose to integrate the layer of clinical information accessible in the EHR to improve the noninvasive diagnosis accuracy. In addition, we propose to take advantage of repeated measures to improve the accuracy of the prediction of cancer and to reduce the time to diagnosis. We therefore propose the following aims. In Aim 1 we will validate advanced quantitative imaging analyses to distinguish early benign from malignant IPNs based on repeated measures of 1000 individuals. In Aim 2. We will test in 150 individuals with lung nodules the added value of repeated measures of hsCYFRA 21- 1 protein blood biomarker in diagnostic accuracy over the baseline concentrations of the biomarker. In Aim 3 we will test a deep learning strategy from the EHR of 20,000 patients from VUMC to identify patterns likely to improve the early detection of lung cancer, and in Aim 4 we will test the added value of monitoring changes in levels of the markers for early detection using repeated pre-diagnosis chest CT studies, serum analysis of hsCYFRA 21- 1, and EHR patterns from our lung cancer screening program. Built upon strong preliminary data and unique resources from VUMC that include access to large imaging and HER data sources this novel integrative study has the potential to generate highly impactful and translatable results to reduce false positive rates among IPNs, and morbidity and mortality from lung cancer. This application responds to PAR 19-264 using low-dose lung screening computed tomography longitudinal analysis integrated with a lead serum biomarker and the power of artificial intelligence to mine the EHR for the discovery of a novel integrative strategy for the early detection of premetastatic lung cancer.