Vanderbilt University Medical Center

NIH Research Projects · FY 2025 · 2021-01

Pseudohypoparathyroidism (PHP) is a rare, genetic disorder caused by impaired stimulatory G protein (Gsα) signaling through downregulation of the gene, GNAS. The resultant hormone abnormalities can be treated with hormone replacement therapy, but other aspects of the disorder such as early-onset obesity and short stature are without effective treatment options. Gsα signaling is essential for the normal hormonal function of the pituitary, thyroid, gonads, renal proximal tubules and hypothalamus. While many of the resulting hormone deficiencies can be treated with hormone replacement therapy (HRT), HRT is not an effective therapy for the severe early-onset obesity and short stature which are major features of the PHP phenotype. Therefore, the goal of this proposal is to test the efficacy of upstream therapy aimed at correcting the function of Gsα-dependent receptors in children with PHP. Gsα-coupled receptor signaling cascade begins with an increase in cyclic adenosine monophosphate (cAMP) which is rapidly degraded by the enzyme phosphodiesterase (PDE). PDE inhibitors act by prolonging cAMP signaling by decreasing the rate of degradation. Given that patients with PHP have reduced, but not completely absent, cAMP production, we seek to test the hypothesis that the PDE inhibitor theophylline will reduce body mass index (BMI), slow the rate of epiphyseal closure, and decrease hormone resistance in children with PHP through improved Gsα-coupled receptor signaling. We will conduct a 52-week randomized, placebo-controlled clinical trial of theophylline in children with PHP. Theophylline is a non-selective PDE inhibitor that is generically available and has a long history of use in pediatric patients, making it an ideal drug for repurposing in youth with PHP. Furthermore, the pharmacokinetics of theophylline are well understood, and serum drug levels are easily measured. Our primary outcome is change in BMI. Secondary outcome measures include change in epiphyseal closure and HRT medication doses. In this revised proposal, we have included additional safety and efficacy data from adults in adolescents treated with theophylline. In response to reviewer comments, we have added an open-label extension period of up to 2 years in order to better evaluate long-term safety and efficacy.

NIH Research Projects · FY 2025 · 2020-12

PROJECT SUMMARY Clostridioides difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea in the United States, causing 12,900 deaths in 2017. CDI has demonstrated a rapid increase in incidence in the last two decades, with rate increases most pronounced in pediatric patients with inflammatory bowel disease (IBD). IBD, a chronic disease characterized by inflammation of the gastrointestinal tract, has also demonstrated increasing incidence in children worldwide and is considered a globally important pediatric disease. The co- occurrence of IBD and CDI is associated with worse outcomes including longer hospital stays, higher charges, and greater need for blood transfusions. Conversely, children with IBD also have high rates of C. difficile colonization, defined as the presence of C. difficile in the absence of symptoms attributable to C. difficile. Symptoms of CDI in IBD patients are indistinguishable from symptoms of an IBD flare in patients with C. difficile colonization. Microbial perturbations, biomolecules associated with germination and metabolism, and antitoxin antibodies have been studied individually for their influence on colonization and CDI but primarily in cross-sectional approaches and not applied to children with IBD. The research detailed in this proposal responds directly to the need to better understand the determinants and sequalae of CDI and C. difficile colonization in pediatric patients with IBD and includes the following specific aims: 1) To investigate the role of germination and metabolic mediators as they relate to the development of, and recovery from, C. difficile colonization, symptomatic CDI, and IBD flares. 2) To examine differences in the intestinal microbiome that are predictive of C. difficile colonization, disease, and recovery in children with IBD. 3) To determine the prevalence and impact of C. difficile antitoxin antibodies in children with IBD. For the past 8 years the candidate has worked closely with her mentor, Dr. Kathryn Edwards on a variety of CDI-related projects which have included the prospective enrollment of over 360 pediatric patients. Through this project, the candidate plans to longitudinally follow children with IBD with serial sampling of stool and serum to better understand the interaction of CDI and IBD. The overarching objective of this mentored career development experience is for the candidate to emerge as an independent clinical investigator of C. difficile and IBD, become established in metabolite determination and microbiome analysis, and serve as an interface between clinical research and laboratory sciences through carefully planned translational approaches. To accomplish this goal, the candidate will augment her prior training with advanced coursework in microbiome analysis, clinical research, and leadership training. Throughout the award period, the candidate will work closely with a multidisciplinary team of mentors including experts in infectious diseases, IBD, biostatistics, microbiome analysis, and molecular techniques to carry out her stated aims and career goals.

NIH Research Projects · FY 2025 · 2020-12

PROJECT SUMMARY At the center of the pathogenesis of allergic diseases is the IgE molecule. In sensitized individuals, re- exposure to the offending allergen results in IgE engagement, causing Fcε receptor cross-linking and activation of mast cells and basophils. This triggers the release of mediators into the local tissue, resulting in the vast array of symptoms associated with allergic diseases, including anaphylactic shock. To date, studies of the human IgE molecule, and its targeted epitopes on allergens, have been very limited. Most of our knowledge of this process has come from studies using allergic patient serum, which contains a mixture of many antibodies, with many specificities, directed toward many different epitopes, and having many different affinities; thus the studies of the molecular interactions of IgE with target allergens are greatly flawed. The ideal way to study this process is to use naturally-occurring human IgE monoclonal antibodies (mAbs), isolated from allergic subjects. Unfortunately, due to many impassible intrinsic technical hurdles no such antibodies have previously ever been made. We have now established a method to grow, identify and immortalize IgE encoding B cells by making human hybridomas from the peripheral blood of allergic individuals. In this proposal, we develop the first comprehensive panels of naturally-occurring peanut allergen-specific human IgE mAbs to define the molecular interactions of the most potent inducers of anaphylaxis. We have already begun comprehensive mapping studies to identify key immunodominant antigenic sites on the major peanut allergen proteins Ara h 1, 2, 3, and 6. In Aim 1, functional antigenic site mapping via peanut induced anaphylaxis will be accomplished by passive sensitization of human FcεRI transgenic mice using IgE mAbs. In Aim 2, prototype mAbs that bind unique antigenic sites will be selected and expressed as recombinant IgG mAbs to use as tools for advanced mapping studies using human serum. IgG mAbs, which bind identically as the IgE mAbs from which they were made, will be employed in blocking studies using a panel of peanut allergic research subjects’ frozen serum and ImmunoCAP diagnostics. This will define the role that each antigenic site-specific population of IgE antibodies play within and between peanut allergic individuals. This information will be used to draw clinical correlates of disease and to select research subjects which possess IgE antibodies not blocked by our panels, allowing for the generation of new site-specific IgE mAbs in Aim 1. Finally, in Aim 3, we will obtain atomic resolution structures to precisely define the first ever naturally-occurring human IgE epitopes on Ara h 2 and 6 by X- ray crystallography. The goal of this work is to create a definitive, complete and comprehensive molecular map of the human IgE antibody response to the major allergen proteins of peanut. The results will serve as a much-needed road map to allow for the design of new immunotherapies and allergy vaccines.

NIH Research Projects · FY 2024 · 2020-09

IMPACT Abstract Despite the tremendous advances in genetic testing for inherited cancer, the promise of this technology cannot be realized through testing alone. Rather, it is critical to access appropriate follow-up care that may include cancer risk management (CRM) options for individuals and their at-risk family members. Current gaps in implementation of guideline-adherent follow-up care based on inherited cancer genetic test results include both over and under treatment among those with pathogenic and likely pathogenic (P/LP) variants or a variant of uncertain significance (VUS). Furthermore, we are missing the opportunity to magnify the uptake and impact of testing among family members who are at high risk due to suboptimal family communication (FC) of genetic test results and cancer family history. Our highly innovative and practice-changing study is designed to shift the paradigm by which individuals with P/LP variants and VUS in inherited cancer genes are provided with information to enhance guideline-adherent CRM and FC of test results. Through our proposed type I effectiveness-implementation hybrid randomized control mixed methods study, we will test two interventions with a diverse group of 600 individuals with a P/LP variant or a VUS result in a variety of inherited cancer genes for which CRM guidelines are available. Intervention A is focused on increasing guideline- adherent CRM (LivingLabReport), and Intervention B is focused on increasing FC and subsequent family testing (GeneSHARE). Alongside developing, refining, and testing interventions to improve guideline-adherent CRM and FC, we will study the implementation of these interventions across racially, geographically, and socio- economically diverse populations and settings. The information gathered through testing effectiveness and implementation of the interventions will be used to develop, modify and pilot test adaptive stepped interventions with the potential to efficiently maximize effectiveness in improving guideline-adherent CRM and FC. This transdisciplinary effort, enriched for accrual of Blacks, rural dwellers, and other underserved populations, will inform policy and the development of scalable models for delivering evidence-based care. Ultimately, our study will help address the need for access to effective information to guide CRM and enhance FC in diverse populations across various genes and settings which is greatly needed if the population at large is to benefit from genomic advances in this era of personalized medicine.

NIH Research Projects · FY 2024 · 2020-09

Project Summary Age is the dominant risk factor for most chronic diseases; yet mechanisms by which aging confers risk are largely unknown. One unifying feature of aging diseases as diverse as cardiovascular disease and cancer is the acquisition of somatic mutations in hematopoietic stem cells (frequently DNMT3A, TET2, JAK2), termed Clonal Hematopoiesis of Indeterminate Potential (CHIP). I will leverage human genomics to identify pathways underlying CHIP acquisition, clonal expansion and disease. Why only some individuals develop CHIP, why only some CHIP clones expand, and why only a minority of CHIP carriers develop disease is presently unknown. I hypothesize that germline genetic variation contributes to CHIP acquisition, clonal expansion and disease. I propose to (1) identify CHIP in existing genome sequencing data and perform genetic association analyses of CHIP in >800,000 individuals and evaluate how CHIP-associated variants alter human hematopoietic stem cell function in in-vitro follow-up experiments. (2) Define the determinants of CHIP clonal expansion and association with disease. (3) Identify gene expression programs that cause clonal expansion and disease. Successful execution of these aims will highlight therapeutic targets for the prevention of CHIP, clonal expansion and disease for which no therapies currently exist. Such a CHIP therapeutic would potentially be an intervention for multiple aging diseases. To succeed in these aims, I will receive significant institutional support from MGH including funding, space, protected time and mentorship to establish my research group. The Broad Institute will provide access to leading-edge genomic resources. I will leverage my unique position at the interface of these two scientific communities to establish a leading research program focused on CHIP. Having completed rigorous training in genomics, cardiovascular biology, and clinical medicine, I am now poised to leverage these skills, resources and mentorship to embark on my own independent research career without delay.

NIH Research Projects · FY 2024 · 2020-09

PROJECT SUMMARY: Thyroid cancer is rapidly increasing in the U.S. and is expected to be the 4th leading cancer diagnosis by 2030, surpassing colorectal cancer. While most patients are cured of their thyroid cancer following initial treatment, a significant portion of patients develop recurrent and aggressive disease. In fact, some well-differentiated thyroid cancers develop into anaplastic thyroid carcinoma (ATC), a highly lethal and treatment-resistant disease with an abysmal 4-month survival. While these ATCs usually carry common driver-mutations such as BRAFV600E, studies suggest that the majority also acquire activating mutations in the Wnt pathway. In addition, BRAF inhibitors have shown limited efficacy in treating these aggressive thyroid tumors. Research in other cancers suggests that Wnt signaling may play a role in the failure of BRAF inhibitor therapy. There is compelling evidence that thyroid carcinomas are dependent on Wnt signaling, particularly poorly differentiated and aggressive disease. The goal of this proposal is to discover the role of Wnt signaling in metastatic, recurrent, and treatment-resistant thyroid cancer. My preliminary data on BRAFV600E-mutant thyroid cancer demonstrate alterations in Wnt/β-catenin signaling following BRAF inhibition. My studies also create a unique thyroid cancer organoid system to study primary patient-derived thyroid cancers across a heterogeneous landscape of genetic alterations. Finally, I create a humanized patient-derived xenograft mouse model for thyroid cancer, with loss of murine MHCII and MHCI that can serve to study the in vivo biology of thyroid cancer and to test new therapeutics (including anti- Wnt drugs) against thyroid cancers resistant to standard-of-care therapy. In this proposal I will test the hypothesis that Wnt signaling causes the increased invasive and metastatic potential of aggressive thyroid cancer. In Aim 1, I will define the in vivo effect of Wnt inhibition on the malignant phenotype of aggressive thyroid cancer. In Aim 2, I will discover the role of Wnt signaling in the resistance mechanism of BRAF-mutant thyroid cancer following BRAF inhibitor therapy. In Aim 3, I will use sequential patient samples to determine the drivers of Wnt signaling upregulation in ATC. Through completion of these studies, I will define the role of Wnt signaling, a major oncogenic pathway, in thyroid carcinoma. I anticipate that these pre-clinical studies will lead to clinical trials of Wnt inhibitors for anaplastic thyroid cancer and dramatically improve detection and treatment of the most aggressive forms of thyroid cancer. In addition, these studies will form the foundation of a strong research program for a promising junior investigator. Through this K08 grant and the guidance by accomplished mentors, I will gain the knowledge and experience needed to become an independently funded and successful physician- scientist.

NIH Research Projects · FY 2024 · 2020-09

PROJECT SUMMARY: Growing evidence suggests that dopamine contributes to key functions in multiple RDoC domains, specifically Positive Valence Systems, Cognitive Systems, and Sensorimotor Systems. In Late-Life Depression (LLD), dysfunction in all these systems is common, portends poor outcomes, and manifests as deficits in motivation and effort, executive dysfunction, and gait impairment. While studies of dopamine function in early and midlife depression primarily focus on reward processing, they often exclude the cognitive and sensorimotor domains relevant for older adults despite a recognized decline in dopamine function with normal aging. The objectives of this collaborative R01 proposal between Columbia University/New York State Psychiatric Institute and Vanderbilt University Medical Center are to: 1) characterize dopaminergic dysfunction in LLD across multiple RDoC domains (Positive Valence Systems, Cognitive Systems, and Sensorimotor Systems) at several levels of analysis (cellular [PET], circuit [MRI], and behavioral / self-report); and 2) examine the responsivity of dopamine-related circuits and behavior to stimulation with levodopa (L-DOPA). Supported by pilot data, this project builds on our past work demonstrating that dopamine function declines with aging, that dopaminergic dysfunction contributes to deficits in behavioral measures of the Positive Valence Systems, Cognitive Systems, and Sensorimotor Systems, and that L-DOPA administration improves performance in these systems. The long-term goal of this line of research is to determine how dopaminergic dysfunction contributes to clinical presentations of LLD, how responsive behavioral symptoms are to modulation of dopamine function, and to identify novel targets for future interventions. Our approach is to enroll 60 psychiatrically healthy elders (30 per site) and 120 depressed elders (60 per site) exhibiting likely dopaminergic dysfunction, characterized as either slowed processing speed or slowed gait speed. Participants will undergo thorough clinical characterization and complete PET imaging measuring dopamine synthesis and dopamine receptor availability, neuromelanin-sensitive MRI measurement of long-term nigrostriatal dopamine transmission, task positive MRI focused on effort-based decision making and reward processing, a comprehensive neurocognitive evaluation, a physical performance evaluation, and measurement of inflammatory markers. To assess responsivity of the dopamine system to modulation, depressed subjects then will be randomized to L-DOPA or placebo for 3 weeks, followed by repeat multimodal MRI and cognitive/behavioral assessments. Using a cross-over design, participants will receive the opposite intervention for an additional 3 weeks followed by clinical and cognitive assessments only. This proposal is significant and innovative, as no prior published study has comprehensively examined dopamine-dependent behaviors in LLD. This will inform treatment approaches focusing on facilitating cognition and movement, reducing the effort cost of voluntary behavior, and promoting behavioral activation.

NIH Research Projects · FY 2024 · 2020-09

Project Summary Diabetic retinopathy (DR) is a major cause of blindness worldwide. DR progresses in many patients despite preventable measures such as blood sugar and blood pressure control. Other available treatments require invasive eye injections and are often ineffective—DR remains the leading cause of legal blindness among working-age adults. Current diagnostic tests fail to identify early disease stages or predict disease progression. Consequently, new biomarkers and therapeutic strategies are needed. DR is an established inflammatory disease with leukocyte involvement. Many inflammatory cytokines (products of leukocytes) are consistently elevated in the aqueous and vitreous of patients with advanced DR and diabetic macular edema (DME). Inflammatory mediators are candidates for direct biomarkers that may predict DR progression as well as treatment response. To date the only validated prognostic DR biomarker is the circulating glycemia marker glycated hemoglobin (HbA1C). HbA1C screening, however, reflects glucose control, which indicates disease risk as opposed to DR pathology. Our central hypothesis is that intraocular inflammatory mediators such as PGE2, IL-6, and IL-8 are markers of DR severity and therefore predict risk of disease progression. Equally important, they represent potential novel targets for inhibition. We have recently demonstrated that topically applied ketorolac, a nonsteroidal anti- inflammatory drug, achieves therapeutic vitreous levels and significantly reduces several elevated inflammatory mediators in eyes with DR. These observations and its commercial availability provide rationale to investigate the relationship of inflammatory mediators with DR severity and the long-term effects of chronic topical administration of ketorolac in diabetic patients. Our current goals include confirming inflammation mediators are biomarkers of both systemic diabetes and DR progression in the aqueous. Like the vitreous humor, the aqueous reflects localized ocular inflammation, however, is technically easier to collect with less risk. We will also determine the long-term effects of sustained ketorolac application on intraocular cytokine levels, DR progression, and DME incidence. Our proposal is the first to use a cornea-permeable NSAID for the treatment of DR. We believe local inflammation control in the eye will transform future treatment options for diabetic patients facing blindness. Tracking and inhibiting local inflammatory mediators through all DR stages has the capacity to reduce or prevent disability in millions of patients per year.

NIH Research Projects · FY 2024 · 2020-09

PROJECT SUMMARY Influenza virus is a significant pathogen in adult solid organ transplant (SOT) recipients. However, these individuals respond poorly to standard-dose (SD) inactivated influenza vaccine (IIV). Recent studies have investigated two strategies to overcome poor immune responses in SOT recipients: (1) administration of high- dose (HD)-IIV compared to SD-IIV and (2) two doses of SD-IIV compared to one dose of SD-IIV in the same influenza season. The first study compared HD-IIV vs.SD-IIV in adult SOT recipients and noted that HD-IIV was safe and reported higher immunogenicity; however, the median post-transplant period was 38 months. In another phase II trial of adult SOT recipients, two doses of SD-IIV a month apart compared to one-dose of SD- IIV revealed increased immunogenicity, with a median post-transplant period of 18 months. Therefore, these studies lack evaluation in the early post-transplant period in this vulnerable population. Additionally, the administration of two-doses of HD-IIV in the same influenza season has not been evaluated in SOT recipients. Thus, the optimal immunization strategy for SOT recipients less than 12 months post-transplant is unknown. In addition, the immunologic predictors and correlates of influenza vaccine immunogenicity in SOT recipients have not been well-defined. The central hypothesis of our proposal is that adult SOT recipients that are 1-11 months out from transplant and are receiving two doses of HD-IIV will have higher hemagglutination inhibition geometric mean titers (GMT) to influenza A antigens compared to adult SOT recipients receiving two doses of SD-IIV over one influenza season. To test this hypothesis and address the critical knowledge gaps outlined above, we propose to conduct a phase II, multi-center, randomized-controlled immunogenicity and safety trial comparing either one dose of HD-IIV, two doses of SD- IIV, or two doses of HD-IIV in adult kidney, heart, and/or liver SOT recipients 1-11 months post-transplant. The results of this study will address significant knowledge gaps regarding influenza vaccine strategies and immune responses in adult SOT recipients and will guide vaccine recommendations in the early post- transplant period.

NIH Research Projects · FY 2024 · 2020-09

PROJECT SUMMARY: The systemic inflammatory response syndrome, driven by a host’s response to inflammatory triggers such as foreign pathogens and cytokines, causes significant dysfunction in the vasculature. This dysfunction is due to the loss of homeostatic mechanisms within the endothelium and manifests as intravascular fluid loss, abnormal leukocyte trafficking, disrupted coagulation and altered vascular tone. Despite its overwhelming and obvious negative effect on patients and their outcomes, targeting vascular pathways, such the vasodilator nitric oxide, has not yielded successful results. The failure of such trials, along with the general absence of effective treatments for acute systemic inflammation, has left clinicians with no therapeutic options beyond supportive care. Unfortunately, the root cause of vascular dysfunction in acute systemic inflammation remains completely unknown and with many unanswered questions. What spatiotemporal protein interactions or metabolic pathways contribute to or counterbalance the dysfunction? Does the presence of vasculopathy lead to specific genomic or proteomic signatures, known as endotypes, and how can they be modeled? What unique endothelial targets exist that can be utilized to improve vascular function and restore homeostasis? To answer these questions and any further that will arise, our research program will focus on three integrated themes. Theme one will explore molecular mechanisms that dysregulate endothelial homeostasis during acute inflammation. Mechanisms such as direct protein-protein interactions, mitochondrial dysfunction and reactive oxygen species signaling will be explored using a variety of techniques including genetic modification, glycolytic and oxidative stress capacity and proximity ligation assays. Theme two will focus on modeling endothelial dysfunction utilizing overlapping procedures in both animals and humans to identify consistent patterns. This theme will test animal models of systemic inflammation in combination with acutely ill human patients using non-invasive vascular reactivity techniques, such as laser doppler perfusion monitoring, coupled with genomic and proteomic signatures. In addition, the use of microfluidic devices (i.e. tissue-on-a-chip) will create a bridge between the more adaptable animal models and the non-adaptable human patient populations to test if a synthetic human system will correlate with data derived from mechanism driven animal studies. The third theme will focus on drug discovery. This theme will use the biochemical mechanisms found in the prior themes to help discover endothelial-specific, targeted treatments. Use of cell-penetrating peptides coupled to novel compounds or peptide sequences will allow cell permeation to the target of interest. In addition, testing of therapies used in chronic vascular dysfunction will be examined to determine if similar mechanisms can be tempered in acute systemic vasculopathy. These integrated themes support the overarching goal of this research program, which is to better understand mechanisms that affect acute endothelial-mediated vascular dysfunction with the overall intent of being able to identify and treat patients with acute vasculopathy during systemic inflammation to improve clinical outcomes.

NIH Research Projects · FY 2024 · 2020-08

PROJECT SUMMARY Despite the recognition of health disparities in obesity, behavioral interventions among low-income and minority populations have consistently met with limited success. This is partially explained by social determinants of health. Constantly changing barriers at the household and community levels impede consistent engagement in healthy behaviors. The current proposal tests a novel, culturally-tailored and multi-level intervention designed to teach families to overcome dynamic barriers as the logical next step to address obesity among low-income Latino families. It is based on the premise that by implementing a personalized multi-level intervention that simultaneously addresses healthy weight for parents and children, we will improve body mass index (BMI) among Latino parent-child pairs. COACH (COmpetency-Based Approaches to Community Health) implements a personally tailored approach, equipping families to engage in health behaviors despite dynamic barriers. COACH is a multi-level intervention targeting 1) the individual child through developmentally appropriate health behavior curriculum, 2) the family by addressing parent weight loss directly and engaging parents as agents of change for their children, and 3) the community by building capacity of Parks and Rec centers to offer parent-child programming. Using novel multi-component assessments throughout the study, the intervention identifies individual, family, and community barriers to healthy behaviors and delivers structured yet personalized intervention content in 7 domains: fruits/vegetables, snacks, sugary drinks, physical activity, sleep, media use, and parenting. Building on a successful pilot, this proposal will implement a randomized controlled trial to test the effectiveness of COACH compared to an attention-matched school-readiness control group. We will enroll 300 parent-child pairs from Latino communities in Nashville, TN. Eligible children will be 3-5 years old and have a BMI >50th percentile. Through our 10-year partnership with the Nashville Parks and Rec department, we conduct COACH in neighborhood community centers, leveraging community infrastructure to facilitate health behavior change. The primary outcome will be child BMI change at 2-year follow-up, using a growth curve analysis. Secondary outcomes will include parent BMI, and parent/child diet and physical activity. The goals of COACH are to 1) implement a novel personalized behavioral intervention, 2) test a two-generation solution to obesity, 3) address health disparities by reducing obesity among Latino families, and 4) develop a scalable and widely accessible approach to behavioral obesity interventions by delivering them in Parks and Rec centers.

NIH Research Projects · FY 2024 · 2020-08

PROJECT SUMMARY This application is for a K08 award for Rebecca Berhanu MD, an Instructor at Boston University’s Department of Global Health in the School of Public Health, who is training to become an independent investigator in the field of molecular epidemiology and tuberculosis (TB) transmission research. TB is the leading infectious cause of death globally and the number one cause of death amongst people with HIV. The identification of recent TB transmission clusters by whole genome sequencing (WGS) methods offers unique insight into transmission patterns which cannot be obtained through traditional contact tracing. The overall research objective is to use WGS coupled with molecular clock, phylogenic and transmission cluster analysis to characterize transmission of rifampin and multi-drug resistant (RR/MDR) TB in Johannesburg, South Africa. The aims of the study are to: 1) Use WGS data to calculate the molecular clock of RR/MDR-TB, 2) Use single-nucleotide polymorphism (SNP)-based cluster analysis and Bayesian transmission analysis to identify recent TB transmission clusters or RR/MDR-TB, and evaluate the impact of HIV status, CD4 count and antiretroviral therapy (ART) on the likelihood of transmitting TB and 3) Determine if WGS transmission cluster identification augmented with demographic and social-network data can identify non-household locations of recent RR/MDR-TB transmission. Dr. Berhanu will receive mentorship from a team of inter-disciplinary experts in TB epidemiology, bioinformatics and TB genomics. Her primary mentor, Dr Horsburgh, is a Professor of Medicine and Epidemiology at Boston University and has over 30 years’ experience in TB clinical and translational research. Her co-primary mentor, Dr. Karen Jacobson, an Assistant Professor of Medicine at Boston University, is an expert in TB epidemiology in high-burden settings and has worked extensively in South Africa using TB molecular data. Dr. Berhanu’s Advisory Board includes Dr. Maha Farhat, Assistant Professor of Biomedical Information at Harvard University, who has published extensively on resistance mutation characterization and markers of recent transmission using TB genomic data; Dr. Nazir Ismail, head of the Centre for Tuberculosis of the NICD in Johannesburg, is an expert in TB molecular epidemiology, and Dr. Evan Johnson, Associate Professor of Medicine and Biostatistics at Boston University, with expertise in bioinformatics methodology. Dr. Berhanu’s training plan links to the proposed research aims: establish a solid foundation in epidemiology; and develop new skills in bioinformatics, phylogenetics and transmission analysis using WGS data. Training will be accomplished through a combination of didactic courses, workshops, and practicums in South Africa and Boston. These training and research activities will allow Dr. Berhanu to mature into an independent investigator and provide a basis for an R01 using molecular and social network data to identify transmission hotspots and areas for targeted case-finding.

NIH Research Projects · FY 2024 · 2020-08

PROJECT SUMMARY Candidate: Dr. Jonathan Casey MD, MSCI is an Assistant Professor at Vanderbilt University Medical Center. Dr. Casey has a strong background in clinical trials of critically ill adults obtained through formal training in clinical research and the conduct of comparative effectiveness trials of respiratory support. His long-term career plan as a physician scientist is to become recognized as a leader in the conduct of pragmatic trials of early respiratory support in critically ill adults. To achieve this, his immediate goals are to adapt the pragmatic trial methodology he has used in the intensive care unit to the chaotic environment of the emergency department, become an expert in the forms of consent used in emergency research, gain experience applying tools from implementation science to improve the quality of pragmatic trials, and learn the advanced modeling methods required for enriching clinical trials and analyzing of heterogeneity of treatment effect. Research Project: Each year more than 1.5 million critically ill patients receive mechanical ventilation in the United States, and the placement of an endotracheal tube for mechanical ventilation in critically ill patients is fraught with complications with one-in-five experiencing hypoxemia and one-in-forty experiencing cardiac arrest. Bag-mask ventilation has been shown to prevent life-threatening hypoxemia among patients in the ICU, but it is unclear if these results generalize to the ED and pre-hospital setting, where the majority of critically patients are intubated. Due to differences in patient populations, patients in the ED are, on average, at lower risk for peri-intubation hypoxemia and higher risk of aspiration (a proposed risk of bag-mask ventilation), and bag-mask ventilation is rarely used in this setting. Improved understanding of the risks and benefits of bag- mask ventilation during tracheal intubation in the ED is urgently needed. The Specific Aims of the proposed research are: Aim 1) Develop a model to estimate the lowest oxygen saturation during tracheal intubation in the ED; and Aim 2) Use the model from Aim 1 for prognostic enrichment, selectively enrolling patients at risk for hypoxemia into the SAFEty of bag-mask VENTilation in the ED (SAFEVENTED) study, a 464-patient randomized trial testing the hypothesis that bag-mask ventilation will increase the lowest oxygen saturation of patients undergoing intubation in the emergency department. Career Development: Dr. Casey's career development plan integrates coursework, experiential learning, and training with his mentors to: 1) learn the modeling techniques required to develop and analyze the SAFE- VENTED trial; 2) develop expertise in EFIC and other forms of consent used in emergency care research; and 3) leverage tools from implementation science to improve delivery of trial interventions during pragmatic trials. Environment: As a supportive and well-resourced institution with international leaders in clinical trials, emergency care research, human subjects protection, bioinformatics, and biostatistics, Vanderbilt is the ideal environment to foster Dr. Casey's development into a national leader in trials of early respiratory support.

NIH Research Projects · FY 2024 · 2020-08

PROJECT SUMMARY Identifying brain-behavior associations for the purpose of informing individual differences, illness trajectories, and neural mechanisms is one of the primary goals of psychiatric neuroimaging. The massively multivariate nature of neuroimaging data, which consists of spatially detailed images of brain structure and function, combined with high-dimensional behavioral data pose significant challenges to meeting this goal. The emerging replication crisis in neuroimaging research has exposed limitations of commonly used spatial extent inference (SEI) methods for analyzing imaging data. These include unrealistic assumptions about the spatial covariance function of the imaging data that lead to highly inflated error rates. This project will develop a new robust semiparametric inference framework for neuroimages to address the need for methods that are robust in real-world data, integrate these methods into the pbj R package, and develop a graphical user interface (GUI) to make the methods accessible to neuroimaging scientists. We will use the methods to study how multidimensional symptoms of psychosis are related to brain function and structure in the Psychiatric Genotype-Phenotype Project (PGPP) collected and Vanderbilt University Psychiatric Hospital (VUPH) and to study cross-sectional and longitudinal changes in functional connectivity in the public-access Nathan Kline Institute Rockland Sample (NKI-RS). We will evaluate the methods using realistic bootstrap-based neuroimaging simulations. In Aim 1 we will develop a multidimensional semiparametric procedure for SEI that will leverage computationally efficient parametric and nonparametric bootstraps for inference. In Aim 2 we will expand the framework to repeated measurement models (including longitudinal data), that will allow scientists to robustly model associations of subject-level covariate measurements and brain structure or function. In Aim 3, to address the need for alternatives to hypothesis testing in psychiatric neuroimaging, we will develop semiparametric Coverage Probability Excursion (CoPE) sets that can be used to construct spatial confidence intervals for semiparametric effect sizes. These methods will be made available to the neuroimaging community through the pbj R package and GUI, and disseminated at neuroimaging conferences.

NIH Research Projects · FY 2024 · 2020-08

Abstract Status epilepticus (SE) is the most common serious neurological emergency among children worldwide. In the low- and middle-income countries (LMICs) of sub-Saharan Africa, the burden of childhood SE-associated mortality and morbidity appears to be especially high. However, the phenotypes of childhood SE, clinical predictors of SE-associated mortality and of SE-associated neurodevelopmental morbidity, and genomic predictors of SE, SE-associated mortality and neurodevelopmental morbidity have not been well-characterized in this region. The clinical and genomic predictors of benzodiazepine-resistant SE, which is common and may contribute to SE-associated mortality, have also not been well-characterized, especially among African children. A large percentage of children (~80%) with SE in northern Nigeria experience SE as their first seizure, and the estimated incidence of childhood SE in Kano is relatively high. Little is known of the clinical and genomic risk factors for the development of epilepsy among African children who experience SE as their first seizure. The H3Africa consortium is yielding insights into the genomic factors of common human diseases across the African continent and and will provide controls for genome-wide association studies (GWAS) of SE. This project, Childhood Status Epilepticus and Epilepsy Determinants of Outcome (SEED), will establish a large cohort of children with SE in Kano, northern Nigeria who present to pediatric emergency rooms in Kano. Innovative capacity building will include the incorporation of point-of-care EEG and EEG-video in large pediatric emergency rooms in Kano, performed by specially trained community health extension workers (CHEWs) who will be trained in both basic epilepsy care and EEG technology. A team of specialists working together at Aminu Kano Teaching Hospital (AKTH) and at Vanderbilt University Medical Center (VUMC) will utilize video exams, EEG-video, detailed histories, and brain MRI to perform deep phenotyping on this large cohort of children with SE. Clinical risk factors for in-hospital SE-associated mortality, short-term SE- associated mortality, long-term SE-associated mortality, and SE-associated neurodevelopmental morbidity will be determined. GWAS will be performed on the entire cohort, with gender matched controls from H3Africa, through collaborations between AKTH, Bayero University Kano, the Sidney Brenner Institute for Molecular Bioscience in South Africa, and VUMC. Genomic risk factors for childhood SE-associated mortality and morbidity will be determined, as well as clinical and genomic risk factors for development of epilepsy among children who experience SE as their first seizure and clinical and genomic risk factors for benzodiazepine- resistant SE. SEED will provide valuable insights into childhood SE in sub-Saharan Africa.

NIH Research Projects · FY 2025 · 2020-07

PROJECT SUMMARY: Deficits in cognitive control are core features of late-life depression, contributing both to emotion dysregulation and problems with inhibiting irrelevant information, conflict detection, and working memory. Clinically characterized as executive dysfunction, these deficits are associated with poor response to antidepressants and higher levels of disability. Improvement of cognitive control network (CCN) dysfunction may benefit both mood and cognitive performance, however no current pharmacotherapy improves CCN deficits in LLD. Supported by our pilot data, we propose that nicotine acetylcholine receptor agonists enhance CCN function and resultantly improve mood and cognitive performance in late-life depression. The objective of this R61 / R33 proposal is to first determine whether transdermal nicotine enhances CCN neural activity in an exposure-dependent fashion during an emotional response inhibition task (the emotional Stroop task). If we meet our Go Criteria by demonstrating exposure-dependent CCN target engagement, we will then conduct the R33 pilot randomized controlled trial to: 1) determine the relationship between target engagement and clinical improvement; 2) examine the specificity of transdermal nicotine’s effects on the CCN; and 3) obtain preliminary evidence of TDN’s clinical effects. The long-term goal of this line of research is to determine whether nicotinic acetylcholine receptor agonists enhance CCN function and provide clinical benefit to individuals with late-life depression. Supported by our pilot data, this project’s rationale is that it will elucidate whether broad nicotinic acetylcholine receptor agonists enhance CCN activity and if so, does that mechanism positively influence clinical symptoms. A negative finding will improve our understanding of the neural effects of broadly active nicotinic receptor agonists and whether targeting the CCN has therapeutic benefit. Our approach for the R61 phase is to examine in 36 older adults with Major Depressive Disorder whether transdermal nicotine patches enhance CCN activity over 12 weeks as measured during fMRI with the emotional Stroop task while measuring nicotine and nicotine metabolite levels. If we meet Go Criteria by demonstrating exposure-dependent target engagement, we will proceed to the R33 pilot clinical augmentation trial. Seventy-two depressed elders on stable SSRI or SNRI monotherapy will be randomized to 13 weeks of active transdermal nicotine or placebo patches, completing MRI and cognitive testing at baseline and at the trial’s end. Dosing will be guided by nicotine blood levels and based on the relationship between exposure and target engagement as observed in the R61 phase. This proposal is significant and innovative as no current pharmacotherapy improves CCN function or improves cognitive deficits in late-life depression. Transdermal nicotine has a mechanism of action that is distinct from current antidepressants, potentially making it an important augmentation agent. If our hypotheses are correct, as patches are commercially available, this approach could be rapidly moved into definitive studies and may have applicability to other psychiatric disorders characterized by CCN dysfunction.

NIH Research Projects · FY 2024 · 2020-07

Project Summary Hypertension is the leading cause of death and disability-adjusted life years worldwide. Despite current therapies blood pressure remains uncontrolled in approximately 50% of individuals with hypertension, and even with adequate control of BP an elevated risk of cardiovascular events remains. Hence, there is a major unmet need for new therapeutic options for hypertension. Emerging evidence suggests an important role for the immune system in the pathogenesis of hypertension. An immune cell subset termed regulatory T cells (Tregs) is an attractive therapeutic target as it plays a suppressive role to limit inflammation. However, recent evidence suggests that Tregs can play pathogenic roles in heart failure and lung fibrosis through inhibiting angiogenesis and promoting fibrosis. Novel evidence provided with this application suggests that a subpopulation of Tregs expressing C-C motif chemokine receptor 10 (CCR10) is selectively decreased in the circulation of hypertensive humans and mice and is increased in the skin of mice with hypertension. Given recent evidence for an important role for skin microvascular rarefaction (defined as loss of microvessels) in hypertension, these results suggest a novel link between CCR10+ Tregs, skin microvessels, and hypertension development. To understand a mechanism for these effects, we evaluated the effects of increased endothelial cell stretch, as occurs with elevated blood pressure, on immune cells and found that CCR10+ Tregs are selectively increased with enhanced endothelial stretch. Thus, studies in this application will test the hypothesis that increased endothelial cell stretch augments CCR10 expression in Tregs and promotes CCR10+ Treg recruitment to the skin to enhance microvascular rarefaction and hypertension development. This hypothesis will be tested with the following specific aims: 1) to test the hypothesis that increased EC stretch enhances CCR10 expression in Tregs via tumor necrosis factor alpha and to determine whether resultant CCR10+ Tregs transmigrate and inhibit angiogenesis in response to CCR10 agonism by C-C motif chemokine ligand 27 (CCL27) in vitro, 2) to determine whether CCR10+ Tregs promote skin microvascular rarefaction leading to elevated blood pressure in salt and angiotensin II-induced hypertensive mouse models in vivo, and 3) to test whether CCR10 and its skin-specific ligand CCL27 promote hypertension in humans using a genetic approach of Mendelian randomization. Execution of the outlined experiments will provide a platform for the applicant to gain further understanding and skills related to the study of regulatory T cells and skin microvasculature as well as human genetic approaches such as Mendelian randomization. This work will be performed at Vanderbilt University Medical Center which has outstanding resources and mentorship to enable successful attainment of the career goals of the applicant, namely to become an independent physician scientist caring for patients with hypertension and studying the role of regulatory T cells in development of this disease to help develop new therapeutic options for treatment.

NIH Research Projects · FY 2024 · 2020-07

PROJECT SUMMARY/ ABSTRACT Breast cancer is the most common malignancy among western women. Although adjuvant and molecularly targeted therapies significantly improve patient survival in some molecular subtypes of breast cancer, the prognosis of triple-negative/basal-like breast cancer (TNBC) remains grim, due to lack of identification of oncogenic drivers. In searching of cancer vulnerability, it was discovered that TNBC is especially dependent on glutamine metabolism, likely due to up- regulation of the glutamine transporter, ASCT2/SLC1A5, and glutaminase, GLS, representing the rate-limiting steps in glutamine consumption. Despite the interest in targeting glutaminolysis in TNBC, it is unclear how global inhibition of glutamine metabolism will affect immune cells in the tumor microenvironment, particularly given that rapidly proliferating tumor infiltrating lymphocytes (TILs) require glutaminolysis to supply macromolecules for cell growth. Specifically, the competition between tumor cells and TILs for glutamine has not been investigated thus far, but is likely to be important for anti-tumor immunity. We have generated preliminary data providing evidence that knockout of GLS specifically in tumor cells increases glutamine concentration in the tumor interstitial fluid and enhances cytotoxic CD8 T lymphocyte activities. The above effects are abrogated in immune-deficient mice, suggesting that adaptive immunity plays a critical role. In addition, pharmacologic inhibition of the glutamine transporter, ASCT2, selectively targeting tumor cells while enhancing TIL function. Based on these findings, we hypothesize that (1) tumor cells outcompete TILs for glutamine to sustain their proliferative programs while simultaneously suppressing antitumor immune response, and (2) selectively targeting glutamine metabolism in tumor cells enhances antitumor immunity. To test these hypotheses, we will first test glutamine competition between tumor cells and TILs and how this competition affects tumor growth, metastasis, and anti-tumor immune responses (Aim 1). We will also define how metabolic changes in GLS loss specifically in tumor cells impact T cell recruitment and activation in situ by MALDI-imaging mass spectrometry (Aim 2). Finally, we will evaluate in vivo pharmacological targeting of glutamine transporter and glutaminase for treating TNBC (Aim 3). The success of the project will elucidate a long-standing issue whether there is a metabolic competition for glutamine between tumor cells and infiltrating lymphocytes, and leverage the knowledge for developing new therapeutic strategies for treatment of glutamine-addicted cancer.

NIH Research Projects · FY 2024 · 2020-07

Abstract Pulmonary fibrosis (PF) is a clinical syndrome that represents the end-stage of chronic parenchymal lung diseases. Dysfunctional repair of the distal lung epithelium has been hypothesized as central to PF pathogenesis, but the mechanisms governing epithelial repair following injury remain incompletely understood. In order to comprehensively profile the cell types and gene expression programs driving PF, we performed single-cell RNA-sequencing (scRNA-seq) of peripheral tissue from PF and control lungs and identified dramatic changes in cell types, states, and expression programs in PF lung epithelium including a previously undescribed KRT5-/KRT17+ “distal basal cell” (DBC) population that produces pathologic extracellular matrix. Independently, using whole-exome sequencing for genetic discovery in families with pulmonary fibrosis (Familial Interstitial Pneumonia, FIP), we identified rare mutations in an orphan G-protein coupled receptor (GPR87) that segregate with disease, implicating GPR87 as a novel FIP risk gene. Our preliminary data indicate that GPR87 gene expression is dramatically increased in lung tissue from patients with sporadic cases of IPF, and localizes specifically to these newly described pathologic ECM-producing DBCs. In mice, as in humans, Gpr87 expression was low in the peripheral lung; however, expression increases substantially after following bleomycin injury, where it localized to distal basal cells. We generated mice expressing an FIP- associated mutant form of Gpr87 using a CRISPR-Cas9 gene editing strategy and found that mice carrying a single-copy of the mutation (Gpr87mut/wt) had increased lung fibrosis compared to control mice following a single-dose bleomycin. Unchallenged mice carrying biallelic mutations (Gpr87mut/mut) develop spontaneous airway epithelial remodeling and striking atypical hyperplasia in vivo. Consistent with these findings, culture of Gpr87mut/mut mouse tracheal epithelial cells (MTECs) in air-liquid interface (ALI) and 3D organoid systems resulted in aberrant epithelial differentiation. Together, our preliminary data implicate DBCs in PF pathogenesis and suggest that GPR87 regulates the fate and function of these cells. Our hypothesis is that GPR87 regulates proliferation and differentiation of distal basal cells, which are required for efficient repair of alveolar epithelium after severe or repetitive injury. Our specific aims are: 1) Determine the role of Gpr87- expressing distal basal cells in promoting lung fibrosis. 2) Identify mechanisms regulating distal basal cell fate and function in severe and chronic alveolar injury. 3) Investigate GPR87-dependent regulation of basal cell function and differentiation. In studies proposed below, we will use innovative transgenic mouse, organoid and inducible pluripotent stem cell (iPSC)-based models to investigate the mechanisms through which GPR87 contributes to fibrotic susceptibility and adaptive versus pathologic lung epithelial repair.

NIH Research Projects · FY 2025 · 2020-07

PROJECT SUMMARY Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are severe, life-threatening immunologically mediated adverse drug reactions representing the same disease across a spectrum of severity.1 There is currently no evidence-based standard of care treatment for SJS/TEN. Preventive efforts have been fueled by strong associations between the HLA Class I allele HLA-B*15:02 which has led to implementation of cost-effective pre-treatment genetic screening programs in many Southeast Asian countries.2,3 However, the lower prevalence (<1%) and negative predictive value of this HLA allele in European American, Hispanic American, and African American populations, and the lack of currently defined HLA associations with drugs commonly used and associated with SJS/TEN in the United States has left many evidence gaps and implementation hurdles.4 The scientific premise of this study is that the most efficacious treatment will impact cellular immune responses mediating, related biomarkers and clinical outcomes of SJS/TEN. We have assembled the North American Therapeutics in Epidermal Necrolysis Syndrome (NATIENS) study, a group of 22 sites across the United States to conduct the first multicenter double-blind double dummy randomized controlled assessment of cyclosporine or etanercept or supportive care. The controlled design will afford the opportunity to collect and assay multiple samples in each treatment arm, in both the acute and convalescent phase, with the aim to discover new strategies for prevention, early diagnosis and targeted treatment. We will use integrated multi-omic, single-cell and high-throughput in-vitro screening approaches to determine the genetic basis, immunopathology and antigen specificity of drug-induced SJS/TEN. In Specific Aim 1 we will establish the most clinically effective therapy for SJS/TEN through the NATIENS multi-centered, double-blind double-dummy randomized controlled trial with a planned accrual of 267 patients over 5 enrollment years to determine whether etanercept and/or cyclosporine have benefit over supportive care for the measured primary outcome of complete re-epithelialization. In Specific Aim 2 we will use genome-wide sequencing, high-resolution HLA sequencing, transcriptomic, and cytokine profiling to identify genetic and biological markers that predict risk and outcome for SJS/TEN. In Specific Aim 3 We will study the immune phenotype of cells in the skin, blister fluid and peripheral blood in acute SJS/TEN based on single-cell RNA and protein expression. Using the dominantly represented T-cell receptor (TCR) in the blister fluid we will use a high throughput in-vitro screening approach to identify specific epitopes recognized by CD8+ T cells at the site of SJS/TEN tissue damage.5 Our study will be the first to examine in a double-blind randomized controlled design both management and mechanisms of SJS/TEN. This will lead to new ways to prevent, diagnosis and treat SJS/TEN, and will create a roadmap and evidence-base for studies of serious immunologically-mediated adverse drug reactions and other immunologically-mediated diseases.

NIH Research Projects · FY 2026 · 2020-07

PROJECT SUMMARY The Electronic Medical Records and Genomics (eMERGE) Network has been at the forefront of genomic medicine research since its establishment in 2007 and has informed national and international research programs, including the All of Us Research Program. Integral to the Network's success is Vanderbilt's longstanding role as a dedicated Coordinating Center (CC). With Vanderbilt as a founding member, eMERGE pioneered the use of large scale genomic and electronic health record (EHR) data for research, developed and validated over 60 electronic phenotypes, integrated clinically actionable genomic data into the EHR, published over 600 manuscripts, and formed a cohort of over 135,000 adult and pediatric participants that is broadly accessible for further discovery. The next phase of eMERGE will develop and return genomic risk assessments (GRA) in diverse populations, utilizing polygenic risk scores (PRS) to predict and manage the risk of common, complex diseases. We are proposing to form the Genomic Risk Assessment Coordinating center for eMERGE (GRACE) with the Broad Institute to add expertise in large-scale genotyping, cloud computing, and genomic data analysis and management, and with Duke University to leverage its proficiency in the implementation of patient-oriented family history tools and delivery of risk assessments. To meet the needs of the Network, GRACE will continue to serve NHGRI, the Network, and its members in all coordination, communication, and collaboration functions while providing a nationally visible home for eMERGE authored tools and scientific productivity. Secondly, we will assist the Network with selecting and validating polygenic risk scores (PRS) for approximately fifteen complex diseases and developing genomic risk assessments (GRAs) which combine the PRS with other clinical risks, family history, and monogenic risks to individuals of diverse ancestry. Finally, we will coordinate a prospective study for 20,000 participants which calculates clinical and genomic risks for participants and their providers. In addition to providing the genotyping and PRS reporting services, we will develop with the Network scalable EHR-based methods to assess uptake of risk-reduction recommendations and clinical impact.

NIH Research Projects · FY 2025 · 2020-06

Project Summary Southwest American Indians (SWAI) suffer from the highest lifetime risk of type 2 diabetes (T2D) and its adverse health consequences of any ethnic group, including cardiovascular disease, renal disease, and early mortality. Over the last 20 years, our collaborators (led by Dr. Leslie Baier; NIDDK-Phoenix) have pioneered longitudinal studies of SWAIs in the Gila River Indian Community in Phoenix, Arizona, to characterize clinical and genetic predictors of T2D in this at-risk population. Through careful integrative metabolic studies (e.g. measurement of insulin action using the hyperinsulinemic-euglycemic clamp technique), they have defined insulin resistance (IR) and acute insulin response (AIR) as significant predictors of T2D. Although both insulin resistance and abnormal insulin secretion have subsequently been shown to predict T2D in other studies of populations, SWAIs have a reduced insulin action and an increased AIR compared to other ethnic groups, the etiology of which remains unclear. Previous studies in Caucasians have highlighted that alternative approaches using small molecule metabolites proximal and specific to metabolic dysfunction can identify pathways of IR. However, these prior studies of IR in Caucasians have not identified precise biologic mechanisms, perhaps due to lack of detailed measures of insulin action (e.g., whole-body, hepatic IR) or secretion. Furthermore, clinical risk and severity of T2D is generally lower in Caucasians relative to SWAIs, suggesting SWAIs may be a population in which discovery of novel mechanisms may be particularly fruitful. Therefore, we propose that identification of novel conserved and unique metabolic pathways (via measurement of metabolites) that increase risk for T2D via effects on insulin action/secretion will be easier to find in a non-diabetic SWAI cohort, who are (1) at high risk for developing T2D; (2) characterized by precise measures of in vivo insulin action/secretion; (3) have pre-existing genomic data and measures of global gene expression in tissues relevant to insulin action. In this application, we collaborate with the NIDDK-Phoenix Epidemiology and Clinical Research Branch to perform metabolite profiling in SWAI adults to define the architecture of metabolism, specifically insulin action and insulin secretion (IS). Our central hypothesis is that circulating metabolites will identify mechanisms of IR and IS in SWAIs. To address this goal, we will study two different populations enrolled in Phoenix by the NIDDK: (1) the Gila River Indian Cohort Study, a prospective cohort study of SWAIs studied as inpatients in the NIDDK-Phoenix Clinical Research Center when non-diabetic; (2) the Phoenix Cohort Study, an outpatient longitudinal study of SWAIs with oral glucose tolerance testing (OGTT) and ongoing clinical surveillance. In Aim 1, we will use measures of IR and IS based on the euglycemic-hyperinsulinemic-3H-glucose clamp (HEC), oral (OGTT), or IV glucose tolerance testing (IVGTT) in the both NIDDK studies to identify metabolic pathways linked to IR and IS in SWAIs without T2D. In Aim 2, we will identify the relationship between metabolite patterns and genetics and harness approaches to implicate causal pathways of T2D. Finally, we will complete integrated studies of metabolites and proteins in the development of T2D and IR, including studies from extant samples (e.g., tissue). Innovation comes in delineating metabolic architecture of IR via 2 complementary strategies: phenotypes (Aim 1) and molecular genetics (Aim 2). Our aims (SAs) are: SA1: To define the metabolic physiology of IR and IS in SWAI adults, based on indices derived from hyperinsulinemic-euglycemic-3H-glucose clamp, IV, or oral glucose tolerance testing. Hypothesis 1.1: Metabolites associated with peripheral IR, insulin secretion (IS), and hepatic IR will identify pathways underlying altered insulin resistance and insulin secretion in SWAIs. Hypothesis 1.2: Metabolites (from SA1.1, above) will identify risk of incident T2D development in SWAIs. Some metabolite-IR/IS associations in SWAIs will be observed in non-SWAIs in a separate cohort. SA2: To define the genetic architecture of metabolism in SWAIs and its causal relationship to T2D using metabolites as specific, proximal markers of human metabolism. Hypothesis 2.1: Variability in patterns of metabolism (by measurements of metabolites) will encode genetic susceptibility to T2D. Hypothesis 2.2: Integration of proteomics and metabolomics will provide additional prognostic information in T2D. This study is a unique collaboration between intramural genetic epidemiologists and physiologists at NIDDK-Phoenix and extramural experts in metabolic epidemiology, metabolite profiling, and bioinformatics. If successful, this application will define underlying metabolic physiology in SWAIs, with resources made available to the general scientific community for future discovery and comparison in the broader population.

NIH Research Projects · FY 2023 · 2020-06

Abstract The human papillomavirus (HPV) causes 90% of cervical cancers and is implicated in multiple other cancers. The HPV vaccine can prevent the vast majority of these cancers, but it is underused in adolescents, especially among those within vaccine hesitant (VH) parents. Dr. Erves, an Assistant Professor in Research at Meharry Medical College and Adjunct Assistant Professor at Vanderbilt University, is poised to become a leader in behavioral cancer prevention research. This Mentored Research Scientist Development Award (K01) will complement her in-depth training in public health research methods, statistical analysis, patient centered outcomes research, and community engagement obtained during her doctoral, post-doctoral, and early career experiences. It will provide the training she needs to further her current cancer prevention research program, characterizing preferences and perceived needs of African American adolescents and parents when deciding about HPV vaccination for cancer prevention. Dr. Erves short-term goals are to become proficient in behavioral intervention development, an expert in conducting clinical trials, and knowledgeable of implementation science by engaging in didactic, clinical research training activities; conducting a pilot, randomized clinical trial; submitting an R01 in Year 3 of this award; increasing manuscript publications; and advancing leadership through scientific presentations. Her mentors include highly-qualified experts in community engagement and clinical trials (Dr. Consuelo Wilkins), HPV vaccination and behavioral interventions (Dr. Pamela Hull), and vaccine hesitancy, clinical interventions, and implementation science (Dr. Amanda Dempsey). State-of-the-art facilities and vast resources at Meharry Medical College and Vanderbilt University provide the environment needed to promote her career development, and complete the proposed research successfully. The proposed research is to develop and pilot test a tailored, health communication intervention aimed to increase HPV vaccination among VH parents. The research will add knowledge on how tailored education provided before a doctor’s visit can play a role in improving HPV vaccination rates among underserved, VH parents. The study aims to develop a tailored, health communication intervention for HPV VH parents (AIM 1); conduct a pilot study of the intervention and study protocol on a small scale to demonstrate feasibility of a future full-scale randomized control trial (RCT) (AIM 2); and examine acceptability of the protocol and intervention among parents and providers (AIM 3). The proposed research is innovative because no evidence-based health communication interventions target HPV VH parents, and we will use stakeholder engagement throughout this study. The knowledge, experience, and pilot data provided by this award will prepare Dr. Erves to secure subsequent R01 funding to assess the intervention’s efficacy in a well-powered RCT and advance her multidisciplinary, research program on behavioral interventions to increase HPV vaccine rates. This award will allow her to establish an independent, long-term career focused more broadly on cancer prevention behaviors.

NIH Research Projects · FY 2025 · 2020-06

Project Summary This R35 application describes a robust research framework to facilitate discovery and translation of new therapeutic targets in Acute Respiratory Distress Syndrome (ARDS), a common cause of acute respiratory failure that carries a high mortality rate and has no beneficial targeted therapies. ARDS remains a significant health problem affecting 190,000 Americans per year, costing billions of dollars, and leaving the majority of patients dead or significantly impaired. New insights into the pathogenesis are needed to deepen our understanding of the underlying mechanisms that lead to ARDS as well as to develop novel therapeutics. Thus, there is an unmet need to define clinically relevant therapeutic targets that can be studied mechanistically and rapidly carried through robust pre-clinical studies. For the last 14 years I have been building my research team to be on the forefront of translational discovery. My group has made major contributions to understanding ARDS pathophysiology. The major focus of my laboratory is defining the key cellular and molecular regulators of alveolar capillary barrier function and dysfunction that underlies ARDS pathology. My R35 research program is designed to identify novel mediators in ARDS using lung tissue imaging mass spectrometry and deep phenotyping of gene expression profiles at the single cell level coupled with advanced statistical methods to identify leading targets. New targets will be studied in in vitro transgenic model systems to define cellular and molecular mechanisms in order to facilitate the development of novel therapeutics to be tested in pre-clinical models. My research framework is centered on three goals: Discovery, Mechanism and Translation. Goal 1 – Discovery. To accomplish this goal, we will break new ground using imaging mass spectrometry and single cell RNA sequencing to create an expression profile and protein “map” of the injured and uninjured human lung. Using advanced statistical approaches, we will identify promising targets to take forward into further studies. Goal 2 – Mechanism. Leveraging our existing lung injury models, institutional resources and new approaches, we will define the fundamental pathologic mechanisms that lead to alveolar capillary barrier permeability in ARDS by generating novel transgenic cell and mouse lines for mechanistic studies. Goal 3 – Translation. Building on our existing ex vivo human lung and in vivo mouse models, we will generate rigorous pre-clinical data based on new targets identified in our Discovery and Mechanism studies. With this R35, my lab will advance the mission of the NHLBI by: generating a catalogue of single cell transcription profiles and tissue protein expression levels in acutely injured and uninjured human lung, identifying novel therapeutic targets in ARDS, defining the cellular and molecular mechanisms regulating alveolar capillary barrier dysfunction and conducting pre-clinical studies in mouse and human models. The R35 will provide the support and flexibility necessary for me to break new ground in ARDS.

NIH Research Projects · FY 2025 · 2020-05

Project Summary – No change from original submission Cancer is a leading cause of morbidity in the United States, with more than half a million deaths estimated in 2019. Systemic cancer therapies are increasingly being designed as long-term oral anti-cancer medications, given the increased convenience of a self-administered regimen. For instance, patients with operable hormone-receptor-positive breast cancer are prescribed adjuvant oral hormonal therapy, with an expectation that they continue their regimen for a minimum of 5 years to maximize the benefits. Although many oral therapies have proven effective in mitigating cancer recurrence and mortality, discontinuation to these treatments are not uncommon. This is a concern because medication discontinuation before the completion of a prescribed treatment protocol leads to lower survival rates, increased risks of recurrence, and higher healthcare costs. To improve treatment adherence and promise better healthcare delivery, it is essential for healthcare providers to know when and why a cancer patient will discontinue their medications. While there have been various investigations into regimen discontinuation, the focus of these studies is either on knowledge discovery or intervention. While knowledge discovery focuses on characterizing the potential factors that lead to medication discontinuation, intervention aims to leverage discovered knowledge to design and test effective strategies to help patients adhere to treatments. Because there are thousands of cancer patients, it is impossible for healthcare providers to apply intervention to each of them. Limited medical resources need to be allocated efficiently, such that patients with a higher risk of discontinuing medications will receive greater, timely attention. Yet, the increasing integration of online communication and mobile computing technologies into the healthcare domain are generating massive quantities of patient-generated information. Thus, we propose to apply online patient-provider communications in a patient portal to supplement traditional EMR data to better understand a cancer patient’s medical experience. The central hypothesis of this project is that such communications together with structured EMRs can be applied to learn and forecast oral anti-cancer medication discontinuation. The specific aims of this project designed to test our central hypothesis are to 1) discover what has been communicated in a patient portal; 2) infer how patient portal messages and structured EMRs are associated with medication discontinuation; and 3) determine who are more likely to discontinue medications. To the best of our knowledge, this is the first study to apply the messages in a patient portal and structured EMRs to investigate medication discontinuation for cancer patients.