Brigham And Women'S Hospital

NIH Research Projects · FY 2025 · 2023-08

Project Summary / Abstract Each year, over 63,000 U.S. infants are born very preterm, prior to 32 weeks of gestation. With >90% now surviving to discharge due to better obstetrical and neonatal intensive care unit (NICU) management, the present challenge is to reduce short- and long-term morbidities experienced by survivors, including the two- to four-fold increased risk of obesity, diabetes, hypertension, and metabolic syndrome that manifest by young adulthood. The Developmental Origins of Health and Disease (DOHaD) framework posits that chronic conditions result from adverse exposures during vulnerable developmental stages known as “critical” or “sensitive” periods. Of particular importance is the first 1000 days of life, when key developmental processes set the stage for lifelong health. Very preterm infants are an especially vulnerable population, as they require NICU support for 2-4 months after birth, coinciding with the 3rd trimester – an established sensitive period for programming of obesity and cardiometabolic risk. In this context, the most highly modifiable and relevant exposure is diet during the NICU hospitalization, which may contribute to the accelerated accretion of fat mass relative to fat-free mass. Hospitalized very preterm infants typically experience impaired weight gain, stunted linear growth, and excess fat accretion relative to the typical fetus. To offset these issues and support brain development, dietary fortification of human milk is provided as standard of care. However, the consequences of dietary fortification for cardiometabolic health in this population are poorly understood. This proposal seeks to uncover the extent to which diet-based interventions that promote physical growth and brain development during a sensitive period may also contribute to cardiometabolic risk. We will study 130 infants born 24-31 weeks of gestation who are participating in the Nourish Study (R01HD097327l; PI: Belfort), an ongoing randomized controlled trial testing the effect of individually targeted human milk fortification vs. standard of care during the NICU hospitalization. By extending follow-up of this cohort and adding cardiometabolic biomarkers at 2 and 5 years of age, we have a unique opportunity to investigate how macronutrient and energy delivery during a sensitive period contributes to, or protects from, cardiometabolic risk during childhood. We are further poised to address key questions about NICU growth patterns in relation to cardiometabolic health in this population. Findings from this work have strong potential to impact clinical care by informing dietary strategies during a sensitive window in development to optimize lifelong health for a vulnerable population.

NIH Research Projects · FY 2025 · 2023-08

PROJECT SUMMARY Female pelvic floor disorders (PFD) which include urinary incontinence (UI) are a major public health problem affecting women of all ages in the United States with significant negative impact on quality of life. Stress urinary incontinence (SUI), the most common type of UI, is defined as the complaint of involuntary urine leakage on effort or exertion, including coughing, sneezing or lifting. Pelvic floor integrity is an important predictor of SUI. The pelvic floor musculature is involved in the support of pelvic organs and micturition. Voluntary contractions of these muscle groups enable control of the urethral sphincter to maintain urinary continence during stress maneuvers. SUI results from weakness of the pelvic floor musculature, fascia and ligaments. Recent studies have shown that androgens may play an important role in pelvic floor and lower urinary tract integrity, as the muscles in these structures are androgen-sensitive and express large numbers of androgen receptors in both animals and humans. In preclinical models, exogenous testosterone administration results in greater increases in pelvic floor muscle mass compared to any other skeletal muscle group, underscoring the high sensitivity of this muscle to androgens. In female animal models of experimentally- induced SUI, testosterone therapy increases pelvic floor muscle mass and improves urodynamic parameters. Observational studies in women with polycystic ovary syndrome who have high testosterone levels show both greater pelvic floor muscle mass and strength as well as fewer UI symptoms compared to controls. Taken together, these data suggest that testosterone has direct anabolic effects on pelvic floor muscles which may provide a therapeutic option in women with SUI. The anabolic effect of testosterone supplementation on pelvic floor muscles in patients with stress urinary incontinence has not been studied in women. The overall goal of this proposal is to evaluate the efficacy of testosterone supplementation in increasing the muscles of the pelvic floor in a double-blind, randomized-controlled trial in older postmenopausal women with stress urinary incontinence. We will also assess the efficacy of testosterone supplementation on urodynamic function, urinary symptoms and quality of life. We propose a 12-week double-blind, randomized-controlled, proof-of-concept trial to determine the efficacy of testosterone supplementation versus placebo in women age 60 years and older with stress urinary incontinence. The following outcomes will be measured: 1) pelvic floor muscle volume with pelvic magnetic resonance imaging, 2) urodynamic function with urodynamic studies, and 3) urinary symptoms and quality of life. Current treatments available for female SUI center largely on surgical interventions and few seek to restore integrity to the dynamic supports of continence. Thus, there is a clear need for innovation to provide a wider range of effective treatment options for women with SUI. If this trial confirms benefits of testosterone therapy, female patients with SUI will have an inexpensive, relatively safe and easy to administer medication available that has the potential to transform the care of these patients.

NIH Research Projects · FY 2025 · 2023-08

Project Summary Antibody-mediated graft rejection (AMR) remains a major barrier to successful solid organ transplantation. Establishing novel treatment strategies based on our understanding of underlying mechanisms may improve long term graft outcomes. Although pathogenic allo-antibodies mediating AMR are produced mainly by GC B cells after induction by follicular T helper (Tfh) cells, regulation of this response is poorly understood. Insight into mechanisms that regulate these GC responses and dampen AMR to improve heart allograft outcomes are needed. We have uncovered and exploited a central role for Qa-1-/HLA-E-restricted CD8 regulatory T cells in the control of Tfh-dependent DSA responses against donor allografts. Our published and preliminary experimental data indicate that CD8 Treg that are restricted by class Ib MHC (murine Qa-1/human HLA-E) can be mobilized by synthetic FL9 peptides to inhibit alloimmune Tfh cells, dampen Ab-mediated injury and prolong heart allograft survival in fully mismatched heart transplant models. These findings open the possibility of HLA-E-targeted vaccine strategies that exploit the limited polymorphism of this MHC class Ib gene and avoid problems of class Ia MHC diversity. The FL9−Qa-1 complex is upregulated by a subset of activated Tfh cells that drive alloantibody responses. Identification of synthetic FL9 agonist peptides that mobilize Ag-specific CD8 Treg after a screen of a yeast peptide library based on the FL9 self-peptide is outlined in SA1. Analysis of mechanisms that underpin peptide- induced regulation of AMR against heart allografts are addressed in SA2. Targeting of co-receptors that modulate CD8 Treg activation and function are the subject of SA3. These studies should allow new and effective approaches to reduce AMR and improve allograft survival.

NIH Research Projects · FY 2026 · 2023-08

Glioblastoma multiforme (GBM) is the most aggressive and incurable brain cancer, with a median survival under 1.5 years. Unlike many other solid tumors, GBM shows little or no benefit from immune checkpoint blockade targeting PD1 or CTLA4, underscoring the urgent need for innovative immunotherapeutic approaches tailored to its unique immune environment. Neoantigens are tumor-specific antigens derived from genetic alterations unique to cancer cells that form the foundation for personalized cancer vaccines and serve as targets for adoptive cell therapy (ACT). Although early-phase clinical trials of neoantigen-based vaccines in GBM show promise, preclinical models amenable for the mechanistic studies of GBM neoantigen responses are lacking. Using the SB28 murine GBM model, which recapitulates the invasiveness and immune landscape of human GBM, my mentor’s lab identified four immunogenic MHC class I–restricted neoantigens that elicit T cell responses. In my K00 phase, I will generate a T cell receptor (TCR) transgenic model for a validated GBM neoantigen to study natural immunity to GBM and develop engineered neoantigen-specific T cells for ACT. A second barrier to effective immunotherapy in GBM is its profoundly immunosuppressive tumor microenvironment (TME). Myeloid cells, including microglia and macrophages, can comprise up to half of the tumor mass and promote tumor progression by exerting immunosuppressive effects. Recent findings from my mentor’s lab show that the checkpoint receptor TIM3 is highly expressed in microglia and macrophages in human GBM. TIM3 limits inflammasome activation in dendritic cells and suppresses microglial phagocytosis. Thus, TIM3 may act as a myeloid checkpoint that suppresses immune responses in the GBM TME, and represents a promising target for therapeutic intervention. Here, I will investigate the role of TIM3 in shaping myeloid cell responses and the immune microenvironment in GBM and test whether combining neoantigen specific adoptive T cell therapy with TIM3 blockade enhances GBM tumor control and survival. Together, these studies will provide new mechanistic insights into immune evasion in GBM, establish innovative tools for studying tumor-specific immunity, and inform the development of next-generation combinatorial therapies. This proposal is rooted in human observations, and its outcomes are expected to advance translational approaches for improving survival in GBM.

NIH Research Projects · FY 2025 · 2023-08

Summary Colorectal cancer is a heterogenous disease influenced by somatic mutations, microbiota, host immunity, and risk factor exposures, necessitating integrative research approaches to better understand the etiology. The proposed project plans to integrates immunology and microbiology into molecular pathological epidemiology (MPE) to gain insights into the interactive role of exposures, microbiota, immune cells, and tumor cells in colorectal cancer and adenoma. This project also plans to develop novel statistical and computational methods for such research. This project leverages tumor tissue datasets in various populations, including the Nurses' Health Study (NHS), NHS2, Health Professionals Follow-up Study, Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO), Multiethnic Cohort Study (MEC), Partners Colonoscopy Cohort (PCC), and CALGB/SWOG 80702 trials. Our multi-level databases have accumulated information on long-term lifestyle factors and tumoral features of colorectal cancer (CRC) and adenoma. Our research involves the assessment of various immune cells and microbiota in tumor tissue using multispectral assays combined with digital image analyses and machine learning algorithms. Characteristics of molecular pathology, microorganisms, and immunity in tumor tissue will shed light on the carcinogenic process. Diet and lifestyle factors will be assessed in relation to incidence of CRC (or adenoma) subtyped by microbial and/or immune features, and in relation to clinical outcomes of these tumor subtypes. The MPE approach is expected to reveal currently unknown risk and prognostic factors for CRC and early-onset CRC, the incidence of which has increased globally for uncertain reasons. Moreover, examining effects of modifiable lifestyle factors on immune cells and microorganisms in tumor tissue will open new ways to develop personalized preventive strategies. Efforts will be made to replicate findings using other independent datasets whenever possible. New statistical methods will address analytical issues such as continuous subtyping, missing biomarker data, intratumor spatial variations, high-dimensional tumor data, mediation analyses, and prediction models. Furthermore, novel computational algorithms will be developed to decipher the spatial patterns of immune cell subsets and tumor cells in the tumor microenvironment. Integrative epidemiological analyses of immunology and microbiology will generate provide the scientific foundation for exploring roles of anti-tumor immunity and microbiota in CRC development. In addition, this project will advance population cancer sciences via the development of new statistical and computational methods.

NIH Research Projects · FY 2025 · 2023-08

PROJECT SUMMARY/ABSTRACT LATE-NC (limbic-predominant age-related transactive response DNA-binding protein of 43 kDa [TDP-43] encephalopathy neuropathological change), a recently recognized form of TDP-43 proteinopathy, is the third most impactful cause of dementia following Alzheimer’s disease neuropathologic change (ADNC) and cerebrovascular disease, accounting for 15-20% of all dementia cases in older adults. Genetic association studies by our group and others revealed unique, LATE-NC-specific risk loci as well as those shared with other common dementia-causing proteinopathies. A transcriptomic study from our group implicated endo-lysosomal dysregulation as a crucial pathophysiologic process underlying LATE-NC. However, molecular and cellular underpinnings of LATE-NC remain largely unknown: we do not even have the knowledge to develop in vitro/in vivo disease models or nominate target pathways, and as a result, we cannot diagnose, treat, or prevent LATE-NC in living persons yet. Defining molecular and cellular changes underlying LATE-NC is a prerequisite to developing translatable in vitro/in vivo disease models and identifying biomarker/therapeutic targets. This critical knowledge gap has been acknowledged by the NIH AD-Related Dementias (ADRD) Summit in 2022, which made a high-priority recommendation to investigate molecular changes associated with LATE-NC. Therefore, this proposal aims to define the transcriptomic, proteomic, and cellular underpinnings of LATE-NC in the human amygdala, the brain region where LATE-NC is thought to originate. Our central hypothesis is that, in the amygdala, endo-lysosomal dysregulation, altered RNA metabolism, glial dysfunction, and neuronal loss underlie LATE-NC pathophysiology. To test the central hypothesis, we propose to generate and analyze transcriptomic, proteomic, and single-nucleus multiome (transcriptome and chromatin accessibility) data from the post-mortem amygdala samples from the extensively characterized Religious Orders Study and Rush Memory and Aging Project participants (n=480). We will pursue the following three specific aims: First, we will determine the transcriptomic underpinnings of LATE-NC. Second, we will identify the proteomic signature of LATE-NC. Third, we will define the single-cell landscape of LATE-NC. We will use statistical modeling approaches to infer causal relationships. We will consider sex-specific effects and the confounding effect of comorbid ADNC pathology throughout the study. The expected outcomes of this project will nominate protein biomarker targets and define plausible upstream and downstream events of LATE-NC. These results will guide our future studies to develop in vitro and possibly in vivo LATE-NC models and, eventually, targeted therapeutics. The large-scale amygdala multi-omic data will be broadly shared with the scientific community to support numerous ADRD research projects, ensuring a significant lasting impact in neurodegeneration research far beyond this proposal. Therefore, this project has the potential to fundamentally improve our ability to diagnose, treat, and ultimately prevent dementia, including LATE.

NIH Research Projects · FY 2025 · 2023-08

PROJECT SUMMARY/ABSTRACT Rural communities in the southern U.S. suffer a disproportionate burden of morbidity and mortality from cardiometabolic disease, with traditional risk factors explaining only a modest proportion of the excess burden of disease. Growing evidence implicates poor sleep health as an important risk factor for cardiometabolic disease. While this is most well established for sleep apnea and insomnia, there is considerable evidence that multiple dimensions of sleep health, including sleep duration, efficiency, timing, and regularity, also affect cardiometabolic disease risk. Moreover, rural Southern communities are likely to experience high rates of impaired sleep health, reflecting high levels of psychosocial and environmental stressors, such as financial stress, social isolation, environmental pollution, and poor built environment in addition to high rates of smoking and obesity. However, there is currently a lack of systematically developed sleep data in rural populations. Recognizing the paucity of research on cardiometabolic risk in this high-risk rural population, the NHLBI recently initiated a new longitudinal epidemiology study in rural Appalachia and Mississippi Delta (the RURAL Study) to identify the complex individual, social and environmental factors contributing to this high burden of disease. The proposed RURAL Sleep Study will complement the RURAL Study by incorporating minimally burdensome measures of multiple dimensions of sleep health at the time of baseline cohort assessment in approximately 4000 adults age 25-64 years, utilizing mobile health technologies to (a) measure sleep apnea over 4 consecutive nights; (b) measure sleep duration, timing, regularity and fragmentation over multiple weeks; and (c) administer standardized questionnaires to assess insomnia, chronotype, sleep quality and sleep-related impairment. These data will allow us to leverage the planned extensive assessments of cardiometabolic risk factors, subclinical disease, and psychosocial and environmental stressors (and resilience factors) to address the following specific aims: Aim 1a. Quantify population distributions of sleep health measures in a rural cohort along dimensions of sleep apnea, insomnia, chronotype, and sleep duration, efficiency, timing, and regularity. Aim 1b. Identify psychosocial, behavioral, and environmental correlates of sleep health in rural communities. Aim 2. Assess the association of sleep health with cardiometabolic risk factors and subclinical cardiovascular disease independent of other established cardiovascular and metabolic risk factors. The results are expected to inform health care providers, public health officials, and the general public of the prevalence, risk factors, and consequences of impaired sleep health in these rural communities, providing a critical basis for prevention, recognition, and management of sleep disorders and improvement of sleep and cardiometabolic health.

NIH Research Projects · FY 2025 · 2023-08

PROJECT SUMMARY Immunosuppressed individuals are increasingly recognized as a focal point of the COVID-19 epidemic. They are at increased risk of chronic COVID-19 infection, therapeutic treatment failure, severe disease and COVID-19 mortality. Evidence is also emerging that they may also be drivers of COVID-19 variant/subvariant emergence, due to their risk of prolonged infection and accelerated viral evolution. However, the immune and viral mechanisms by which chronic infection, viral evolution, and drug resistance occur in this population are poorly understood. To improve health outcomes for this high-risk population and to reduce the risk of viral evolution and drug resistance, there is an urgent need to address gaps in our understanding of which immune deficiencies increase the risk of chronic COVID-19 infection and accelerated viral evolution. The primary goal of this proposal is to determine the host and virologic characteristics that promote chronic viral infection and viral evolution. The proposing investigators will an existing translational research infrastructure with experience recruiting cohorts of immunosuppressed individuals with COVID-19 and broad expertise in clinical research, viral quantification, viral culture, sequencing, and immunology. The results will provide critical new data about COVID-19 pathogenesis, variant evolution, therapeutic response, and inform the clinical care of immunosuppressed populations. By deepening our understanding of the immune pathways of viral clearance, the results from this proposal may also identify potential targets for the next generation of vaccines and therapeutics.

NIH Research Projects · FY 2025 · 2023-08

Cancer prevention remains one of the most pressing public health challenges worldwide. Cancers of the cervix, anogenital tract, and oropharynx disproportionately affect people in low-resource settings, and South Africa carries one of the heaviest burdens due to the intersection of high HIV prevalence with elevated rates of infection-related cancers in young people. Cervical cancer is the leading cause of cancer-related mortality among women in South Africa. In 2014, the National Department of Health launched a national, school-based program to reduce future cancer burden. While initial implementation was promising, completion rates declined substantially after 2014, with fewer than four in ten girls receiving effective cancer prevention strategies in 2021. These declines reflect prior service interruptions, challenges in delivery, and reduced confidence in health systems. Important access gaps also remain for boys and for adolescents outside the public school system. Addressing these gaps is critical for effective cancer prevention. The overall objective of this project is to refine and evaluate a school-based, multi-level education and communication strategy that supports parents and caregivers in making informed decisions, equips teachers and schools with effective materials, and ensures shared decision-making through accessible and trusted channels. The project will be conducted in partnership with the Department of Health and schools in Gauteng Province, a region with high burden of preventable cancers. Investigators from the United States and South Africa bring expertise in cancer prevention, health communication, participatory design, and community engagement to pursue two specific aims: (1) to refine components of a multi-level education strategy to strengthen informed parental choice and shared decision-making for effective cancer prevention strategies for girls and boys; and (2) to evaluate feasibility, early outcomes, and criteria necessary to advance to a full-scale trial. Our systems-focused approach leverages established partnerships with schools that serve diverse populations not always reached by traditional health services. Education and parental engagement will be central, integrating the voices of communities living in low-resource settings to identify and reduce barriers to cancer prevention. This proposal is directly responsive to NCI’s call for cancer prevention and control clinical trials planning grants (PAR-22-173) through its emphasis on active stakeholder engagement and its focus on engaging a diverse, scientifically appropriate study population.

NIH Research Projects · FY 2024 · 2023-08

Project Summary / Abstract Cumulative evidence from large-clinical and neuroimaging studies suggests that the pathophysiology of schizophrenia involves an increased vulnerability to premature aging. However, this knowledge has not been translated into clinical practice due to the lack of understanding of the biological underpinnings of premature aging in schizophrenia. Additionally, there remains a current lack of diagnostic tools for detecting and monitoring individuals who experience premature aging in a clinical setting. This lack establishes the critical need to develop in vivo biomarkers of premature aging in schizophrenia to provide a novel avenue toward diagnosis and neuroprotective treatment. The current proposal provides a step to tackling this challenge through a large, multimodal study of schizophrenia. The central hypotheses state that individuals with schizophrenia are more vulnerable to premature aging, as indicated by an increased expression of senescence-associated secretory phenotype (SASP) proteins, and that the increased expression of SASP proteins explains abnormalities in physical health, cognition, and brain structure in schizophrenia. The applicant, Dr. Johanna Seitz-Holland, has access to several cross-sectional datasets, including clinical, cognitive, blood, structural, and diffusion data, spanning the schizophrenia lifespan. In the K99 phase, she will utilize data from 80 individuals with early schizophrenia and 80 matched healthy individuals to establish the increased expression of SASP proteins as a biomarker for increased vulnerability to premature aging in early course schizophrenia. In the R00 phase, Dr. Seitz-Holland will include data from over 700 individuals (18-85 years) and characterize the role of the increased expression of SASP proteins as a mediator between schizophrenia, physical health, cognition, and structural brain abnormalities across the lifespan. Successful completion of these aims will yield several impactful outcomes. The findings will inform the development of a clinically feasible, minimally invasive, and low-risk biomarker for premature aging. In addition, the findings will allow the development of a parsimonious hypothesis that accounts for aspects of brain and physical health deficits. Lastly, they will provide a scientific basis for developing novel neuroprotective treatments. Dr. Seitz-Holland’s long-term goal is to conduct translational research to increase the life quality of those with psychotic disorders. This application builds on her postdoctoral training in multimodal trajectory schizophrenia studies and complements it with training from world-class experts in the use and analysis of blood biomarker data and geriatric science. This award will thus provide her with a unique opportunity to develop into an independent researcher who can effectively conduct multimodal psychiatric studies and translate findings into the evidence-based diagnosis and treatment strategies needed in clinical science.

NIH Research Projects · FY 2024 · 2023-08

ABSTRACT Sleep disordered breathing (SDB) affects more than 20% of the older population and increases the risks of multiple cardiometabolic diseases and mortality. Candidate gene and genome-wide association studies (GWASs) have identified genes and pathways associated with SDB. However, the causality is not clear. Transcriptome- wide Mendelian randomization (MR) studies have recently been conducted to elucidate molecular mechanisms of complex diseases. However, the power is limited by the number of tested genes and tissues and small effects of single genes. Building on our preliminary data, we hypothesize that pathway-level transcriptional MR will have better power than single gene MR to identify causal molecular mechanisms for SDB. In this study, we will leverage well-established canonical pathways and existing methods to calculate pathway expression scores, as well as available transcriptomics and genomics data in population-based studies. We will address the following specific aims: 1) To describe tissue-specific and cross-tissue pathway activities using pathway expression scores and identify genetic associations for these scores by performing GWAS; 2) To identify causal associations between pathway activities and SDB by performing MR using GWAS summary statistics of pathway expression scores and SDB traits. Results of this study will advance our knowledge of the molecular basis of SDB, help identify SDB biomarkers, and provide novel treatment targets. This study also will provide a new approach to understand causal mechanisms for other complex diseases.

NIH Research Projects · FY 2026 · 2023-08

Delirium (acute disturbance in mental status) occurs in 46-56% of persons living with dementia (PLWDs) during hospitalization. Alzheimer’s disease and related dementias (ADRD) are among the strongest risk factors for developing delirium during hospitalization. Although an off-label use, antipsychotic medications (APMs) are the most commonly used pharmacotherapy to manage psychological symptoms of delirium. Because PLWDs often have a prolonged recovery course from delirium due to acute illness, ~30% of the patients who newly initiate an APM during hospitalization are discharged with them, and >60% of those discharged with an APM persist for >6 weeks. Since APMs may cause numerous life-threatening adverse reactions, it is critical to discontinue them after hospitalization in a timely fashion. However, several critical knowledge gaps limit the necessary evidence generation to guide such a deprescribing process: 1) There is currently no direct data from randomized control trials (RCT) on discontinuation of APMs used for delirium because it is extremely difficult to recruit and consent PLWDs or their healthcare proxies when the patient is in an acute delirious state to participate in an RCT, and any interventional study would severely underrepresent frail PLWDs seen in routine care. 2) In the non-randomized settings, adjusting for confounding is challenging when comparing different deprescribing strategies of a medication used for acute delirium, and the detailed clinical information required for such analyses is not typically available in routine care data. Our objective is to establish an analytical framework that enables valid causal effect estimation comparing continuation and multiple deprescribing strategies (e.g., abrupt discontinuation vs. gradual dose reduction) of APMs in PLWDs with delirium after hospitalization. We will integrate electronic health records (EHR), national claims data, and multiple clinical assessment data, covering >502,000 PLWDs from 2013 to 2026, and employ high-dimensional machine- learning aided confounding adjustment and phenotyping algorithms. Our specific aims include 1) To integrate EHR with Medicare claims data, Minimum Data Set (MDS), Outcomes and Assessment Information Set (OASIS), and Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) and to develop novel algorithms to determine key clinical phenotypes; 2) To assess APM utilization/discontinuation patterns and risk factors of prolonged use of APMs for delirium in PLWDs after hospitalization; 3) To assess the health impact of different discontinuation strategies (considering the amount and rate of dose reduction) of APMs vs. continuing APMs in PLWDs with delirium after hospitalization. The subgroup effects by key clinical phenotypes, typical vs. atypical APMs, and type of admission will also be determined. This proposal will generate evidence reflecting routine care delivery to inform post-discharge APM management in PLWDs with delirium. It will also establish a generalizable analytical framework assessing the health effects of deprescribing pharmacotherapies for delirium with detailed treatment effect heterogeneity evaluation necessary for precision medicine.

NIH Research Projects · FY 2025 · 2023-08

PROJECT SUMMARY Infertility is estimated to affect ~15% of all couples worldwide and male factors account for 40% of infertility among couples. Only ~10% of U.S. reproductive age women get pregnant each year and only ~60% are intended pregnancies. Despite the increasing use of medical treatment among couples with decreased fecundity, success rates of live birth have remained stable. Thus, identifying modifiable factors, such as environmental exposures, that can impact human fertility is a major clinical and public health matter. Intake of fruits and vegetables in the U.S. general population is the primary source of exposure to non-persistent pesticides, which has been associated with different adverse health effects, including infertility, reproductive disorders, and pregnancy and perinatal complications. While it has been shown that paternal environmental exposures may impact the sperm epigenome and consequently offspring health, no epidemiological studies to date have explored pregnancy and perinatal effects of paternal pesticide exposure and potential biological mechanisms that explain the associations. To address these important knowledge gaps, we aim to determine the association of male urinary concentrations of pesticide biomarkers (individually and as a mixture) with semen parameters, sperm DNA methylation and mitochondrial DNA biomarkers (aim 1), with pregnancy and perinatal outcomes adjusting for female urinary pesticide biomarkers (aim 2), and also with epigenetic aging in semen and leukocytes. Epigenetic age or DNA methylation aging biomarkers have recently emerged as excellent biomarkers of age-related diseases such as infertility and reproductive health. To examine these novel aims, we will leverage two prospective cohorts of couples attending fertility centers: the Environment and Reproductive Health (EARTH) Study in Boston, MA (main study), and the Sperm Environmental Epigenetics and Development Study (SEEDS) in Springfield, MA (validation study). The proposed study will increase our understanding of non-occupational pesticide exposure for a relatively understudied area of male reproductive health and will also open an important area of inquiry into better understanding of how paternal environmental exposures can impact couples’ and offspring’s health and potential biologic mechanisms linking the paternal environment to his children’s health. Most importantly, this project addresses strategic priorities of the National Institute of Environmental Health Sciences (NIEHS) for advancing environmental health sciences, including assessing coexposures and individual susceptibility to environmental chemicals. We are currently collecting detailed health measures on children who were born to couples who participated in the EARTH Study to determine the extent to which paternal and maternal preconception environmental exposures are associated with neurodevelopmental and metabolic endpoints. Incorporating the assessment of exposure to several classes of pesticides will provide data that can be linked in future studies on children’s health outcomes.

NIH Research Projects · FY 2025 · 2023-08

Approximately 20% of pediatric outpatient visits result in a prescription. Half of these prescriptions are off label, a number that rises to 80% among infants. The safe and effective prescribing of medications is essential to providing the highest quality care, and yet many children are receiving medications that have not been evaluated in their age group or in their disease area by rigorous randomized controlled trials (RCTs). There is a tremendous amount of data collected in the routine clinical care of patients via electronic health records (EHRs), claims data, and patient-reported data. These “real-world data” (RWD) can be harnessed with advanced epidemiologic methods focused on causal inference to generate “real-world evidence” (RWE) of medication safety and effectiveness. RWE studies, if conducted with scientific rigor, have the potential to complement RCTs and address important evidence gaps in the use of medications in children. This project aims to develop a framework for the rigorous conduct of RWE studies of pediatric medication use through the following specific aims: (1) to emulate 10 RCTs of medication effects in children using routinely collected healthcare data, (2) to evaluate alternative approaches to minimize bias when emulating RCTs in pediatric populations, and (3) to conduct 3 pediatric RWE studies on medication effects in clinical areas that lack RCT evidence. We will use RCTs as our gold-standard and use advanced causal inference and pharmacoepidemiology methods to design RWE studies to emulate published RCTs as closely as possible. Ten model RCTs will provide the scaffold for the evaluation of which methods perform best for the emulation of RCTs using RWE, and under which conditions. We will identify and summarize the methods that lead to the most successful emulation of RCTs. We will use best practice approaches to conduct three novel RWE studies. We will use three large healthcare utilization databases, including publicly and commercially insured children, as sources of RWD to conduct the RWE studies. These databases have detailed diagnostic and prescription information, making them well suited to studying medication use in children. The Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital provides the ideal setting for this endeavor. I will work with a team of mentors with expertise in pharmacoepidemiology, causal inference, comparative safety and effectiveness, pharmacology, and pediatric research to successfully complete the proposed project. This project provides the ideal framework to develop expertise in advanced pharmacoepidemiology and causal inference methods and support the overarching goal of my research: to generate high-quality evidence of medication safety and effectiveness in pediatric patients when no RCT data is available. Hands-on training and direct mentorship will be complemented by coursework at the Harvard T.H. Chan School of Public Health. This endeavor will provide the necessary foundation for me to become an independent investigator in pediatric pharmacoepidemiology.

NIH Research Projects · FY 2024 · 2023-08

PROJECT SUMMARY Tumor metastasis remains responsible for >65% of cancer-associated mortality and nearly all breast cancer deaths. Given the difficulties in treating metastatic disease, preventive approaches that block the successful dissemination of tumor cells to distant organs like the lung offer an attractive and under-researched therapeutic strategy for breast cancer patients at risk of metastatic disease. Primary tumors increase metastatic efficiency by reprogramming the microenvironment of distant organs before the arrival of circulating tumor cells. These tumor- permissive sites are commonly referred to as the “pre-metastatic niche” (PMN) and undergo a series of cellular and structural adaptations that support arriving tumor cells, including the recruitment of inflammation-promoting and immunosuppressive cells, neoangiogenesis, and stromal remodeling. Despite their archetypal roles in hemostasis, blood platelets are integral to inflammatory lung diseases and regulate many of the hallmarks adopted by the PMN. I, therefore, hypothesize that platelets promote the lung PMN. My preliminary data support this statement, demonstrating that platelets are sequestered in pre-metastatic lungs and that lowering platelet counts reduces immune cell recruitment to the lung PMN. To expand on these initial findings, this research will determine the contributions of platelets to the lung PMN (Aim 1), elucidate mechanisms by which platelets impact the lung pre-metastatic environment (Aim 2), and test if therapeutically targeting pre-metastatic platelet number or function impairs metastasis (Aim 3). The technical skills and scientific expertise I will obtain throughout the K99 award period will prove instrumental in my transition into an independent researcher, with the long-term goal to develop novel preventative and adjuvant therapeutic strategies for patients at risk of metastatic breast cancer. To reach these long-term goals, I have outlined a detailed career development plan, which will provide me with the technical and leadership skills to establish a successful research laboratory. The K99 phase of research will be conducted under the excellent (co)mentorship of Drs. Elisabeth Battinelli and Sandra McAllister at the Hematology Division of Brigham and Women’s Hospital. My Research Advisory Committee and collaborators are leading experts in the breast cancer PMN (Dr. Moses), platelet production (Dr. Italiano), and targeting platelets for breast cancer therapy (Dr. Chen). This K99/R00 award will provide me unparalleled support for my successful transition to an independent investigator studying platelet and cancer biology.

NIH Research Projects · FY 2025 · 2023-08

This K08 Mentored Clinical Scientist Career Development Award describes a five-year research and training program of the principal investigator (PI), Dr. Fotios Spyropoulos, that will enable his transition to independent scientific investigation in the field of oxidative stress-induced cardiac metabolic reprogramming and mitochondrial dysfunction. Premature infants are particularly susceptible to oxidative stress-induced injury and early heart failure is an increasingly recognized complication of preterm birth leading to increased morbidity and mortality. The PI has completed post-graduate training in neonatal-perinatal medicine and his long-term goal is to identify the link between prematurity and heart failure. Thus, the PI’s proposal initially focuses on the characterization of an adult model of chemogenetic heart failure with a plan to apply the skills gained from this award to future investigation of neonatal heart failure models. The PI will use a novel transgenic mouse model (DAAO-TGCar) that enables robust and specific generation of oxidative stress, in the form of hydrogen peroxide (H2O2), in the heart. He aims to delineate the role of oxidative stress in the development of mitochondrial dysfunction and heart failure. He shows novel preliminary data implicating chemogenetic H2O2 mediated inactivation of Sirtuin 3 (Sirt3) in the development of mitochondrial dysfunction. To test this hypothesis the following specific aims are proposed: 1. Characterize the heart failure phenotype of the DAAO-TGCar mouse model, 2. Assess the role of Sirt3 oxidation on cardiac oxidant balance and mitochondrial function, and 3. Determine the mechanisms of H2O2 mediated regulation of cardiomyocyte physiology and energetics. This research has significance, as understanding oxidant stress-induced mitochondrial damage may identify new therapies for the prevention and treatment of this debilitating condition. The PI will perform the proposed work under the co-mentorship of Dr. Michel, expert in oxidant signaling pertaining to cardiovascular biology and heart failure, live-cell imaging, and chemogenetic applications, and Dr. Christou, an expert in vascular biology and cardiovascular physiology. The PI will receive additional guidance from his scholarship oversight committee composed of senior scientists with complementary expertise in cardiac hemodynamics and bioenergetics, mitochondrial biology, and experimental models of heart failure. The training environment and the resources provided by the PI’s institutions, Brigham and Women's Hospital and Harvard Medical School, are ideal for his professional development. The PI is guaranteed >75% protected research time to devote to the proposed K08 program. Mentored research, didactic coursework, and presentations at scientific meetings are all part of a detailed career development and training plan. The PI outlines a timeline for completing the proposed aims, writing scientific manuscripts, and submitting a future R01 application. At the end of this award, the PI will obtain R01 funding and transition to independence by applying the knowledge and concepts gained from this award to future investigations focused on identifying the effects of oxidative stress on the development of the neonatal myocardium.

NIH Research Projects · FY 2025 · 2023-08

Abstract Obesity is an ongoing epidemic and a serious public health problem. Preventative and therapeutic interventions have mostly focused on diet and physical activity, aimed to understand mechanism and improve efficacy. Notably, there has been a long-term debate over whether macronutrient content in the diet, specifically a low fat vs. low carbohydrate diet can help in management of body mass. Recent insights into the involvement of the circadian system in energy balance control offer a new perspective to understand the relationship between macronutrient intake and weight control. We and others have shown that disruption of the circadian system leads to adverse metabolic effects, including changes in energy balance control mechanisms that can increase the risk for obesity. Indeed, circadian disruption is a recognized critical risk factor for metabolic disorders, as also recognized by the Nobel Prize Committee who awarded the 2017 Nobel Prize in Physiology or Medicine to three circadian pioneers. Given the intimate reciprocal interactions between metabolism and the circadian clock, it has been proposed that dietary macronutrient content may impact whole-body physiology in part through changes in the circadian organization. Consistently, breakthrough animal experimental work has shown that high fat diet leads to disrupted circadian rhythms, including blunted rhythms and lengthened circadian period (cycle length). These findings are consistent with our Preliminary Data in humans, in which we found that higher percentage of 24-h fat intake is associated with (i) a blunted endogenous circadian rhythm in hunger; (ii) a higher caloric intake in the biological evening; (iii) lengthened endogenous circadian period; and (iv) a delayed endogenous circadian phase. Taken together, these results provided strong premise for high fat diet-induced circadian disruption. However, despite the growing realization of the importance of circadian organization and the influence of fat intake on the circadian system, there is very limited experimental data in humans that has tested the effect of high fat diet on the circadian clock or circadian control of metabolism. Therefore, in this proposal, we will address these knowledge gaps by testing the following hypotheses: high fat diet, as compared to low fat diet results in (Aim 1) blunting and delaying of endogenous circadian rhythms of the central clock and measures related to the peripheral clocks; (Aim 2) blunting and delaying in daily and endogenous circadian rhythms in energy intake- related measures; (Exploratory Aim 3) blunting and delaying in daily and endogenous circadian rhythms in energy expenditure-related measures. These aims will be tested in a within-subject, randomized, crossover design in healthy individuals undergoing two protocols. Each of both protocols has a short-term field-based dietary intervention (2 weeks to avoid substantial weight change) followed by a 6-day highly controlled in- laboratory visit. Understand the link between macronutrient intake and the circadian system will lay the groundwork for evidence-based dietary intervention integrating timing in the prevention and treatment of obesity and metabolic health.

NIH Research Projects · FY 2024 · 2023-08

PROJECT SUMMARY/ABSTRACT The proteasome is the main intracellular protease and is responsible for degrading thousands of different proteins. The main signal for degradation by the proteasome is thought to be the post-translational attachment of ubiquitin molecules onto a substrate protein. While some proteasome substrates have been reported to be targeted to the proteasome without the use of ubiquitin, the extent and mechanism of ubiquitin-independent proteasomal degradation remain unclear. We have recently identified hundreds of peptides that, when fused to the C-terminus of enhanced green fluorescent protein (EGFP), are degraded by the proteasome in a ubiquitin- independent manner. Here, we propose to investigate the mechanism of this ubiquitin-independent degradation and determine the endogenous substrates of this pathway. First, we will determine if the EGFP fusion substrates are recognized by the proteasome directly, or if they are shuttled to the proteasome by an intervening factor (Aim 1). Next, we will characterize the interaction between the receptor and substrates using a combination of genetic and biochemical methods (Aim 2). Finally, we will identify endogenous substrates of the ubiquitin-independent pathway (Aim 3). Overall, these experiments will characterize in detail this newly-uncovered ubiquitin-independent proteasome pathway, which may have profound implications for our understanding of the proteasome and of protein homeostasis more generally. I will perform this research as a postdoctoral fellow under the mentorship of Dr. Stephen Elledge at Brigham and Women’s Hospital/Harvard Medical School (HMS) and into my future independent research career at a top U.S. institution. To accomplish my proposed aims, I will need to learn essential skills in the K99 period from Dr. Elledge pertaining to advanced genetic screening techniques. I have assembled a team of collaborators and advisors from around HMS (Dr. Alfred Goldberg, Dr. Wade Harper, Dr. Eric Fisher, Dr. Phil Cole, and Dr. Eugene Oh) who complement my skill set and will help me effectively accomplish my proposed projects and prepare for my future independent career. The local training environment in the Elledge lab and at HMS will support me with all the materials, equipment, and professional development opportunities necessary to become a world-class researcher. Receiving the K99/R00 Pathway to Independence Award would provide me with critical resources to realize my project and career goals.

NIH Research Projects · FY 2024 · 2023-08

Project Abstract Tumor-intrinsic factors in cancer cells modulate the immune milieu to enable prolonged survival and growth of tumors. In breast cancer (BC), the 2nd leading cause of cancer-related deaths in women, molecular subtyping of these factors effectively guides targeted therapies, but does not guide immunotherapy approaches as immune infiltrates vary significantly within each subtype. The presence of tumor-infiltrating lymphocytes (TILs) is highly prognostic for survival and therapeutic benefit in BC, but the tumor-intrinsic factors governing their presence are not well defined. Using TCGA RNA analysis, I have identified loss of function in the transcriptional repressor REST as being a key correlate to reduced lymphocyte infiltration into tumors of multiple BC molecular subtypes. Loss of functional REST in BC (~15-20% of tumors) is associated with poorer prognoses, however, the mechanisms by which loss of REST function modulates the tumor immune microenvironment are not known and may provide novel targets for enhancing therapeutic responses. I recently generated a murine Rest knockout BC line (Rest-less) and my in vivo studies confirmed that Rest-less tumors contain significantly less lymphocytes while also revealing a significant increase in pro-tumor macrophages, a cell population our lab has identified as being key modulators of lymphocyte suppression in BC. Furthermore, my in vitro studies identified lymphangiogenic Vegfc and Vegfd among the most differentially upregulated genes in Rest-less BC cells. Tumor lymphangiogenesis is linked to T cell suppression in solid tumors and may provide a reason for Rest-mediated suppression of lymphocytes. Based on my preliminary data, I hypothesize that lymphocyte suppression in Rest- less tumors is orchestrated by the polarization of tumor-associated macrophages (TAMs) and lymphatic endothelium to a suppressive phenotype. I propose two specific aims to test my hypothesis. In Aim 1, I will determine the role of tumor intrinsic Rest on TAM-mediated lymphocyte suppression using co-culture assays of TAMs from Rest-less tumors together with lymphocytes in vitro and macrophage depletion through anti-CSF-1R treatment in an antigen-specific (GFP; JEDI) Rest-less model in vivo. In Aim 2, I will evaluate how Vegfr3, the receptor for Vegfc and Vegfd, regulates the REST-less tumor microenvironment and responsiveness to immunotherapy. To accomplish this task, I will test anti-Vegfr3 blockade on Rest-less tumors with or without anti- PD1 and comprehensively analyze tumor growth, lymphatic depletion, and immune responses using RNAseq, spectral cytometry, and cyclic immunofluorescence. Our proposed research will provide an understanding of a previously uncharacterized facet of REST-mediated immune suppression in BC and will use novel murine orthotopic models to test strategies that block immune suppressive mechanisms. Ultimately, I anticipate my findings will reveal targetable mechanism(s) to inhibit Rest-mediated immunosuppression in BC and provide a considerable impact on the treatment of REST-less tumors overall.

NIH Research Projects · FY 2025 · 2023-08

Project Summary/Abstract Migraine, a chronic intermittent headache disorder, ranks in the top five causes for years lived with disability. Due to the high disability burden associated with migraine, individuals who experience migraine often seek treatments to reduce the frequency and severity of their attacks and often express interest in non- pharmacologic and integrative approaches. One promising treatment may be chiropractic care due to the co- morbidity of migraine and musculoskeletal complaints. We recently completed a pilot single-site multimodal randomized clinical trial among 61 adult women with episodic migraine evaluating chiropractic care (CC) (10 visits over 14 weeks) and enhanced usual care (EUC) versus EUC alone on migraine frequency, severity, duration, and medication use. Recruitment, retention, and adherence to our study protocols were demonstrated to be feasible and preliminary clinical outcomes were promising. Our long-term goal is to conduct a multi-site large-scale fully powered trial evaluating the effectiveness of a validated multimodal chiropractic care intervention to reduce migraine frequency, severity, and disability. However, several important knowledge gaps remain which need to be addressed before undertaking a large- scale study. We need to: 1) recruit and train teams of chiropractors from established chiropractic care clinics, refine our interventions, and assess fidelity of intervention protocols; 2) establish infrastructure in preparation for a multi-site trial including coordinated institutional review board oversight, data sharing agreements, as well as harmonized data collection and reporting procedures across sites; and 3) refine recruitment and retention procedures across multiple settings, and to other groups, particularly men, who were not included in our pilot study. To help inform the design of a large-scale trial with both pragmatic and explanatory features, we propose to conduct a two-arm pilot randomized attention-controlled trial at two sites which are representative of sites to be included in the future large-scale trial. We will recruit and randomize 60 individuals (30 per site) to either 1) 14 visits of CC (6 visits of CC over 3 weeks followed by 8 visits of CC over 12 weeks); or 2) 14 sessions of headache health education (15-minute 1:1 virtual sessions focused on pre-defined migraine- specific topics) – both added to usual medical care. This study will allow us to address the following aims: 1) To train a team of chiropractors from established clinics within two academic medical centers with existing partnerships with headache programs, refine our intervention, and assess fidelity of intervention protocols; 2) To optimize data collection, data management, and reporting procedures across sites and establish the infrastructure needed for a large-scale trial; 3) To assess the feasibility of recruitment, retention, and adherence across multiple study sites; 4) To assess participant expectations and treatment experience.

NIH Research Projects · FY 2025 · 2023-08

Neuronal aggregation of the protein alpha-synuclein (αS) in Lewy bodies is a hallmark of key Alzheimer Disease and Related Disorders (ADRDs) including Lewy Body Dementia (LBD), Parkinson’s disease with dementia (PDD) and mixed AD/LB dementia. Collectively these disorders affect millions of US citizens. Understanding mechanisms of αS toxicity thus holds key import for understanding and treating ADRD. αS reversibly associates with cellular membranes in neurons and this interaction is clearly important for toxicity, but the underlying mechanisms remain unclear. Moreover, αS is also highly abundant in the cytosol. What αS is doing in different cellular compartments and how this may be relevant to neurotoxicity when αS abnormally accumulates in ADRD remains unknown. Our previous extensive genetic and physical αS interaction mapping connected αS not only to membrane trafficking proteins but also to a surprising number of RNA-binding proteins (RBPs). However, while RBP dysregulation and loss of RNA homeostasis are clearly important contributors to neurodegeneration in general, a direct link between αS and RBPs was elusive until now. We recently found that αS can perturb RNA homeostasis by directly interacting with and disrupting the mRNA decapping machinery found in Processing Bodies, membraneless ribonucleoprotein complexes responsible for mRNA turnover. αS strongly interacts with decapping proteins of P-bodies in neurons. Importantly, the exact same (N-terminus) αS region is responsible for binding to membranes and to P-body proteins. This sets up a dichotomous relationship whereby alterations at the membrane can directly affect gene regulation through redistributing αS between membrane and cytosolic compartments. On the basis of our findings in human iPSC neurons and postmortem brain, we hypothesize that αS shuttles between membranes and P-bodies and, upon accumulation to toxic levels, disrupts P- body composition and mRNA turnover. Model organism and human genetics analyses also support a causal influence of the P-body pathway in modulating αS toxicity an PD risk. Here, we will, first, rigorously test these connections by measuring P-body perturbations in a wide-range of synucleinopathy models, postmortem brain and mouse models and assess the direct impact of P-body genes on neurotoxicity. Second, we will investigate which specific mRNA transcripts and subclasses of mRNAs are impacted by αS accumulation or mutation. Finally, we will investigate how αS modulates decapping enzymology and composition in a fully in vitro reconstituted system. We anticipate that this study will reveal that RNA homeostasis disruption is a key aspect of Lewy body disease pathogenesis and motivate new treatment strategies for ADRD.

NIH Research Projects · FY 2025 · 2023-08

Summary/Abstract Airway wall remodeling is one of the most documented hallmarks of asthma. Despite being a key clinical trait of long-term asthma, this pathological condition remains largely uncontrolled even with front-line therapies. Remodeling processes have been traditionally described as an aberrant response to chronic inflammation. However, this picture is challenged by increasing evidence of airway remodeling as a primary mechanotransduction event. Recent studies point to mechanical abnormalities in the airway epithelium as a core factor of asthma pathogenesis. In vitro and in vivo experiments show that the mechanical effects of asthmatic bronchoconstriction can trigger alone genomic, molecular, and morphological patterns of airway remodeling even in the absence of inflammatory stimuli. As such, the traditional picture of asthma as a predominantly inflammatory disease is giving way to a complex, multifactorial scenario where mechanical forces, immune response, and tissue remodeling all contribute to the development of the disease. Building upon these findings, this proposal hypothesizes that the mechanogenetic response of the airway epithelium to excessive mechanical stress constitutes a route to aberrant airway remodeling that is independent of inflammation. To test this hypothesis, Dr. De Marzio will develop a novel systems biology approach that combines genomics, biostatistics, and network medicine. RNA-Sequencing and clinical data from asthma population studies will be integrated with protein interaction networks to: 1) Identify the mechanogenetic signature of bronchoconstriction in the asthmatic epithelium and understand its role on asthmatic phenotypes; 2) define the role of airway epithelial cell heterogeneity in response to mechanical compression; and 3) determine the signaling pathways mediating compression-induced airway remodeling to discover candidate therapeutic markers. In doing so, this project will represent the first comprehensive study on the mechanogenomics of asthma. The intrinsic interdisciplinary nature of this proposal makes Dr. De Marzio uniquely qualified to pursue this research direction. The proposed research will leverage her physics background and her experience in computational biology and network modeling to understand the pathogenic role of mechanical forces in asthma. For the successful development of this project, she will receive additional training in airway pathobiology and pulmonary medicine and she will be supported by an outstanding mentoring team composed of biologists, network scientists, and pulmonologists. Dr. De Marzio's long-term career goal is to establish an independent research program at the intersection of genomics, biomechanics, and network science. The resources offered by this award combined with the rich intellectual environment of the Channing Division of Network Medicine will put her in an advantageous position to transition to independence and submit multiple R01s. Dr. De Marzio's findings will pave the way for the future development of a mechanomedicine of asthma.

NIH Research Projects · FY 2025 · 2023-08

Gliomas are a particularly aggressive type of brain cancer with poor prognosis that affect about 20,000 newly diagnosed patients in the US annually. There is high interest in identifying predictive biomarkers of response to established treatments such as Temozolomide, and to identify response and resistance biomarkers for new single and combinations treatments for gliomas, as there is evidence that an effective adjuvant treatment strategy can improve survival outcomes for patients. Few tools exist currently to identify such biomarkers and prioritize which agent(s) to administer to individual patients in order to maximize the impact of drug treatment. We will conduct a clinical study in which we measure the tumor responses to 20 distinct therapies across a cohort of 32 patients. Using only intrasurgical procedures, implantable microdevices (IMD) are placed into tumors placed into tumors during already scheduled tumor resections, remain in the patient for the duration of surgery, and are extracted along with the resected tumor specimen. IMDs enable readouts for each treatment that include immunohistochemical, transcriptomic, immune and tissue biomarkers, thereby effectively performing 20 biomarker trials at minute drug exposure levels in each patient with three-fold replicates. Several key advances will be achieved in this project. First, safety, feasibility and clinical integration of the technical workflow will be demonstrated in a statistically significant manner. This is key towards establishing broader clinical use for this technology in the intrasurgical setting. Secondly, we will examine in a retrospective analysis whether the IMD readout at Temozolomide (TMZ) reservoirs can serve as a predictive marker for standard systemic TMZ treatment response and progression-free survival at 6 months for each patient. This would constitute a major advance for glioma patients, as TMZ is the most frequently administered adjuvant treatment in this disease, and the MGMT promoter methylation status is only a limited predictor of TMZ efficacy for a subset of glioma patients. Third, we will use multiplexed state-of-the-art deep tissue phenotyping to characterize the biological response of each patient’s tumor exposed to each of 20 drugs on the microdevice. This will result in a comprehensive catalogue of drug phenotypes for 20 distinct therapies in GBM patients, and we will use this data to systematically identify resistance pathways to available therapies. In addition, by examining the tumor for genetic and physiologic changes, we can in vivo correlate existing ‘omic’ biomarkers of tumor response to multiple drugs. This addresses a major knowledge gap in the field, as such a dataset is not feasible to obtain with traditional systemic clinical trials. The drug phenotyping includes spatial transcriptomics and metabolomics to identify specific biomarkers in the tumor microenvironment that correlate with high and low phenotypic response to each therapy. This study will lay the ground work to prove that local intratumor response to microdoses of multiple agents can be used to effectively screen for and tailor optimal treatment for glioma patients. Assessing the predictive value of the IMD for therapy selection opens the door to broader use as a precision medicine and drug development tool to improve outcomes in glioma.

NIH Research Projects · FY 2024 · 2023-07

Abstract: Novel implantable miniaturized devices (IMDs) placed directly in patient tumors can rapidly evaluate multi-drug responses in-situ. They can be used in any solid tumor to provide direct, comprehensive, spatial multi- omic readouts of >20 drugs simultaneously, with potential to eclipse liquid and tissue biopsy biomarker capabilities. However, placing and retrieving IMDs in tumors currently requires highly invasive surgery with excessively high patient morbidity and complication risks. For most cancer patients, these risks are prohibitive, and as a result ongoing first-in-human IMD trials have had limited enrollment. We have developed a fully interventional (minimally invasive) non-surgical method to place and retrieve IMDs. We use custom needle biopsy devices and image guidance to deliver and precisely remove only the IMD and adjacent drug-exposed tissue. This is a simple outpatient procedure similar to routine percutaneous tumor biopsies, using a single tiny (<2mm) skin incision. It reduces the morbidity and risks of IMD use, and would greatly increase enrollment in current and future clinical IMD trials. However, a preclinical study in an animal model is needed to demonstrate technical feasibility and safety of this interventional method prior to first-in- human use. This proposal describes a preclinical study in a rabbit hindlimb tumor model that closely simulates a typical soft tissue sarcoma setting, with the following specific aims: 1) determine the technical feasibility of our interventional (non-surgical) approach for IMD-placement and retrieval; and 2) determine the overall safety and adverse event rate of this same interventional method. Interventional IMD placement and retrieval procedures will be performed in a statistically-powered cohort of 15 rabbits. Technical feasibility and safety endpoints will be assessed, and used to inform further method refinement and ultimately first-in-human trials. The proposed study is innovative as it will develop and validate new interventional tools for personalized cancer treatment that could serve as the next generation of tumor biopsy. It is significant as it will directly enable a first-in-human trial to evaluate IMD-based drug optimization in patients with advanced soft tissue sarcomas. It will also enable greater enrollment in ongoing IMD clinical trials in other similar or lower risk anatomic regions (e.g. breast). Ultimately, if the overall long-term goal of clinically validating IMD-based personalized treatment optimization is achieved, the interventional methods developed here could be applicable to every oncology patient with a percutaneously accessible tumor (similar to routine percutaneous tissue biopsies).

NIH Research Projects · FY 2025 · 2023-07

ABSTRACT In a recent study published in Nature Nanotechnology, we demonstrated that cancer cells form physical nanoscales tentacles (nanotubes) to connect with and harvest mitochondria from immune cells. Such mitochondria hijacking metabolically depleted the immune cells and augmented the cancer cells. These findings have significant implications as it emerges as a novel mechanism of immune evasion by cancer cells, which can limit the efficacy of immune checkpoint inhibitors. Here we propose to develop next- generation immunotherapies that can perturb this novel immune evasion phenomenon. We are specifically developing novel small molecule inhibitors of the exocyst complex, which we have implicated in the above phenomenon. Our preliminary results show that such small molecules can exert a powerful antitumor efficacy, augment classical immune checkpoint inhibitors and display an excellent safety profile. In Aim 1. We will synthesize and characterize exocyst inhibitors in vitro to test the hypothesis that rationally designed small molecule inhibitors of the exocyst complex can inhibit nanotube assembly. In Aim. 2. We will establish the safety pharmacology of exocyst inhibitors in vivo. In Aim 3, we will test the hypothesis that exocyst inhibitors can improve antitumor outcomes with immune checkpoint inhibitors. Achieving these aims will lead to fundamental insights into a new mechanism of cancer-immune cell communication. Our preliminary results indicate exocyst inhibitors can emerge as a new class of immunotherapy.