Children'S Hosp Of Philadelphia

NIH Research Projects · FY 2025 · 2021-09

PROJECT ABSTRACT Pediatric cardiac arrest is common, with resultant high morbidity and mortality. Neurologic disability occurs in up to 80% of children who survive a cardiac arrest. Brain injury after cardiac arrest is caused by the initial hypoxic-ischemic event and from secondary brain injury that occurs in the following hours to days. The focus of post-cardiac arrest care is to reduce secondary brain injury. Cerebral autoregulation (CAR) is a physiologic process by which cerebral blood vessels dilate or constrict to maintain relatively constant cerebral blood flow (CBF) across a range of mean arterial blood pressures (MAPs). Impaired CAR makes the brain vulnerable to states of hypoperfusion and hyperperfusion which can contribute to secondary brain injury and preventable neurologic disability. There is a knowledge gap regarding the MAP at which CAR is most intact after pediatric cardiac arrest, and the impact of the deviation from this optimal MAP on brain injury and clinical outcomes. The central hypothesis of this proposal is that patients with larger differences between their MAP and optimal MAP after cardiac arrest will have worse microstructural brain injury and clinical outcomes. For this proposal, CBF will be measured directly using an advanced, non-invasive optical imaging technique called diffuse correlation spectroscopy (DCS), which will be used to calculate optimal MAP. Brain injury will be quantified using diffusion magnetic resonance imaging (MRI). The primary clinical outcome is neurologic disability at hospital discharge based on the Pediatric Cerebral Performance Category. The objectives of the proposed research are to determine whether patients with larger deviations from their DCS- determined optimal MAP have worse clinical outcomes (Aim 1) and microstructural brain injury on diffusion MRI (Aim 2) compared to patients with smaller deviations from their optimal MAP. In addition, regional CBF derived from DCS will be correlated with CBF derived from arterial spin labeled (ASL) MRI (Aim 3). The successful completion of these studies will further our understanding of the mechanisms underlying post-cardiac arrest brain injury and inform future trials of cerebral physiology-targeted management strategies to improve pediatric cardiac arrest outcomes. The applicant, Dr. Matthew Kirschen, a pediatric intensivist and neurologist at the Children’s Hospital of Philadelphia and University of Pennsylvania, will engage in a rigorous training program of didactic courses and mentoring by experts in pediatric cardiac arrest, cerebral physiology and autoregulation, and brain imaging. He will gain expertise in clinical biostatistics through the Master of Science in Clinical Epidemiology program, advanced optical imaging, and diffusion MRI analytics. Through the proposed studies, his parallel career development plan, a team of dedicated and experienced mentors, and a world-class environment, Dr. Kirschen will achieve his goal of becoming an independent neurocritical care research scientist with special focus on neurologic resuscitation following pediatric cardiac arrest.

NIH Research Projects · FY 2025 · 2021-09

PROJECT SUMMARY/ABSTRACT Dr. Jessica Foster's career goal is to become a translational physician-scientist focused on immunotherapy for pediatric brain tumors. This proposal describes a five-year plan to facilitate her transition to independence through the acquisition of critical technical skills and scientific training in brain tumor modeling and evaluation of the tumor microenvironment with single cell RNA sequencing, integrated with comprehensive mentoring from a diverse team of faculty members. She will conduct the proposed studies under the proven mentorship of Dr. John Maris, an international leader in translational neuroblastoma research and immunogenomics. Additionally, her dedicated Advisory Committee is comprised of highly regarded physician-scientists with diverse expertise in immunotherapy and pediatric brain tumors. Finally, the collaborative research environment with unparalleled resources at the University of Pennsylvania and the Children's Hospital of Philadelphia provides an ideal setting to conduct these translational studies. Diffuse intrinsic pontine glioma (DIPG) is a devastating pediatric brain tumor that remains incurable despite decades of clinical trials, with a median survival of 11 months. This proposal seeks to use chimeric antigen receptor (CAR) T cell therapy, a form of immunotherapy, to target DIPG. Recently GD2 was identified as an immunotherapeutic target for DIPG, and lentiviral GD2-directed CAR T cells were able to successfully treat murine models of DIPG. However, a significant number of mice treated with CAR T cells died due to inflammation and herniation, prompting concerns for potential toxicity from this therapy, in particular in the pons. This proposal is building upon the applicant's experience utilizing mRNA for the creation of CAR T cells that are transient and can be titrated to effect to avoid toxicity, here using repeated local delivery of GD2- directed mRNA CAR T cells to effectively treat DIPG while still maintaining safety. Aim 1 will determine the effect of GD2-directed mRNA CAR T cells on tumor, microenvironment and normal tissue using both immunocompetent and xenograft models of DIPG. Aim 2 will use single cell RNA sequencing to investigate the role of microglia in DIPG development and test mRNA CAR T cells in combination with inhibition of microglia. Dr. Foster's ultimate goal is to create a clinical trial for patients with DIPG using mRNA CAR T cells directed against GD2, as well as generating a new treatment platform for all pediatric brain tumors. These efforts will provide an outstanding foundation for her career as a physician-scientist and the development of an independent translational research program.

NIH Research Projects · FY 2025 · 2021-09

ABSTRACT Advances in hematopoietic cell transplantation (HCT) have led to improvements in survival. Adolescents and young adults (AYAs) who undergo HCT are at an especially high risk of developing sarcopenia (loss of skeletal muscle mass) due to the impact of HCT-related exposures on the immature musculoskeletal system. We have shown that sarcopenia occurs earlier in HCT survivors than would be expected from advancing age alone. HCT survivors who are sarcopenic have a two-fold risk of non-relapse mortality excess rates of premature cardiovascular disease. Therefore, to improve the lives of AYA HCT survivors, it is of critical importance to develop interventions to increase skeletal muscle mass, metabolism, strength, and function. Skeletal muscle is highly reliant on mitochondrial energy production, as measured by oxidative phosphorylation (OXPHOS) capacity. Thus, one strategy to improve skeletal muscle function is to increase muscle OXPHOS in these survivors. Home-based exercise (aerobic and resistance) training is a well-established intervention to increase skeletal muscle mitochondrial OXPHOS, as well as mass, strength, and function. Another approach is to use an “exercise mimetic”, an intervention designed to recapitulate the physiologic benefits of exercise. Precursors of nicotinamide adenine dinucleotide (NAD+), a cofactor required for ATP production, are exercise mimetics. In humans, short-term oral nicotinamide riboside (NR) supplementation has been found to increase the NAD+ muscle metabolome and reduce chronic inflammation associated with aging. Exercise combined with NAD+ precursor supplementation may yield additional benefits compared to either alone, but this approach has not been tested in AYA HCT survivors. We propose a randomized controlled trial with a 2x2 factorial design testing 16 weeks of exercise and NR in AYA survivors of HCT, with a primary outcome of muscle strength. We will also examine the effects of these interventions on exercise capacity, use an innovative non-invasive imaging technique to measure muscle mitochondrial function, and metabolomics to test circulating correlates of increased ATP production, including NAD+, acylcarnitines, and organic acids. Individuals (N=80, ages 15-30y) will be recruited 6-24 mos post-HCT and randomized to 1 of 4 arms: exercise+NR, exercise alone, NR alone, or control. We will use DXA to measure lower leg lean muscle mass, non-invasive MRI to measure OXPHOS, dynamometry to test strength (primary outcome) and cardiopulmonary exercise testing to measure maximal oxygen uptake (VO2max; secondary outcome), at baseline and 16 wks. We expect exercise+NR will produce larger changes than exercise alone in key outcomes, and that changes will be mediated by increases in muscle OXPHOS. This study will address a shared NCI and NHLBI research priority, namely how best to prevent the late development of complications following HCT, and thereby reduce the burden of HCT-related morbidity and mortality. Our findings will inform strategies to prevent or mitigate the myriad downstream adverse effects of low muscle mass in AYA HCT survivors, an important area of focus for the NCI and NHLBI.

NIH Research Projects · FY 2024 · 2021-09

Hemophilia A (HA) is an X-linked bleeding disorder caused by a deficiency in factor VIII (FVIII) due to mutations in the F8 gene. The disease affects 1:5,000 male born worldwide. Replacement therapy with FVIII protein is effective in preventing/controlling bleeding but ~30% of patients develop inhibitors to FVIII (neutralizing alloantibodies) that renders FVIII ineffective; thus, increasing morbidity and mortality. Immune tolerance induction (ITI) is the only successful strategy for eradication of inhibitors/restore immune tolerance to FVIII. ITI regimens are based on FVIII protein injections for months/years and is efficacious in ~60% of cases, but the high cost (~1million/year) prevents its use outside the developed word. Thus, new approaches for inhibitor eradication are urgently needed. Ongoing AAV liver gene therapy clinical trials for HA without inhibitors resulted in therapeutic FVIII. These studies are using vectors manufactured in either HEK-293 or Sf9 cells that differ in their basic biology and clinical outcomes. Our central hypothesis is that AAV-FVIII liver gene therapy is an ideal ITI regimen based on our proof-of-concept report in inhibitor HA dogs (Finn et al Blood, 2010) and novel preliminary data. We will use 2 novel distinct high-responding inhibitor HA dog models with the canine F8 gene mutations associated with the most challenging inhibitor patient group that likely would benefit from AAV ITI. The rationale of this proposal is that a single injection of AAV liver gene therapy provides (A) efficient eradication of high titer inhibitors, (B) restoration and maintenance of immune tolerance to FVIII in high responding HA dogs and (C) continuous FVIII expression that improves the bleeding phenotype after inhibitor eradication. The specific aims are Aim 1: Determine the efficacy of AAV gene therapy in inducing immune tolerance in high-responding HA dog models.We will advance our efforts testing AAV gene therapy in dog models across several distinct breeds to define the factors associated with kinetics of inhibitor eradication (transgene levels/duration). Aim 2: Determine the potential of ITI by rAAV-Sf9-derived AAV-cFVIII gene therapy in high-responding HA dog models. Recent unexpected decline of FVIII expression after 3 years post- AAV-Sf9- FVIII in HA patients raised concerns of durability. To date, the underlying mechanism is unknown. We hypothesized that this could be a combination of Sf9-derived vector and/or FVIII. We will determine in dogs if AAV-Sf9 impacts FVIII expression levels over time and its ability to eradicate inhibitors and to induce tolerance to FVIII. Aim 3: Define the mechanism(s) underlying AAV-mediated ITI. In these novel dog models, we will characterize specific B cells and especially T regulatory cells pool and function following AAV-ITI and to determine the underlying mechanism of immune tolerance in both cell line-derived vector systems. Successful completion of this proposal would support AAV liver gene therapy clinical trial for inhibitor HA patients. The ability of gene therapy to induce immune tolerance is likely to be relevant to other genetic diseases treated with enzyme replacement therapy and complicated by antidrug neutralizing antibodies.

NIH Research Projects · FY 2025 · 2021-09

PROJECT SUMMARY/ABSTRACT Deimplementing overused health interventions is an essential step in maximizing quality and minimizing waste in the United States health care system. Acute bronchiolitis is a common lung disease of young children caused by respiratory viral infection. Continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who are not receiving supplemental oxygen is an overused intervention that has persisted despite evidence that it is ineffective in this population and may cause harm. Three national guidelines now discourage continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who are not receiving supplemental oxygen. In preliminary studies, the investigators showed that continuous pulse oximetry overuse occurs in nearly half of all hospitalized infants with bronchiolitis for whom there is no monitoring indication, and there is high between-hospital variability in overuse. The overarching goal of the applicants is to determine which strategies are most effective for deimplementing overused health interventions that have the potential to harm children. The overall objective of this application is to conduct the Eliminating Monitor Overuse (EMO) SpO2 trial, a hybrid type III effectiveness-deimplementation trial with a longitudinal cluster-randomized design in 32 Pediatric Research in Inpatient Settings Network hospitals. The trial will test an unlearning deimplementation strategy (educational outreach with audit & feedback) vs. a combined unlearning + substitution deimplementation strategy (adding an electronic health record-integrated clinical pathway) on sustainability of continuous pulse oximetry monitoring deimplementation in children with bronchiolitis who are not receiving supplemental oxygen. This proposal includes three Specific Aims: (1) Compare the effects of the unlearning only strategy versus the unlearning + substitution strategy on deimplementation outcomes, (2) Identify deimplementation strategy mechanisms linked to penetration and sustainability using mixed methods, and (3) Examine the effects of deimplementation on clinical outcomes and unintended consequences. This approach is innovative because it focuses on the under-researched area of pediatric deimplementation, the experimental design reflects state-of-the-art theoretical framing of deimplementation interventions, and the primary outcome focuses on long-term sustainability of deimplementation, which is highly relevant to the public. The proposed research is significant because it will advance the science of health care delivery for a high incidence pediatric lung disease that hospitalizes 100,000 children annually, acute viral bronchiolitis. The trial will also provide new insights into the processes, mechanisms, costs, and outcomes of large, rigorously- designed deimplementation efforts.

NIH Research Projects · FY 2025 · 2021-09

Project Summary/Abstract Insufficient sleep doubles the risk of obesity among youth and increases the risk of cardiovascular disease (CVD) in adulthood. Over 75% of US high school students do not meet national sleep recommendations. Given these alarming trends, a better understanding of the environmental determinants of sleep in adolescents is needed in order to identify targets for interventions and public health strategies to promote healthy sleep. While research increasingly suggests that home and neighborhood context impact sleep, key methodological issues limit understanding of the environmental determinants of adolescent sleep. Research on the influence of neighborhood-level factors (e.g. crime, disorder) on sleep typically focuses on the area surrounding adolescents' homes. This approach does not account for mobility and the accumulation of exposures across multiple contexts (e.g. home, school, in transit) during daily activities, leading to exposure misclassification. The home sleep environment (e.g. light, noise) may also vary by night, but is typically assessed at a single timepoint. Mobile health methods including smartphone GPS tracking and ecological momentary assessment (EMA) offer an innovative opportunity to overcome the limitations of past studies by developing person- centered measures of environmental exposures that account for variation over space and time. With this career development award, I will develop critical skills in environmental exposure assessment and health behavior science necessary to pursue a novel independent research program that identifies modifiable environmental determinants of sleep and other CVD-related outcomes and their mechanisms of effect using advanced, cutting-edge methods. In the proposed research study, I will enroll a diverse cohort of 160 adolescents aged 15-18 through a large urban pediatric primary care research network. I will use smartphone GPS tracking, EMA, geographic information systems (GIS), and actigraphy to collect high-resolution longitudinal data on adolescents' exposures to the home and neighborhood context and sleep outcomes over a 14-day period. The research aims include 1) quantifying adolescents' exposure during daily activities to neighborhood factors hypothesized to influence sleep, 2) determining the extent to which adolescents' exposure to adverse sleep environments varies across nights and by housing conditions, and 3) determining the extent to which daily measures of home and neighborhood exposures are associated with adolescent sleep outcomes. With guidance from an expert, interdisciplinary mentorship team at the Children's Hospital of Philadelphia and the University of Pennsylvania, I will obtain training in 1) space-time data collection and analysis, 2) ecological momentary assessment, and 3) sleep research. Completion of the K01 research and training plan will prepare me to compete successfully for R01-level research funding and will uniquely position me as an independent investigator who conducts large-scale epidemiologic investigations on spatiotemporal, environmental determinants of child and adolescent health behaviors related to cardiovascular health.

NIH Research Projects · FY 2025 · 2021-08

Shared decision making (SDM) between providers, parents, and youth is posited to be one of the processes of self-management for a chronic condition. Adequate conceptual models for involving youth in decision making must attend to the youth-parent-provider triad, recognize that there are multiple ways for youth to be involved in the process of decision making, and underscore that parent, provider, and youth decision making behaviors and roles should change with development. The field lacks empirical research to understand the nature of parent-youth-provider interactions about decisions and outcomes of different patterns of behavior over time, including adherence and health outcomes in youth with a chronic illness. This lack of research is due, at least in part, to the absence of feasible, reliable, valid, and conceptually sound measures that assess the complex interplay of decision making behaviors during medical encounters. The primary objective of this proposal is to develop a measure of youths’ involvement in decision making during outpatient visits for pediatric chronic illness (specifically, type 1 diabetes, sickle cell disease, juvenile idiopathic arthritis, and inflammatory bowel disease). Aim 1 is to utilize semi-structured qualitative interviews with youth, parents, and providers (Study 1, Phase 1) and cognitive interviews with youth and parents (Study 1, Phase 2) to develop items for a new measure- the Decision Making Involvement Scale-Medical Encounters (DMIS-ME)- and ensure alignment between participant interpretation and intent of the items. Aim 2 is to evaluate the psychometric properties and validity of the DMIS-ME, utilizing both classical and modern test theory. Validity will be assessed by examining whether DMIS-ME subscales are associated with youth age, decision self-efficacy, perceived global health, self-management skills, and adherence. Secondary Aim 2 is to develop a typology of visit profile classes based on DMIS-ME subscales, using latent class analysis, and examine whether the classes vary based on socio-demographics and variables tested in Aim 2. For Aim 2 (Study 2), we will enroll and assess youth and their parents, immediately after attending an outpatient specialty care visit related to their chronic illness. They will complete the DMIS-ME and measures of decision self-efficacy, perceived global health, self-management skills, and adherence. The development of the DMIS-ME addresses a critical gap in the field of pediatric self-management and decision making. The DMIS-ME can be used in future research to describe youths’ decision making involvement in a multidimensional way that accounts for the youth-parent-provider triad, identify outcomes of involvement, and inform the development and evaluation of interventions to enhance youth involvement in decision making, and ultimately, health behaviors and outcomes, as they mature.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY/ABSTRACT – Children’s Hospital of Philadelphia The Collaborative Pediatric Critical Care Research Network (CPCCRN) is essential to advancing the science and practice of pediatric critical care medicine. The overall aim of this site proposal is for Children’s Hospital of Philadelphia (CHOP), under the continued leadership of Athena Zuppa and Robert Berg, to continue as a clinical site in the new and expanded CPCCRN. Drs. Zuppa and Berg, site-PIs for the past 11 years, are pediatric intensivists with a wealth of clinical and translational research experience, who have successfully mentored many junior investigators and produced numerous scientific publications for the CPCCRN. CHOP is a free-standing, tertiary care, academic children’s hospital located in Philadelphia that serves children and families with diverse racial, ethnic, and socioeconomic backgrounds. CHOP, one of the largest children’s hospitals in the country, is a 559-bed children’s hospital with 49 pediatric medical and surgical subspecialties, a staff of over 14,585, a faculty of 860, and an annual operating budget of $3.2 billion. CHOP is home to one of the largest pediatric research programs in the country with more than $147 million in total federal awards and an annual budget of more than $404 million (FY19). The “Personalized Immunomodulation in Sepsis-Induced Multiple Organ Dysfunction Syndrome (MODS)” trial proposed in this application is a large RCT of personalized, targeted management of immune function in children with sepsis-induced MODS. The trial addresses the hypothesis that immunosuppressed children will benefit from granulocyte macrophage-colony stimulating factor (GM-CSF), and children with hyperinflammation will benefit from targeted anti-inflammatory therapy with anakinra (recombinant IL-1 receptor antagonist) or tocilizumab (IL-6 receptor blocking antibody). Benefit will be evaluated in terms of short- and long-term health-related quality of life. This study builds on CPCCRN studies that have demonstrated the existence of specific immune phenotypes among children with sepsis-induced MODS, and successful reversal of immune suppression by administration of the GM-CSF. It also complements the ongoing NICHD R01-funded study investigating the risk factors for immunoparalysis in pediatric MODS, of which Dr. Zuppa is a co-PI. This study proposes a transformative approach to personalized immune-targeted care of the septic child. Drs. Zuppa and Berg and their research team are thoroughly familiar with the CPCCRN studies on which this trial is based including methods of sample collection and processing for immunophenotyping, dosing and administration of GM-CSF, and collection of short- and long-term sepsis-related outcomes. Drs. Zuppa and Berg, and the ancillary site PI Dr. Neal Thomas have the full support of their respective institutions to participate in the CPCCRN, and are strongly committed to collaboration with other CPCCRN sites and the Data Coordinating Center, as well as the inclusion and mentoring of junior investigators in CPCCRN activities.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY/ABSTRACT Addressing a paucity of training in multilingual research methods, we propose a unique, short term education program to provide child health researchers with the sensitivity, skills, and knowledge to recruit and engage Limited English Proficiency (LEP) children and families in research. In the US there are approximately 7.8 million children and adolescents with no English-proficient parents. These children and youth are often excluded from child health research because of language barriers, and this threatens both the validity and the generalizability of research findings. And because Latino and Asian children are often affected by language barriers, lack of preparation to conduct multilingual research is also a barrier to adherence to the NIH policy regarding the inclusion of minorities as subjects in clinical research. To address this gap, we propose a training program with three components: First, we will offer a 3-day virtual workshop including hands-on training sessions with expert medical interpreters; orientation to an anthropological understanding of language and communication; practice in the development of multilingual enrollment and study instruments; and attention to team-building and budgeting for language resources. Second, we will deliver monthly webinars to address specific, practical issues that arise in the experience of trainees following the short course, e.g., writing for peer review. Third, we will create opportunities for participants to convene, network, and engage in professional development—e.g., by collaborating on conference workshop submissions and holding monthly, virtual works-in-progress—to build an intellectual community for multilingual child health research. Seasoned researchers, educators, and professional interpreters from Children’s Hospital of Philadelphia, University of Pennsylvania, and Pennsylvania State University will lead these activities in collaboration with senior researchers from the project’s Invited Faculty and Advisory Committee. The short course will be appropriate for graduate, postdoctoral, and other child health investigators, including early and mid-career faculty, with prior research methods/design training and who are seeking specialized training in multilingual methods. By training and supporting a cohort of investigators, we hope to help transform the practice of child health research by making inclusion of LEP children and families the norm rather than the exception. We believe this short course will enhance the rigor, validity, and generalizability of child health research, leading to better health outcomes for children in the US.

NIH Research Projects · FY 2025 · 2021-08

ABSTRACT The proposal in this application outlines a five-year career development plan to prepare the candidate, Dr. Jonathan Edwards, MD, for a career as an independent physician-scientist defining mechanisms of right ventricular failure (RVF). The research and development plans are carefully structured to expand Dr. Edwards’s scientific foundation in cardiovascular research by providing technical training and expertise in in vitro cardiomyocyte biology, molecular biology, transgenic murine model development, and characterization of RV function in murine models. Dr. Edwards’s development plan will also strengthen his communication, leadership, and collaboration skills through attendance of high yield coursework, workshops, and seminars. RVF is a significant health problem that is a strong predictor of death, and for which there are no proven therapies. The lack of human or animal work investigating molecular mechanisms of RVF, which could foster the development of critically needed novel RVF therapies, is a significant gap in our field. I found that the fetal noncanonical WNT receptor ROR2 is strongly reactivated in the RV of patients with severe RVF and in mice with RVF from pressure overload. Further, this ROR2 activation was associated with upregulation of the ROR2/Ca2+ responsive protease calpain and target protein cleavage. I hypothesize that pathologic ROR2 expression is a novel and potentially targetable molecular driver of RVF and pathologic cardiomyocyte remodeling, which acts via calpain-mediated cytoskeleton and sarcomeric disruption and apoptosis in a subcellular Ca2+-dependent manner. Three interrelated, but independent Specific Aims will address this hypothesis: 1) Determine the mechanistic role for Ror2 in in vitro cardiomyocyte cytoskeleton and sarcomeric disruption and apoptosis; 2) Determine if RV-specific Ror2 overexpression is sufficient to cause RVF; and 3) Determine if RV Ror2 expression is necessary for pressure overload-induced RVF. This research training will be conducted under the mentorship of Dr. Zoltan Arany, MD, PhD (Director, Cell Biology, Physiology, and Metabolism), with co-mentorship by Dr. Benjamin Prosser, PhD (Associate Director, Penn Muscle Institute) at the University of Pennsylvania. Dr. Edwards has assembled an interdisciplinary advisory committee with expertise in in vitro cardiomyocyte biology, molecular biology, translational science, Ca2+ regulation, WNT signaling, RVF murine modeling, transgenic animal model development, and leadership. Currently he is a board-eligible pediatric cardiologist, advanced clinical fellow in pediatric cardiomyopathy, heart failure, and heart transplantation, and a postdoctoral fellow in the Arany laboratory. His long-term career goals are to serve as a physician-scientist with expertise in RV myocardial biology and the clinical management of pediatric patients with heart failure as an academic faculty member at a pediatric research hospital. Dr. Edwards will benefit from his robust and balanced mentorship team, research environment, and unequivocal divisional and institutional commitment, all of which will support his path to independence.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY The epilepsies affect up to 1% of the global population and more than 150 genetic etiologies have been discovered over the last two decades. Genetic testing is emerging as a diagnostic standard and the diagnostic yield frequently approaches 30-40% for individuals with epilepsy who receive testing. Knowledge about the underlying genetic etiology is increasingly used for personalized medicine and a wide variety of gene-specific treatments with novel pharmacological compounds, gene-regulating strategies such as use of anti-sense oligonucleotides, and viral gene therapy are under development. However, information with regards to gene validity and variant pathogenicity is often not standardized. This highlights an ongoing, critical need to assess the validity of gene-disease relationships in the epilepsies, given that variant information is increasingly used for therapeutic decision-making. Our ClinGen Epilepsy Gene Curation Expert Panel (GCEP) already curated nearly 120 genetic etiologies for the epilepsies and our Epilepsy Sodium Channel Variant Curation Expert Panel (VCEP) has already modified ACMG/AMP variant criteria for ion channel-related epilepsies as the most important gene group in the epilepsies. The current project represents an urgently needed continuation of our gene and variant curation efforts, which we aim to accomplish through two aims. First, we will curate 100 gene-disease relationships in the epilepsies in newly defined etiologies (Aim #1) given the ongoing discovery of novel genetic etiologies in the epilepsies. We will use our previously developed epilepsy-specific Standard Operating Procedures (SOPs) with regards to phenotype-based pre-curation to capture relevant clinical subgroups, novel concepts for the inclusion of relevant model system data, and reassessment of prior curations based on updated literature. We expect that these SOPs will allow for evidence-based classification in 90% of all genetic etiologies according to different levels of certainty. Secondly, we will curate variants in synapse genes and continue curation for channelopathies (Aim #2). The overall frequency, disease burden, and heterogeneity of the disorders of the synapse has only become apparent in the last five years. We therefore will establish a new VCEP for synapse disorders (STXBP1, SYNGAP1, DNM1, and STX1B) and modify ACMG/AMP criteria. Combining variant curation in synapse disorders with our continued effort for variants curation in the ion channels, we plan to curate 1,500 variants, aiming for reduced VUS rates by >20%. By the end of the proposed research period, we will have addressed the lack of reliable, objectively reviewed information on the causative nature of newly identified epilepsy genes and will have re-categorized a significant proportion of disease variants in synapse disorders, jointly with our continued effort within the sodium channel VCEP. Combined with our prior work, this will provide a much-needed foundation for the emerging era of precision medicine in genetic epilepsies.

NIH Research Projects · FY 2025 · 2021-08

PROJECT SUMMARY/ABSTRACT This K23 Mentored Patient-Oriented Research Career Development Award will prepare Dr. Catherine Avitabile, a pediatric cardiologist and pulmonary hypertension specialist, for an independent research career focused on exercise interventions to improve lean mass, functional capacity, and quality of life in children with pulmonary hypertension and other heart diseases. Dr. Avitabile’s application is strengthened by her clinical expertise and her prior research demonstrating lean mass (skeletal muscle) deficits in association with worse exercise performance in cardiac patients. Under the mentorship of Drs. Babette Zemel and Stephen Paridon, Dr. Avitabile will pursue a comprehensive career development plan with training in exercise physiology and interventions, body composition assessment, wearable activity monitoring, and qualitative methods. The growing population of pulmonary hypertension survivors report low quality of life and exercise intolerance. Children with pulmonary hypertension engage in less physical activity compared to peers, which is a concern since adult data support exercise as a non-pharmacologic therapy. Exercise training safely improves exercise performance and quality of life in adults with pulmonary hypertension and in one small pediatric study, but therapeutic exercise has not been widely adopted in pediatric pulmonary hypertension. While cardiopulmonary status may limit exercise participation, other barriers to participation have not been explored. It is also unclear how exercise interventions have a clinical effect as they may have multiple targets. Skeletal muscle abnormalities are associated with worse exercise performance in adults with pulmonary hypertension and could be modifiable through exercise interventions. Dr. Avitabile has identified skeletal muscle abnormalities in children with pulmonary hypertension, and these are the focus of her research interests. Exercise interventions that slow symptom progression would improve wellbeing for pediatric pulmonary hypertension survivors and their families. Dr. Avitabile’s proposed research will increase understanding of the health consequences of physical inactivity and identify barriers to exercise in pediatric pulmonary hypertension patients in order to design effective exercise interventions. Aim 1 explores the association between physical inactivity and muscle deficits. Aim 2 employs qualitative interviews to identify barriers to physical activity in order to strengthen intervention design. Aim 3 tests the feasibility and preliminary estimates of efficacy of a home exercise intervention to increase physical activity and improve functional status. The intervention is enriched by data from wearable activity monitors, closely aligned with the priorities of the 2016-2020 NIH-Wide Strategic Plan. This K23 award will support Dr. Avitabile’s pathway to independence as a pediatric cardiologist/pulmonary hypertension expert skilled in exercise physiology and interventions, body composition assessment, and mobile health technologies. These skills will support her future R01 proposals that will use exercise to improve survivor wellbeing and will provide a model for exercise interventions in other cardiac patient groups.

NIH Research Projects · FY 2024 · 2021-07

PROJECT SUMMARY/ABSTRACT This proposal focuses on genetic determinants underlying human hematopoiesis, specifically the development of hematopoietic progenitor cells (HPCs) and their precursors. There is considerable interest in augmenting in vitro HPC production from cultured induced pluripotent stem cells (iPSCs), as this would support research and development of many blood cell-based therapies. To better understand genes and genomic loci that might improve in vitro blood cell yields, I used computational modeling to analyze blood trait genome wide association study (GWAS) data. I identified and validated Tropomyosin 1 as a gene that normally constrains in vitro production of HPCs and their endothelial precursor cells. In Aim 1 of this grant, I will determine mechanisms by which Tropomyosin 1 regulates HPC precursor development using well-defined in vitro iPSC culture models. In Aim 2, I will define other genes and genetic mechanisms that regulate HPC biology using novel adaptations of complementary statistical genetics approaches. The proposed five-year training program outlines development of my research career as an academic pediatric physician-scientist seeking to develop a research program investigating genetic mechanisms that regulate hematopoiesis. I completed an MD and PhD in cell and molecular hematology, pediatrics residency training, and am currently in my third year of fellowship training in neonatal and perinatal medicine at the Children’s Hospital of Philadelphia (CHOP). The proposed research will be carried out under the mentorship of Benjamin Voight, PhD, a leader in the field of complex human genetics; Stella Chou, MD, a leader in iPSC-derived hematopoiesis and transfusion medicine; and Deborah French, PhD, a leader in iPSC manipulation, hematopoietic culture, and blood cell biology. In addition, I am supported by an advisory committee composed of scientists and physician-scientists in relevant and complementary fields, who have together supported multiple K-award trainees. I have secured complete support from my institution, and will benefit from exceptional didactic training, extensive resources and core facilities, and world-class mentorship available at CHOP and the University of Pennsylvania for the duration of this award period. Training in an ideal academic environment, afforded by K99 support, will help me develop the skills required to become an independent physician-scientist studying hematopoiesis genetics during the R00 phase of this award. My goal is to run a laboratory that uses computational and biochemical approaches to understand genetic mechanisms and therapeutic strategies that enhance blood production. In this grant, I will obtain rigorous training in data science and hematopoiesis modeling. This will expand my repertoire of skills, propel my transition to independence, and increase my likelihood of success competing for R01 funding.

NIH Research Projects · FY 2025 · 2021-07

(RESEARCH PLAN- OVERALL) PROJECT SUMMARY With this application, we seek funding for the Intellectual and Developmental Disabilities Research Center (IDDRC) at the Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania (Penn), which has been continuously funded for the past 30 years. Our IDDRC supports an interdisciplinary program and is the chief agency at CHOP/Penn for the promulgation of research into the Intellectual and Developmental Disabilities (IDDs). Our mission, to identify the pathogenesis of and develop therapies for individuals with IDDs, is pursued through three aims. (Aim 1) Lead a cutting-edge IDD research agenda. We will support five research cores that harness innovations in genetics and neuroscience to identify the causes of IDDs, to determine how gene variants alter brain structure, circuitry, and behavioral outputs (cognitive, motor, sensory, social, affective), and to utilize this information to develop biomarkers and new treatments for IDDs. Our cores deploy complementary state-of- the-art technologies, focusing on studies performed in two species (mouse & human), making it easier for center members to perform more impactful research. Cores emphasize research along the developmental spectrum. These strategies ensure that the advances will have a translational impact. The cores provide cost-effective support for 61 world-class center members, who are funded by 78 grants totaling $29.1 million annually to study the pathogenesis of IDDs, to identify new biomarkers of IDDs, and to develop novel interventions (pharmacologic and genetic). In addition, we will support an innovative research project that uses center cores to determine if magnetoencephalography (MEG) measures of auditory processing in infants at genetic risk for IDD can be used to predict cognitive and language outcome. Our cores focus on rigorous and reproducible research practices, including sound experimental design for hypothesis testing, well-justified sample sizes, and robust data analytics. (Aim 2) Lead a multi-disciplinary career development program to support trainees and early-stage faculty. Our trainees are diverse and have PhDs, MDs, and MD/PhDs with backgrounds in genetics, neuroscience, and related disciplines. They receive support from IDDRC-administered programs: a NINDS-funded T32 Training Grant in Neurodevelopmental Disabilities, a CHOP Research institute-funded supplement program for clinical research fellows, and a CHOP-institute funded New Program Development award for Assistant Professors. They obtain multidisciplinary training that helps them become future leaders in IDD research. (Aim 3) Support Networking/Collaboration, Advocacy, and the Dissemination of IDD Research findings. The Center leadership will enable networking to support collaborative initiatives, both within the CHOP/Penn IDDRC community and between IDDRCs. Center leadership will advocate both internally and externally to advance an IDD research agenda. Finally, the Center will lead an effort to disseminate research advances to patients, their families, to government officials, and to other scientists. With this comprehensive approach, the IDDRC at CHOP and Penn will achieve our goal of advancing patient-centered innovative treatments for individuals with IDDs.

NIH Research Projects · FY 2024 · 2021-07

Project Summary/Abstract The goal of the proposed research is to elucidate the molecular pathogenesis of severe congenital neutropenia (SCN) due to mutations of caseinolytic peptidase B (CLPB). SCN is an inborn disorder of granulopoiesis characterized by severe chronic neutropenia from birth, premature death secondary to infectious complications, and transformation to myeloid malignancy. Through exome sequencing of a large SCN cohort, the candidate has recently identified heterozygous missense mutations in CLPB as a new and frequent cause of SCN. CLPB is a nuclear-encoded protein that resides within the inner mitochondrial membrane space where it functions as a molecular chaperone to disaggregate and facilitate re-folding of misfolded proteins. However, the mechanisms linking impaired CLPB function to a defect in granulocyte formation are unclear. In this proposal, the principle investigator will test the hypothesis that mutant CLPB acts in a dominant fashion to disrupt the chaperone function of CLPB, resulting in impaired mitochondrial stress responses and induction of apoptosis in promyelocytes. To test this hypothesis, the following specific aims are proposed: Aim 1) to determine whether CLPB mutations impair the mitochondrial response to endoplasmic reticulum stress in granulocytic precursors; Aim 2) to examine the impact of CLPB mutations on the switch from glycolysis to oxidative phosphorylation in early granulocytic precursors. The proposed studies should provide an understanding of the molecular pathophysiology of CLPB- mutant SCN. Ultimately, a better understanding of normal and SCN-related granulopoiesis may suggest new therapeutic approaches to treat or prevent neutropenia in patients with SCN, and in patients receiving myeloablative chemotherapy. The long-term goal of this physician-scientist candidate is to establish a productive and independent laboratory at a major academic institution studying normal and malignant hematopoiesis. The primary mentor is Dr. Daniel Link, a distinguished scientist who is also an experienced and committed mentor. A panel of senior investigators with complementary scientific and translational expertise will serve on a formal K99 mentorship committee to provide both scientific and career guidance. Washington University is an exceptional environment to train junior investigators, especially those interested in hematopoiesis. There is ready access to numerous core facilities and a strong intellectual environment with experts in stem cell biology, neutrophil biology, mitochondrial biology, and cellular models of hematopoiesis. In addition to taking courses in biostatistics and bioinformatics, the candidate will take advantage of the broad portfolio of workshops offered at Washington University to help junior investigators establish and run an independent laboratory. Washington University has committed to providing laboratory space and resources to facilitate the candidate’s transition to independence.

NIH Research Projects · FY 2025 · 2021-07

Project Summary Children with disseminated neuroblastoma have a very high risk of treatment failure and death despite receiving intensified chemotherapy, radiation therapy and immunotherapy. The long-term goal of the Mossé and Maris translational research programs is to substantively improve neuroblastoma cure rates by developing patient-specific therapies that target the unique oncogenic drivers of each case. Within the context of the National Cancer Institute’s Pediatric In Vivo Testing Program (Ped-In Vivo-TP) we propose a Neuroblastoma Research Program built on richly annotated and highly characterized patient derived xenograft (PDX) and other recently developed murine models of this disease. The central hypothesis to be tested in this Program is that neuroblastoma-specific oncogenic drivers and optimal immunotherapeutic targets can be defined and exploited through rationally designed therapies based on validated and clinically measurable biomarkers. Through our dedicated focus on neuroblastoma and our central role in the former Pediatric Preclinical Testing Program and Consortium, we have developed an investigative team and rich set of resources and reagents to be uniquely positioned to achieve the goals of the Ped-In Vivo-TP. Here we propose to use a large (and growing) collection of PDX models that have been fully characterized with the most modern genomic technologies to address the challenge of prioritizing the large armamentarium of anti-cancer agents in development so that early phase biomarker-driven clinical trials can be designed with the objective of showing potent and specific anti-tumor activity. We propose three specific aims directed towards 1) developing and characterizing highly annotated models of human neuroblastoma; 2) performing preclinical trials with drugs directed against defined therapeutic vulnerabilities in order to prioritize agents for the clinic, and 3) developing the portfolio of preclinical data required for design of clinical trials with robust biomarkers for patient selection and monitoring. In collaboration with other preclinical testing programs, we will seek to determine if discoveries in our program are relevant to other childhood cancers and collaborate across disease groups on clinical development strategies. Thus, this Program will seek to shift the paradigm for how high-risk neuroblastoma patients are treated with the goal of substantively improving the outcomes, both in terms of cure rates, but also by decreasing the toxicity associated with current standards of care.

NIH Research Projects · FY 2025 · 2021-07

PROJECT SUMMARY / ABSTRACT Reversing the developmental switch from fetal (HbF) to adult hemoglobin is an important therapeutic approach in sickle cell disease (SCD). HbF expression in healthy adults, patients with SCD, or those treated with pharmacologic HbF inducers is distributed heterogeneously in a subset of cells called “F-cells”; increasing the number of F-cells as well as the HbF content in each F-cell are both important for treatment of SCD. I have developed techniques for purification and characterization of primary human F-cells and their comparison to equivalent A-cells, which do not express HbF. My preliminary data show that the two cell types differ primarily in their globin content but not in expression of any known HbF regulators, and that F-cells have increased long- range chromatin contacts between the locus control region (LCR) enhancer and the promoters of the g-globin genes. My preliminary studies and the experiments proposed in this proposal represent the first attempt to characterize F-cells by direct comparison to A-cells. I propose to further characterize F-cells from healthy adults, patients with SCD, and following treatment with three pharmacologic HbF inducers using cutting-edge techniques for studies of transcriptional bursting kinetics, chromatin accessibility and long-range chromatin interactions. In addition, I will explore the function of three chromatin remodeling enzymes identified in a loss of function genetic screen for modulators of HbF expression. My proposed studies will further our understanding of the mechanisms of HbF regulation and heterogeneity of HbF expression in clinically important contexts and will guide the development of more effective therapeutics for sickle cell disease. This proposal describes a five-year training plan for the development of my independent research career as an academic pediatric hematologist physician-scientist studying red cell biology and hemoglobin regulation. I am an Instructor in Pediatrics at the University of Pennsylvania and an attending physician in the Division of Hematology at the Children’s Hospital of Philadelphia (CHOP) with previous PhD training in cell and molecular biology and red blood cell biology. The goals for this award are to develop and refine the essential skills that will be required for a successful career as an independent investigator, including expertise in gene regulation, epigenetics, and bioinformatics. My mentor for this award is Dr. Gerd Blobel, an internationally recognized leader in epigenetics, erythroid gene regulation, and developmental control of hemoglobin switching. I have also enlisted an advisory committee composed of scientists and physician-scientists with complimentary expertise and mentoring experience, and have the full resources of CHOP and the University of Pennsylvania available for the completion of my research and career development goals. Completion of this proposal in a mentored environment will leave me optimally positioned for a career as an independent physician-scientist.

NIH Research Projects · FY 2025 · 2021-07

ABSTRACT The genomic contribution to the development of very early onset inflammatory bowel disease (VEO-IBD), IBD diagnosed at <6 years of age, remains understudied, yet elucidation of genetic risk factors would undoubtedly enhance our understanding of pathogenesis and suggest novel therapeutic approaches. The aggressive phenotype, often refractory to conventional therapy, early onset, and strong family history points to an enrichment of monogenic defects. Indeed, we and others have identified causal variants in VEO-IBD that has changed care for these children. Whole exome sequencing has radically changed our approach to VEO-IBD, however, it has only been successful in ~18% of cases, despite evidence highly suggestive of an underlying genetic defect. In addition, linking the identified variant to the development of the VEO-IBD phenotype remains difficult. The goal of this proposal is to widen our genetic analysis through whole genome sequencing (WGS) and leverage transcriptome modifications to enhance our capacity in identifying causal variants. Our central hypothesis is that a proportion of VEO-IBD is a monogenic disease, a subset of which will alter gene transcription, and transcriptome analysis, including single cell analysis, will allow us to more rapidly and accurately identify such mutations among the detected candidate variants. Using a novel innovative method, based on WGS, we will expand our repertoire of causal defects in VEO-IBD. We will integrate these findings with RNA-seq and scRNA-seq data, which can generate a more sensitive and specific approach to detect causal variants and characterize their mechanism of action. In addition, when WGS cannot identify a clear causal variant, RNA-seq and scRNA-seq can provide insight into the underlying disease mechanism, supporting the implication of candidate mutations. To test our central hypothesis, in Specific Aim 1 we will expand our dataset of potential causal mutations in VEO- IBD through WGS. We will validate candidate genes in additional VEO-IBD cases. In Specific Aim 2, we will test the ability of transcriptional profiling of colonic tissue and PBMCs to enhance the identification of novel causal variants of VEO-IBD. Finally, in Specific Aim 3, using scRNA sequencing, we will assess the colonic and immune cell heterogeneity and characterize genes and pathways associated with infantile onset IBD using transcriptional profiling of individual cells from colonic tissue and PBMCs. Completion of this project will result in the identification of novel genetic causes of VEO-IBD, providing a fertile source of biologic processes to pursue to better understand the basic mechanisms of disease, with the ultimate goal of translating this knowledge into improved care for children with VEO-IBD through individualized and targeted therapy.

NIH Research Projects · FY 2025 · 2021-05

Project Summary Tobacco smoking is a serious public health concern and is 2 to 3 times more prevalent among HIV-infected individuals than the general population. Smoking reduces the efficacy of combination antiretroviral therapy and substantially impacts the long-term survival of HIV-infected individuals. Several studies have suggested that chronic tobacco (cigarette) smoking and HIV infection have harmful additive or synergistic effects on the brain, leading to greater psychopathology, impulsivity and cognitive dysfunction. Little is known about the neurochemical profile related to the combined effects of HIV infection and smoking. HERCULES is a novel J- difference-edited magnetic resonance spectroscopy (MRS) technique that can measure up to seven low- concentration brain metabolites (e.g., GABA) with relatively short scan times. However, HERCULES is sensitive to subject motion, which affects both localization accuracy and spectral quality. Both HIV-infected subjects and tobacco smokers have greater impulsivity that might lead to greater subject motion. Therefore, the aims of this project are: 1) K99 phase: the candidate will be mentored in the development of the motion-corrected HERCULES sequence, which will allow robust investigation of these neurometabolites; he will also assess the reproducibility of HERCULES with and without motion correction in seronegative (SN) healthy controls; 2) K99 phase: to learn to conduct a pilot clinical study using the optimized motion-corrected HERCULES to evaluate the neurometabolic profile of HIV-infected individuals or tobacco smokers, compared to SN healthy controls; 3) R00 phase: to measure a comprehensive neurochemical profile in four groups of individuals (SN/tobacco-, HIV+/tobacco-, SN/tobacco+, HIV+/tobacco+), using the motion-corrected HERCULES sequence. Based on the proposed clinical training and didactic courses, the candidate will work with experienced globally recognized experts in the fields of MRS and clinical HIV research to achieve five training goals: (1) develop expertise in research design and clinical assessments of HIV-infected individuals and tobacco smokers; (2) conduct a pilot study to evaluate the independent effects of HIV and tobacco smoking on neurometabolite levels; (3) learn to apply an advanced MRS technique to clinical research, especially in HIV+ individuals and tobacco smokers; and (4) learn to apply advanced statistical methods to analyze complex clinical data from patient populations. The long-term career objective of the candidate is to become an independent scientist with a complete repertoire of skills in MRS methodologies and their clinical applications. The motion-corrected HERCULES can be applied to study metabolic processes in other diseases as well, adding scope and impact to this research proposal, which is also responsive to NIDA’s mission of “strategically supporting and conducting basic and clinical research on drug use (including nicotine), its consequences, and the underlying neurobiological mechanisms involved.”

NIH Research Projects · FY 2025 · 2021-05

PROJECT SUMMARY Training: The purpose of this K23 proposal is to prepare Dr. Diana Montoya-Williams for a career as an independent clinician scientist. Her long-term career objectives are to contribute to the development of policies and interventions that diminish health disparities among pregnant minority women and their infants. Her immediate goal is to obtain the knowledge and skills to complete rigorous longitudinal studies of maternal-infant dyads aimed at defining assets that protect women against adverse neonatal outcomes. To meet these goals, Dr. Montoya-Williams and her mentor team have devised a career development plan that integrates: 1) intensive mentorship from successful investigators; 2) focused training in longitudinal cohort and statistical path analyses; and 3) innovative research on the relationship between resilience, stress and adverse neonatal outcome disparities. Research: Significant racial, ethnic and nativity-related disparities exist for birth weight, gestational length and breastfeeding in the U.S. and have major implications for our elevated infant mortality rates. Maternal psychosocial stress has been linked to these adverse neonatal outcomes and is disproportionately experienced by minority women. Resilience is the ability to respond to stress and appears to change in the face of stressors. Higher resilience has been linked to improved outcomes in conditions like diabetes and cardiovascular disease; there is also evidence that resilience can be improved. However, our knowledge of resilience in pregnancy is scarce and a major limitation is the cross-sectional nature of existing data. It is not clear whether resilience changes through the course of pregnancy and whether it modifies the relationship that exists between maternal stress and adverse neonatal outcomes. In addition, resilience may vary by race, ethnicity and nativity but data is limited. Dr. Montoya-Williams’ mentored research will address these key knowledge gaps. By creating a diverse longitudinal cohort of pregnant women, she will: 1) explore the association between resilience, three different types of perceived self-reported stress (acute, intermediate chronic and remote traumatic) and the physiologic manifestations of stress (i.e. allostatic load) at the onset of pregnancy; 2) describe whether resilience measured repeatedly in pregnancy changes in response to acute pregnancy-related stressors; and 3) investigate associations between the trajectory of resilience in pregnancy and adverse neonatal outcomes. Importantly, she will describe any differences that may exist in these relationships for women of different ethnoracial and cultural backgrounds. Summary: Findings from this study will inform an R01 proposal to test resilience interventions that may mitigate the stress-related drivers of neonatal health disparities. Through this award, Dr. Montoya-Williams will also emerge as a leading independent clinician scientist contributing to the amelioration of neonatal racial/ethnic health disparities.

NIH Research Projects · FY 2025 · 2021-05

PROJECT SUMMARY Acute respiratory distress syndrome (ARDS) is characterized by severe hypoxemia and pulmonary edema not fully explained by cardiac dysfunction or fluid overload. This syndrome affects 45,000 children annually in the United States; the mortality rate is 20% in the United States and 30% worldwide. Pediatric ARDS morbidity and mortality are primarily mediated through cardiovascular dysfunction with subsequent organ failure rather than lung injury itself. There are no specific pharmacologic therapies for adult or pediatric ARDS despite numerous trials that have mainly targeted improving oxygenation. Pediatric ARDS pathophysiology itself and treatments such as high positive end-expiratory pressure and permissive hypercapnia contribute to the development of pulmonary vascular dysfunction (leading to pulmonary hypertension) and right ventricular systolic dysfunction (RV dysfunction). Pulmonary hypertension is a risk factor for RV dysfunction and RV dysfunction causes impaired systemic cardiac output and, therefore, exacerbates multi-organ dysfunction. Thus, studies to define the roles of pulmonary hypertension and RV dysfunction in ARDS outcomes are needed. Two-dimensional speckle tracking echocardiography (or strain echo) is a sensitive indicator of RV dysfunction. Recent evidence suggests that RV dysfunction (as measured by strain echo) and pulmonary hypertension are associated with worse patient outcomes in pediatric ARDS. In addition, plasma-based biomarkers of RV dysfunction and pulmonary endothelial injury may help to detect and predict these cardiovascular abnormalities. The proposed study leverages existing infrastructure at the Children’s Hospital of Philadelphia and University of Pennsylvania to conduct a prospective longitudinal cohort study using serial echocardiography and plasma biomarker assessments over the first week following pediatric ARDS onset. A diverse and experienced mentorship and collaborative team, with expertise in translational and clinical research, has been assembled. They will provide guidance for the candidate through a rigorous training plan involving research conduct, didactics in advanced epidemiological analyses, training in echocardiographic methods, and intensive mentorship. The proposed studies will define the clinical impact of RV dysfunction and pulmonary hypertension and investigate the role of a novel biomarker of pulmonary endothelial damage in 250 patients with pediatric ARDS. Given the importance of cardiovascular dysfunction in pediatric ARDS outcomes, cluster analyses will be used to classify patients into cardiovascular subphenotypes that will be used in future studies for risk stratification and to test targeted therapies to improve patient outcomes. Finally, the candidate will gain the necessary training in clinical research, echocardiography, and biomarkers to mature into an independent clinician-scientist working to improve outcomes for critically ill and injured children.

NIH Research Projects · FY 2025 · 2021-04

PROJECT SUMMARY / ABSTRACT The school is a key setting for the delivery of mental health services to children. School-wide positive behavior interventions and supports (PBIS), a service delivery strategy based on the public health model, is a useful vehicle for implementing mental health EBPs. In PBIS, schools implement universal (Tier 1) interventions to improve school climate and safety, and can employ targeted (Tier 2) group interventions for children with or at risk for mental health disorders. Very little research has been conducted on using mental health EBPs at Tier 2. Adequate and ongoing training opportunities are frequently identified as “essential practices” needed to successfully sustain the benefits of interventions. School personnel, with or without prior mental health training, can implement Tier 2 interventions with fidelity and clinical effectiveness when provided adequate support. School mental health programs that successfully implement targeted group interventions often use ongoing supervision from internal supervisors. A number of studies have shown that more experienced school personnel can successfully be trained to serve as coaches and supervisors for those implementing EBPs. In order for these schools to receive the potential public mental health benefits of targeted mental health interventions in schools, an efficient, scalable, cost-effective and sustainable model of training and consultation that can be transferred from experts to school coaches and from coaches to EBP implementers is needed. Little is known about which models of support for sustainment are effective, feasible, and cost-effective. The aims of the study are (a) to compare fidelity, cost-effectiveness, and student outcomes of Tier 2 mental health interventions across 2 sustainment conditions, (b) assess mediators and moderators of consultation support on implementation fidelity, and (c) assess perceived feasibility and acceptability of consultation support. The study proposes to use a 2-arm, randomized controlled trial, Type 2 Hybrid cluster randomized design. Sixty school personnel from 12 schools will receive full initial implementation support for 1 year and then will be randomly assigned to receive one of 2 sustainment conditions: (a) remote consultation provided by school district coaches who themselves will be receiving remote support from expert external consultants (Sustainment 1 [S1]); and (b) consultation as usual provided by district coaches with no external support (Sustainment 2 [S2]). S1 will have a period of diminished support followed by a period of no support. The interventions to be implemented by school personnel are EBPs for the most common externalizing and internalizing mental health disorders. Our guiding framework is the Interactive Systems Framework (ISF) for dissemination and implementation research. The results of the proposed study will provide a scalable and cost- effective strategy for the sustainment of PBIS mental health supports in under-resourced schools.

NIH Research Projects · FY 2025 · 2021-04

Modified Project Summary/Abstract Section Difficulties with emotion expression and social behavior characterize multiple psychiatric conditions and negatively impact child development. However, existing measurement tools for indexing social-emotional function are imprecise and subjective, or require specialized training that is costly and time-intensive, prohibiting widespread implementation. The imprecision of existing tools has a major negative impact not only on research, but on the ability to assess and treat individuals with mental health concerns. Here, we propose to address this problem by quantifying social and emotional behavior using novel biobehavioral markers derived from computer vision (facial expression analysis) and computational linguistics (social/sentiment analysis). Our team has successfully used these markers to predict the presence of autism spectrum disorder (ASD) with 91% accuracy. In this proposal, we determine the extent to which our markers can serve as continuous measures of social behavior and negative emotion to advance clinical phenotyping and interventions. The proposal brings together two high-bandwidth clinical research programs at the Children’s Hospital of Philadelphia and Baylor College of Medicine to collect data on 750 adolescents (ages 12-17 inclusive) with ASD, a primary anxiety or depressive disorder, or without any developmental/psychiatric condition. At a single assessment, all youth will participate in an extensive clinical phenotyping battery consisting of validated clinical interviews and child-/parent-report scales assessing converging and diverging mental health constructs, and three tasks eliciting positive/negative emotion, social stress, and mild frustration. A subsample of 150 adolescents will be reassessed 6-10 weeks later to allow retest/stability analyses. A novel camera apparatus will capture naturalistic synchronized verbal and nonverbal signals from dyads. Our analytic approach combines state-of-the-art machine learning, computational linguistics, and computer vision – including facial emotion recognition methods that rival several commonly used alternatives. The ultimate goal of this proposal is to develop valid and objective measures of the Social and Negative Valence Systems using novel biobehavioral markers in a large transdiagnostic sample of youth. Secondary goals are to develop easy-to-follow methods to widely disseminate our tools and procedures, and to characterize individual variability in these key RDoC metrics by age, sex, and diagnosis. The achievement of these goals will provide researchers with sorely needed measures of social and emotional behavior, and provide clinicians with a new set of tools for identifying and tracking youth in need of mental health treatment.

NIH Research Projects · FY 2025 · 2021-03

Project Summary Neuroblastoma (NB) remains one of the deadliest childhood cancers. NB exhibits a paucity of recurrent protein coding mutations and few targetable mutations (2-5), providing the rationale for this proposal. Noncoding variants can disrupt regulatory and/or structural DNA leading to dysregulated transcriptional programs that promote tumorigenesis. Our objective here is to identify noncoding variants and mechanisms that drive NB. Our central hypothesis is that germline variants and somatic mutations within noncoding regulatory regions of DNA potently influence NB initiation, progression and/or disease relapse. We will test our hypothesis in three specific aims: 1) Define and evaluate differences in the epigenomic landscape of NB and NB precursor cells. First, a panel of genetically diverse human-derived NB cell lines and neural crest cells (NCC; NB precursor cells) will be characterized. 3D chromatin architecture at all promoters will be ascertained using an ultra-high-resolution promoter-focused Capture C approach. Cells will be further profiled by whole genome sequencing (WGS), RNA- seq, ATAC-Seq, and ChIP-seq for histone marks and key structural proteins. Evolution of the epigenomic landscape from NB precursor to NB cells will be assessed. Data will be integrated with transcription factor binding site functional predictions to provide a comprehensive resource for the interpretation of noncoding variants. 2) Identify germline noncoding variants influencing NB tumorigenesis. We will perform variant-to-gene mapping at NB susceptibility loci identified by GWAS and identify putative causal variants mapping to open chromatin and involved in chromatin interactions in NB precursor or NB cells. Next, rare germline noncoding mutations from WGS will be assessed in a similar manner to identify variants interacting with known cancer predisposition genes. Further in silico prioritization will be accomplished via clinical correlative and integrative host-tumor analyses. The mechanism by which top prioritized noncoding variants promote NB will be determined using genetic manipulation in cell models in combination with Capture C, ChIP-seq, RNA-seq and/or functional studies. 3) Discover and assess biological relevance of somatic noncoding drivers of NB. We will integrate WGS of diagnostic and relapsed NB tumors to identify noncoding mutations affecting regulatory DNA and chromatin interactions in NB genomes. Recurrent variants will be further characterized through integration with matched RNA-seq (n=443), DNA methylation (n=223) and clinical correlative studies. We will elucidate biological relevance of prioritized mutations via massively parallel reporter assay (MPRA) coupled with CRISPR-based genetic manipulation in cell models in combination with Capture C, ChIP-seq, RNA-seq and/or functional assays. This work will have a sustained and positive impact on the field by providing substantial insights into the role of the noncoding genome in this important childhood cancer, and has the potential to inform development of clinical biomarkers and/or evidence-based therapies to improve outcomes of children with NB.

NIH Research Projects · FY 2025 · 2021-02

Project Summary Interleukin-2 is a potent T cell growth factor with crucial roles in both immunity and self-tolerance. Genome-wide association studies (GWAS) in humans have shown that genetic variation at the IL2 and IL2RA loci influence susceptibility to multiple immune-mediated diseases including allergic asthma, systemic lupus erythematosus, and inflammatory bowel disease (IBD), identifying this as a key molecular axis that controls immune activity. However, mechanistic basis of disease risk for these polymorphisms is poorly understood. We have new evidence that the cis-regulatory architectures of IL2 and IL2RA extend much further from the gene than previously appreciated, encompassing regions harboring known disease-associated variants, and we hypothesize that polymorphisms within these elements control the level and timing of IL-2 and IL-2RA expression to control the balance of tolerance vs. inflammation. In this application, we propose a comprehensive screen for potential cis-regulatory elements that interact with the IL2 and IL2RA genes using state-of-the-art epigenomic approaches like ATAC-seq and Capture-C-seq. We will establish how these elements contribute to IL2 and IL2RA gene expression using powerful, CRISPR/CAS9-based genome editing approaches. To study the impact of disease-associated genetic variation at these regulatory elements on immune function in in vivo systems, we will analyze the responses of genetically characterized subjects curated from the Benaroya Research Institute biorepository, and create mice in which orthologous murine Il2 and Il2ra enhancer sequences have been replaced with human risk alleles, assessing the disease susceptibility in models of allergic asthma, SLE and IBD. Our studies will provide comprehensive maps of the transcriptional architecture of IL2 and IL2RA, insights into the molecular basis for the genetic association of IL2 and IL2RA with autoimmune disease, and may guide the design of new approaches for the treatment of organ transplant rejection and inflammatory disease.