Children'S Hosp Of Philadelphia

NIH Research Projects · FY 2026 · 2024-04

Abstract We propose to use third generation, long-read sequencing (LRS) to resolve inconclusive diagnoses and maximize the diagnostic yield in patients with suspected Mendelian disorders. The diagnostic yield of whole exome and genome sequencing stands at 40-50% including a significant proportion of patients receiving an inconclusive diagnosis. The limitations of the current short-read technologies can be attributed to the negative and inconclusive molecular diagnoses that prevent us from maximizing the diagnostic yield. Also, the vast majority of the patients undergo a long diagnostic odyssey due to the practice of sequential testing paradigm. In the proposed study, we will perform LRS in a cohort of patients with heterogenous pediatric disorders to resolve a) inconclusive diagnoses in patients with a single disease associated variant in an autosomal recessive disorder gene, and two disease associated variants in the same gene with unknown phase, and b) variants of uncertain significance or variant of unknown parent-of-origin in patients with epigenetic or imprinting disorder. We will determine the diagnostic utility of LRS and its impact on uncertainty in diagnoses against the current standard of care exome/ genome sequencing. We will build upon the existing resources of our clinical lab and our own cutting-edge genomic and bioinformatic capabilities. We anticipate that our studies will contribute new knowledge about the increased diagnostic yield from resolution of inconclusive diagnoses and lead to the faster adoption of long-reads in clinical settings.

NIH Research Projects · FY 2026 · 2024-02

PROJECT SUMMARY The Penn-CHOP proposal builds on collaborations and complementary expertise in phenomics and genomics. The 22q11.2 deletion syndrome (22qDS) is associated with high risk for neuropsychiatric disorders across the lifespan. The clinical presentation and course are markedly heterogeneous, with a range of developmental neuropsychiatric disorders, including ADHD, Anxiety, ASD, and Psychosis Spectrum Disorders. Notably, presentation and course resemble idiopathic disorders. Therefore, beyond the specific genetic syndrome investigated, the proposed accelerated longitudinal design will identify convergent risk mechanisms for developmental trajectories of neuropsychiatric disorders in the broader population. We are uniquely positioned to establish developmental trajectories during a critical period, adolescence and emerging adulthood. Lacking in the literature of 22qDS is a systematic examination of environmental exposures, which play an important role in psychopathology and neurocognition in the general population. The nature and degree of medical burden have likewise not been examined in 22qDS. Taking a ‘genetics first’ approach of ascertainment based on a known deletion will allow us to overcome barriers posed by the genetic and phenotypic complexity of idiopathic developmental neuropsychiatric disorders. We postulate that 22q11.2 deletion exerts a large main and multifactorial effects on psychopathology, with contributions from multifaceted environmental exposures and common and rare genetic variants. Dissecting these effects with dimensional measures of psychopathology and neurocognition can elucidate the combined contribution of genetic and environmental mechanisms to psychiatric conditions and build models of risk prediction. Our ability to pursue such a large-scale study capitalizes on our existing successful collaborations, complementary expertise, and institutional commitments to achieve these goals. We propose to parse dimensional measures of psychopathology, neurocognition, and environmental exposures, to elucidate the architecture of risk for neuropsychiatric disorders in 22qDS focusing on the emergence of psychosis. Prospective evaluation with dimensional measures relevant to neuropsychiatric disorders will be applied to a cohort of 300 individuals with 22qDS and their parents, establishing trios. Thus, we will examine family and environmental factors that can contribute to the heterogeneity of presentation and developmental course in 22qDS. Recruitment for longitudinal prospective phenotyping will leverage an existing large cohort with a wealth of clinical data, many of whom have already been ascertained and comprehensively characterized with a range of phenotypic measures. We will also utilize existing genetic data from the largest available case-control samples in the PGC to generate polygenic risk scores for the most common neuropsychiatric disorders evident in 22qDS and examine their relation to outcome. This project will contribute to common phenomic and genomic resources established for data sharing.

NIH Research Projects · FY 2026 · 2024-02

PROJECT SUMMARY For youth with chronic kidney disease (CKD), cardiovascular disease (CVD) is a leading cause of morbidity and early mortality. Youth with CKD are less physically active than their healthy peers. They also have lower muscle strength, which may be a proxy for overall physical inactivity or could represent an independent predictor of CVD. Physical activity is a well-recognized determinant of health and quality of life, but physical activity’s effects on muscle strength may be compromised in CKD. Characterizing the relationships between physical activity, muscle strength and CVD can inform potential therapeutic targets to improve cardiac outcomes. Identification of effective strategies to increase physical activity, and the extent to which physical activity and muscle strength mitigate CVD complications are major knowledge gaps in pediatric CKD research. Aim 1 will test the efficacy of a 12-week physical activity intervention in 64 adolescents with CKD. Guided by the Multiphase Optimization Strategy (MOST) framework, an optimization trial will identify intervention components that increase average daily moderate to vigorous physical activity by 15 min/day, a clinically meaningful increase. The components will be grounded in established behavioral change theories and be delivered via Way to Health, a web-based platform, to overcome barriers at the point of clinical care where time and resources are limited. Aim 2 will leverage existing longitudinal data from the Chronic Kidney Disease in Children Study (CKiD) to determine the extent to which physical activity and muscle strength mitigate CVD complications. This aim will quantify the associations of self-reported physical activity and hand grip strength, a validated proxy of muscle strength, with early changes in cardiac structure and function: left ventricular hypertrophy and diastolic dysfunction. Left ventricular hypertrophy, defined by an elevated left ventricular mass index, is the most common cardiac abnormality in children with CKD and is the strongest predictor of sudden cardiac events in adults with CKD. Diastolic dysfunction occurs early in pediatric CKD and associates with death in adults with CKD. These aims will advance knowledge by identifying the optimized digital-based intervention components, specific to youth with CKD, to increase physical activity and by quantifying the impact of physical activity and muscle strength on CVD. They are responsive to the NIDDK Strategic Plan for Research by utilizing 1) technology to improve access to participants; 2) an innovative trial design; 3) direct participant feedback to engage stakeholders; and 4) data from an existing NIH-funded cohort study. Within the outstanding research environment of The Children’s Hospital of Philadelphia and the University of Pennsylvania and under the mentorship of Drs. Sandra Amaral, Babette Zemel, and Knashawn Morales, this K23 provides training in longitudinal data analysis, health behavior science, and clinical trial design and analysis, incorporating digitally based tools. This will launch the PI’s career as a pediatric nephrology researcher with unique expertise in health behavior change and digital-based interventions to improve the health and longevity of youth living with CKD.

NIH Research Projects · FY 2026 · 2024-02

PROJECT SUMMARY Several members of the orthopoxvirus (OPXV) genus, including variola (the cause of smallpox), monkeypox virus (MPXV) and camelpox virus (CMPV) pose serious threats to human health, while the ultimate impact of emerging OPXVs of concern such as Alaskapox virus (AKPV) is unknown. Other OPXVs are highly pathogenic in their natural hosts, including ectromelia (ECTV), the cause of mousepox - a disease with many similarities to smallpox. It is concerning, then, that the extreme virulence typical of the OPXVs remains poorly understood. Central to OPXV virulence are the virus-encoded proteins that impede host defenses. This proposal focuses on members of the B22 family of OPXV immunoevasins due to their potency, complexity and limited characterization. With respect to potency, MPXV197 significantly enhances mortality in a nonhuman primate model, and ECTV C15 alone determines whether ECTV is 100% lethal or 100% survivable in a BALB/c mouse infection model. With respect to complexity, B22 family members are exceedingly large (~1900 aa), highly homologous multimembrane-spanning glycoproteins. We have observed that C15 is novel in targeting both adaptive and innate host responses, preventing activation of CD4+ and CD8+ T cells (TCD4 and TCD8), and interfering with the ability of natural killer (NK) cells to engage infected cells. Other B22 members have been implicated in hindering only TCD4 and/or TCD8 function; however, given the high degrees of homology, we suspect common functionalities, including targeting of NK cells. With respect to limited characterization, essentially no structure/function studies have been done with any B22 member. Through application of such studies to B22 members, key insights into OPXV virulence will be gained, potentially leading to novel therapeutic strategies and enhanced general principles of viral virulence. Guided by published and preliminary data, we propose a model in which topologically complex B22 members contain two functional subunits created by posttranslational cleavage: 1) an upstream (N-terminal) subunit that interferes with NK cell recognition via an MHC class I-like structure. 2) a C-terminal subunit that inhibits conjugation of TCD4 and TCD8 with their cognate targets. This model will be tested by pursuing three complementary aims that: 1) reveal the structural properties of B22 members, 2) identify and map the functional activities of B22 members, and 3) elucidate the viral and cellular binding partners of B22 proteins. The value of these studies derives from: a) the significance of many OPXV members as human pathogens, b) the potency of B22 members as virulence factors, c) the enigmatic immunoevasion activities of B22 members, and d) the potential for the proposed work to lead to new insights into virus:host interplay, the development of novel antiviral strategies and many future lines of investigation, including elucidation of the advantage to aggregating innate and adaptive immunoevasion activities into a single protein.

NIH Research Projects · FY 2025 · 2024-02

PROJECT SUMMARY The objective of this proposal is to gain a deeper understanding of the genetic programs that give rise to the development of specialized areas within the human cerebral cortex. Abnormalities in cortical development can lead to a wide range of neurodevelopmental disorders, which often affect different cortical areas differently. Despite of its significance, the process by which specialized areas develop remains poorly understood. This proposal aims to address this gap of knowledge by studying primary tissue and human stem cell-derived brain organoids. The first aspect of the research will utilize spatially resolved transcriptome analysis to examine human fetal cortex samples from multiple areas and embryonic ages, to identify the genes that are involved in area-specific neuronal fate specification. The second part will focus on developing the method for inducing areal identities in human brain organoids by pharmacological manipulation of signaling pathways, serving as a model for how morphogens induce area-specific cell fates in vivo. The proposed aims are attainable due to the strong background of the candidate and supportive environment provided by the mentor’s laboratory and the institution. The anticipated outcome of this research will be new insights into the principles of human cortical development, which could shed light on the etiology of neurodevelopmental disorders and ultimately transform our understanding of cortical development in health and disease. The candidate’s career goal is to become an independent researcher in an academic institution, leading a research program that utilizes human stem cell models and neurogenetics approaches to study neurodevelopmental disorders. The candidate’s prior research in the development and application of organoids as model for human brain development and diseases sets a strong foundation. The proposal outlines a comprehensive plan for scientific and professional growth that encompasses hands-on training, didactics, and mentorship. Key scientific training goals include acquiring expertise in single-cell bioinformatics, spatial transcriptomics, disease genetics analysis, and conducting rigorous optimization of organoid protocols. Additionally, the candidate will engage in structured trainings in career development to facilitate independence. The candidate will be mentored by Dr. Christopher Walsh, a renowned neuroscientist who has mentored dozens of successful independent investigators. The candidate will also benefit from the support of an advisory committee with complementary expertise. The mentored phase of the proposal will take place in the laboratory of Dr. Walsh at Boston Children’s Hospital and Harvard Medical School, known for providing exceptional research and training environments. The proposed training and research will provide the candidate with the necessary resources and support to establish a thriving independent research program.

NIH Research Projects · FY 2025 · 2024-01

PEDSnet Scholars: A National Pediatric Learning Health System Embedded Scientist Training and Research Program SUMMARY Creating integrated learning health systems (LHSs) that improve child health will require a new generation of pediatric scientists with diverse backgrounds who will be embedded in healthcare organizations’ clinical and research operations. We propose to address this need by creating a Pediatric LHS Embedded Scientist Training and Research Center. The Center will be integrated within PEDSnet, a PCORnet Clinical Research Network and a national pediatric LHS with 11 institutional members that provide care for 10% of the nation’s children. The Center will extend and enhance the successful PEDSnet Scholars program, which is an AHRQ LHS Center of Excellence (K12) and has trained 29 junior faculty. The aims for the Center are: Aim 1 (Center Organization and Integration): Establish a national, pediatric embedded LHS scientist training and research center with administrative, education and training, research and data analysis, and scientist development cores; Aim 2 (Scholar Development): Select, retain, and mentor a diverse cadre of pediatric scientists, called PEDSnet Scholars, who are within 5 years of their initial academic appointment or those making a mid-career transition, creating a community of national leaders who will help realize the promise of LHS science for children; Aim 3 (Education Program): Deliver a core curriculum that builds competence in LHS science with an emphasis on authentic stakeholder engagement and patient- centered outcomes research; Aim 4 (Research Support): Provide project management, engagement, methodological, and dissemination and implementation resources and support to PEDSnet Scholars and their research projects; and, Aim 5 (Program Evaluation): Evaluate the impact of the Center and its activities on scientists’ professional development and patient and system outcomes. We anticipate using AHRQ/PCORI funding for 14 individuals and up to an additional 16 can be funded by their institutions. Scholars will conduct projects that are meaningful, impactful, and outcomes-focused addressing health and healthcare challenges facing children, their families, and the health systems that serve them. We have added a Scientist Development Core, which will implement an innovative Diversity Plan, mentoring, and all activities related to Scholar professional development. The three MPIs have complementary expertise and are national leaders in LHS science, multi-institutional research, faculty training, enhancing workforce diversity, and the science of health equity. The PEDSnet Scholars working within the Center will become institutional and national leaders in advancing outcomes and the leaders who will forge the national pediatric LHS system of the future. The PEDSnet Scholars program is not a project for PEDSnet or its member institutions; it is part of a strategic campaign to create an integrated LHS for the nation’s children.

NIH Research Projects · FY 2025 · 2023-12

PROJECT SUMMARY Brain tumors are the most common form of cancer in children between 0-19 years of age in the United States, and are the largest cause of cancer-related deaths. Our long term goal is to improve the outcomes of children diagnosed with brain tumors by characterizing the germline and somatic events driving tumorigenesis so that rational, evidence-based therapies can be developed. Our objective here is to perform an integrative germline- tumor analysis of the Gabriela Miller Kids First (GMKF) X01 CA267587 pediatric brain tumor cohort to identify both inherited and de novo pathogenic or likely pathogenic (P-LP) genetic variants that may be exploitable for subtyping, risk prediction, and/or therapeutic intervention. Data from the GMKF cohort will be combined with extant sequencing data from the Pediatric Brain Tumor Atlas (PBTA) to yield 3,849 germline DNA and 4,438 tumor DNA/RNA sequences. The combined cohort spans seventeen broad histologies and includes robustly- annotated patient-parent triads/dyads (n=771). Our central hypothesis is that both inherited and de novo P-LP germline variants influence the initiation and progression of pediatric brain tumors. Here, we will test our hypothesis and accomplish our objective in two specific aims: Aim 1) Identify and assess heritability of rare P-LP variants in pediatric brain tumor triads and dyads. Rare single nucleotide variants (SNVs) and insertion- deletions (INDELS) will be investigated through a well-developed computational pipeline. Pathogenicity will be assessed using our American College of Medical Genetics (ACMG)-guided approach. Triad/dyads will be studied to assess whether variants are inherited or acquired de novo. Rare variant burden testing will be performed through comparison to multiple cancer-free cohorts. Clinical and tumor-biological correlative studies and survival analyses will be undertaken. Aim 2) Perform integrative tumor-normal analyses to elucidate functional relevance of germline P-LP variants. Somatic second hits at the gene and pathway level will be assessed for the entire cohort (N=2,558). Next, using pediatric high-grade glioma (pHGG) as a model, an expanded integrative in silico evaluation of recurrent or aggregate germline events using matched tumor DNA and RNA sequencing will be performed (N=367 pHGGs). Germline copy number variants (CNVs) will be identified and heritability assessed. Tumor sequencing data will be processed through OpenPBTA somatic workflows designed to evaluate SNV, INDELS, structural variants (SVs), and mutational signatures in DNA and account for expression profiles, isoforms, fusions and other novel transcripts in RNA. Through integration of the X01 CA267587 pediatric brain tumor cohort with extant childhood cancer and structural birth defect data, we expect to advance our understanding of the genetic basis of a diverse array of pediatric brain tumors, with insights here being applicable to the genetic basis of other childhood conditions. Moreover, we will address, for the first time, whether pediatric brain tumor genetic risk factors are inherited or acquired de novo. Completion of this project will have a sustained and positive impact on the field by identifying clinically actionable genetic alterations in these important cancers.

NIH Research Projects · FY 2024 · 2023-09

PROJECT SUMMARY/ABSTRACT Addressing both care coordination needs and unmet social needs for children with chronic conditions is a high- priority goal for the United States health care system. Many children with chronic conditions live in poverty and have associated unmet social needs, such as food insecurity and housing instability, which can limit their access to care and lead to poor health outcomes. Their caregivers must navigate both complex health care systems and complex social service systems to access resources their children need to stay healthy. In my preliminary studies, I found that 51% of caregivers of children hospitalized with multiple chronic conditions reported having unmet social needs, and these caregivers expressed a desire for longitudinal care coordination support and assistance addressing their social needs after hospital discharge. In addition, I found that care coordination burdens disproportionately impact low-income, Black, and Hispanic children and are associated with forgone health care, perpetuating inequities in child health outcomes. To promote health equity and increase access to high quality medical care for low-income children with chronic conditions, there is an urgent need for effective family-centered interventions addressing both care coordination needs and social needs. Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized, theory-based, community health worker (CHW)-led approach to addressing care coordination needs and social needs for low-income adults with multiple chronic conditions. The intervention builds on CHW's lived experience and expertise and their unique ability to serve as a bridge between health systems and communities. IMPaCT includes three key components: (1) development of a detailed, patient-centered care plan, (2) longitudinal support focused on addressing medical and social needs, and (3) connection with needed follow-up care. In multiple randomized controlled trials in adults, IMPaCT has been found to improve patient-reported quality of care while reducing acute care utilization. The goal of this application is to target, develop, and test a pediatric adaptation of IMPaCT targeting both care coordination needs and social needs for hospitalized children with multiple chronic conditions. My specific aims are to 1) Identify social needs that are associated with decreased access to preventive care and increased acute care use among hospitalized children with complex chronic conditions, 2) develop an adapted IMPaCT intervention for pediatric patients with complex chronic conditions and unmet social needs, and 3) determine feasibility and acceptability and assess preliminary efficacy of the pediatric IMPaCT intervention. This work is relevant to Special Emphasis Notice (SEN): NOT-HS-21-014: Health Services Research to Advance Health Equity, given its focus on adapting and implementing an evidence-based intervention to advance equity within healthcare delivery systems, care delivery for persons with multiple chronic conditions, and integration of social determinants of health and social needs care within healthcare delivery.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY DNA modifications, such as 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) on DNA, as well as RNA modifications, such as N6-methyladenosine (m6A) on mRNA, have been implicated in gene regulation and human diseases. Synthetic base analogs, such as BrdU, EdU and IdU, have been used as genomic markers to study fundamental biological processes. However, conventional approaches to detect DNA/RNA modifications rely on indirect readout (such bisulfite treatment or immunoprecipitation), cannot assay repetitive regions (due to the use of short reads), and suffer from various technical biases. While direct DNA/RNA sequencing on the Oxford Nanopore platform can address these technical limitations, there is an urgent need to develop reliable bioinformatics methods to detect common DNA/RNA methylations from ionic current data, with the ability to extend to rare forms of modifications. We have years of dedication to the development of computational tools for signal-level analysis of long-read sequencing data. We developed NanoMod which detects synthetically introduced DNA modifications into replicating cells, and DeepMod which uses a deep neural network to predict 5mC directly from ionic current signals from Nanopore sequencing. In the current proposal, we will: (1) Develop LongReadSum, which will be implemented by multi-threaded C++ with modules for diverse formats (FASTA, FASTQ, FAST5, BAM, POD5, etc), for ultrafast quality control (QC) and signal summarization from Nanopore sequencing. The signal summarization procedure generates user-specified feature vectors that can be used by other downstream machine-learning tools for calling modifications. (2) Develop ModDNA, where we will use connectionist temporal classification (CTC) and transformers, two neural network models, to call modified bases such as 5mC, 5hmC and 6mA. Additionally, we will adapt the computational pipeline to reduced representation methylation sequencing (RRMS) data, which enables assaying a human genome in one single MinION flowcell. (3) Develop ModRNA, an integrative model which combines prior genomic features with context-dependent features (for example, enrichment in 3’ end of genes) for both de novo and model-based detection of RNA m6A modifications and other rare modifications. (4) Validate and improve the computational tools via benchmarking data sets. We will perform Nanopore DNA sequencing from cancer samples with paired methylation profiles from clinical diagnostic labs, as well as mouse reference cell lines with or without 5- Aza-2’-deoxycytidine (methylation inhibitor) treatment. We will perform direct mRNA sequencing on reference cell lines with or without METTL3/METTL14 knockdown, or with in vitro transcription, or with and without KSHV infection which alters epitranscriptomic profiles. Successful completion of the proposed project delivers a computational toolbox for DNA/RNA modification detection via Nanopore sequencing, provide reference datasets to the community, and greatly facilitates our understanding of the human epigenome and epitranscriptome.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT Microglia are the long-lived resident macrophages of the brain and spinal cord, which constantly survey the microenvironment to respond rapidly to injury and infection. Unlike neurons or other glia, microglia are transplantable, making them ideal candidates for targeted therapies to treat neurological diseases. A major barrier to creating and refining such treatments is an inability to genetically engineer microglia with lentiviruses. This proposal aims to identify and overcome microglia restriction factors to enable gene editing with lentiviruses and gain insights into microglia-mediated antiviral immunity. Aim 1 will test the hypothesis that cGAS/STING, a known anti-viral pathway, underlies microglial viral restriction using inhibitors and transgenic mouse microglia in vitro, with in vivo validation using a new microglia-specific Cre mouse. In Aim 2, I will perform an unbiased microglia-focused CRISPR knockout screen using newly created AAVs with microglia tropism to discover new anti-viral pathways that prevent lentiviral infection. Aim 2 demonstrates the first CRISPR screen in primary microglia. This Early Independence application offers a vision for my independent research program. It is based on a platform of microglia-based discovery tools I created over the last decade, and driven by my work as a pediatric neurologist who cares for children with neuroimmunological conditions including leukodystrophies and interferonopathies. It will provide new approaches to genetic targeting of microglia for neurotherapeutics, direct testing of microglia antiviral immunity, and will influence future directions related to the neurological sequelae of HIV latency and the pathogenesis of neuroimmunological disease.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY Neurodegenerative disorders remain a public health burden and lack effective treatments. Rare genetic disorders can cause neurodegeneration in children, which is particularly devastating. Regardless of whether rare or common, the mechanisms underlying neurodegeneration remain incompletely understood. For instance, why neurons may be more susceptible to cell death when a genetic mutation is present throughout the body? Such is the case in TBCK encephalopathy (TBCKE), a rare autosomal recessive disorder that causes developmental delay and neurodegeneration in children. We previously characterized the neurologic phenotype of Puerto Rican children with a homozygous null mutation (p.R126X) in TBCK, and later found mitochondrial respiratory defects and evidence for abnormal mitochondrial quality control (i.e. mitophagy) in patient-derived fibroblasts. Nevertheless, the (1) physiologic role of TBCK and (2) how TBCK-deficiency leads to mitochondrial dysfunction and neurodegeneration, remain unclear. Our data support that Tbck protein may be part of a novel mRNA transport complex (Five-subunit Endosomal Rab5 and RNA/ribosome intermediary- FERRY). This complex may attach to early endosomes to deliver RNA transcripts, and therefore contribute to newly synthesized proteins, to cellular compartments distant from the nucleus, such as axons. Deficits in RNA transport and local protein translation, particularly to distant axonal mitochondria, have been recently proposed as a novel mechanism underlying a common neurodegenerative disorder (ALS, amyotrophic lateral sclerosis). Hence, our central hypothesis is that neuronal vulnerability in TBCK-deficiency stems from impaired transport of mRNA and/or local protein translation disrupting mitochondrial function. We predict this leads to compartment-specific mitochondrial deficits, with distal axonal mitochondria being more susceptible to TBCK- deficiency than those in the neuronal soma. In Aim 1 we will test how TBCK-deficiency impacts mitochondrial function and mitophagy, using human iPSC-derived neurons (iNeu). Then in Aim 2, we will test how TBCK- deficiency may affect the function of the FERRY complex, by examining effects in the RNA transcriptome in a compartment-specific fashion (neuronal soma vs axons). We will also directly assay local protein synthesis to test if TBCK is leading to mitochondrial dysfunction because of impaired protein translation in axonal compartments. These experiments will address a gap in knowledge regarding the role of neuronal RNA transport defects in mediating neurodegeneration, how these defects may particularly impact mitochondria and the role that Tbck protein may play in the novel FERRY complex. Support from this R01 award will be instrumental in growing my independent research program as a physician-scientist in a superb institutional environment. It will also contribute to my long-term goal of untangling disease mechanisms of pediatric neurodegenerative disorders linked to mitochondrial dysfunction; in order to, ultimately, identify novel therapeutic targets.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY Two-thirds of lysosomal storage disorders (LSD) affect the brain, yet most LSD treatments do not improve central nervous system (CNS) symptoms. Several trials of brain-directed gene therapy have failed to show clinical benefit despite restoring protein expression in the CNS. Outcomes are especially poor in subjects who have developed neurologic deficits, suggesting rescue of expression alone may be insufficient to correct function once diseased neuronal circuits are established. In CLN3 Disease, a representative LSD and the most common cause of pediatric dementia, patients develop blindness, seizures, and dementia. Several CLN3 disease mouse models have been developed. While all recapitulate the storage accumulation seen in patients, behavioral phenotypes are subtle and variable. To overcome this limitation, we identified robust, reproducible phenotypes on network-level electrophysiology studies in two CLN3 models, a knockout and a human mutation model. Unlike histopathology, physiologic measures directly reflect function and, therefore, may be a better readout for therapy development. Our work suggests CLN3 disease, traditionally considered a degenerative disorder, disrupts early neurodevelopment, especially in the hippocampus, a vulnerable region in CLN3 disease. On in vitro voltage sensitive dye imaging (VSDI) and in vivo electroencephalogram (EEG) recordings, Cln3-/- mice have decreased excitability of the hippocampal dentate gyrus (DG), faster EEG background activity, and loss of hippocampal sharp wave ripples, oscillations that encode new memories. Also, DG neurogenesis is upregulated, perhaps as a compensatory mechanism, early (2mo) but not later (6mo) in disease. Similar network changes arise in other models of neurodegeneration including Alzheimer’s disease (AD). Deep brain stimulation of the entorhinal cortex has been shown to improve outcomes in mouse models of AD. Previously, we found that very early Cln3 gene replacement at p0 corrects network dynamics in a Cln3 knockout mouse. Our central hypothesis is that abnormal neuronal circuit development will limit the window of time, i.e. ‘therapeutic window’, when gene replacement will improve network physiology in CLN3 disease. Furthermore, we predict that altering activity in a key circuit could modify the therapeutic window and efficacy of gene therapy. Our Specific Aims are to: 1) define abnormal dentate gyrus development in CLN3 disease mice, 2) determine the therapeutic window for correction of hippocampal circuit dynamics by gene replacement, and 3) test if modifying entorhinal cortex activity alters circuit defects and response to gene therapy. In this way we will use CLN3 Disease as a representative LSD, to explore the relationship between network activity and response to gene therapy. Our long-term goal is to develop network-directed therapies that, when combined with gene replacement, improve outcomes in LSDs.

NIH Research Projects · FY 2025 · 2023-09

To end the HIV epidemic, we need integrated care models that address HIV and PrEP care, and co-existing substance use (SU) disorders that disrupt uptake and consistent use of effective interventions. The overarching goal of this R01 proposal is to conduct a randomized controlled trial to assess the ability of a Collaborative Care Prevention, Treatment, Navigation, Engagement, Resource (PrTNER) intervention to increase initiation of preexposure prophylaxis (PrEP) (for those at-risk for HIV) and decrease viral load (for those living with HIV) among young men through engagement in SU treatment. The Collaborative Care (CC) PrTNER is a multi-component intervention developed by members of our research team specifically for young men aged 15 to 29 who are at-risk for or living with HIV. This model moves beyond the individual to consider the broader context in which, substance use and HIV risk are (re)produced. Enhanced models that integrate SU treatment into HIV and PrEP primary care services (using a collaborative care approach that incorporates feedback from a psychiatrist and support from a peer coach) are needed to address the nuance of substance use in this population. We, therefore, are proposing to conduct a randomized trial to evaluate an integrated collaborative care model (CC PrTNER) using the following aims: Specific Aim 1: To compare the proportion of young men with co-existing SU at risk for HIV infection who initiate (start or restart) PrEP over the 12 months in the CC PrTNER arm versus standard of care (SOC). Specific Aim 2: To compare the proportion of young men with co-existing SU living with HIV infection who are HIV virally suppressed at 12 months in the Collaborative Care PrTNER arm versus SOC. Specific Aim 3: To compare the effect of CC PrTNER versus SOC on non-tobacco SU in young men with co-existing SU and examine the effect of change in SU on PrEP uptake and HIV viral suppression. This proposal directly addresses goals 1, 2, and 4 of the 2022 National HIV/AIDS Strategy to End the HIV Epidemic through: prevention, treatment, and addressing co-existing SU disorders through comprehensive integrated care delivery. It further can transform the adolescent, health department and Ryan White care settings serving young men through harmonization of PrEP, HIV and SU treatment care delivery and implementation of a collaborative care model to address the multi-level barriers that impede uptake and adherence.

NIH Research Projects · FY 2025 · 2023-09

There is a critical need to train the next generation of scientists and expand the workforce to improve care for children with kidney disease. Effective mentoring at early career stages is fundamental to successful career advancement in biomedical research. The candidate for this NIDDK Investigator Award to Support Mentoring of Early Career Researchers is Michelle Denburg, MD, MSCE. Dr. Denburg is an Associate Professor of Pediatrics and Epidemiology at the University of Pennsylvania Perelman School of Medicine (PSOM) and is a practicing pediatric nephrologist at the Children's Hospital of Philadelphia (CHOP). PSOM and CHOP offer an ideal setting for collaboration, mentorship, didactic training, and opportunities in patient-oriented research, and Dr. Denburg’s leadership roles and responsibilities are highly synergistic with the goals of this award. Dr. Denburg’s multidisciplinary research program is focused on managing complications of and improving health outcomes in childhood kidney diseases, including chronic kidney disease (CKD), glomerular disease, and kidney stone disease, with a particular interest in bone health and altered mineral and vitamin D metabolism. Her research includes analyses of large electronic health record databases, ancillary studies to existing NIDDK-funded prospective cohort studies, and observational, translational, and interventional patient-oriented studies. Dr. Denburg has a long-standing and demonstrated commitment to research and career mentoring. Over the past 13 years, Dr. Denburg has mentored over 40 individuals across multiple disciplines, institutions, and career stages. The majority of these individuals have continued their careers in academic medicine and remain engaged in research. With this award, Dr. Denburg aims to continue to provide effective mentoring in the conduct of rigorous patient-oriented pediatric research to early career researchers, with a focus on recruiting and mentoring individuals pursuing patient-oriented research in kidney disease. Dr. Denburg will pursue additional evidence-based training programs designed to reinforce and enhance skills in mentoring of early career researchers and fostering their transition to independence. She will develop sustainable mentoring approaches that contribute to the wider mentoring environment and expand training infrastructure and resources to promote research in kidney disease at CHOP and Penn. Dr. Denburg’s long-term career goals are to conduct interdisciplinary clinical and translational research that improves the health and well-being of children and young adults with kidney disease and to catalyze the careers of trainees to become independent investigators in kidney disease research. Support from the K26 award will help sustain her active mentoring program and expand her mentoring capacity to enable her to take on 1-2 new postdoctoral mentees and at least one predoctoral summer student each year of the proposed award.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT The overall objective of this K23 application is to provide support for the additional training and experience that the principal investigator, a pediatric endocrinologist and epidemiologist, needs to develop an independent, patient-oriented research program in hyperinsulinism. Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in infants and children. Onset of hypoglycemia in HI overlaps with a critical period of neurocognitive development that occurs in the first years of life. While children with HI are more likely to have neurocognitive deficits, little is known about the factors influencing trajectories of neurocognitive development in affected children. This project will: (1) identify neurocognitive trajectories in children with HI employing an accelerated longitudinal design, and (2) examine the relationship between timing of hypoglycemia exposure and neurocognitive outcomes through comparison of two clinical phenotypes of HI with natural variation in clinical course. To accomplish these aims a comprehensive neurocognitive battery will be administered at baseline and repeated at 1- and 2-years after baseline, to school-aged children with cured, focal HI (hypoglycemia exposure limited to early life), diffuse HI (early life and ongoing hypoglycemia exposure), and age, sex, and socioeconomic status matched healthy controls. The results of this project will fill critical gaps in knowledge about the impact of hyperinsulinemic hypoglycemia during periods of marked brain development and carry significant implications for clinical practice. This study may also have broad implications for other disorders associated with hyperinsulinemic hypoglycemia, including diabetes mellitus. The principal investigator will take full advantage of the rich scientific environment and outstanding resources afforded by the Children’s Hospital of Philadelphia and University of Pennsylvania to achieve her research and training goals. The proposal includes advanced training in longitudinal data analysis and longitudinal neurocognitive outcome assessment, which will be achieved through a combination of didactic coursework, practical research experience, and support form an expert, multidisciplinary mentorship and advisory team. The support of this K23 will enable the principal investigator to launch a successful career as an independent investigator dedicated to optimizing neurocognitive outcomes for children with hyperinsulinism.

NIH Research Projects · FY 2025 · 2023-09

Despite Graduated Driver Licensing (GDL), motor vehicle crashes remain a leading cause of death and injury for US adolescents. GDL typically applies to those <18 and restricts initial driving experience to lower risk conditions; however, these drivers <18 years enter licensure underprepared and have the highest crash rates. New evidence from our R21 showed an association between decreased crash rates and man- dated driver education and training in the context of GDL in Ohio, but few states require such training. In Ohio, which requires GDL and professional behind-the-wheel (BTW) training for licensure before 18 (those >18, exempt from GDL and training), those licensed <18 years demonstrate lower crash rates, higher licensing exam pass rates, and safer performance on a validated virtual driving assessment (VDA) than those licensed at 18. By contrast, Pennsylvania and most other states have no professional training requirements for young drivers, which can largely be attributed to the negative results of a randomized controlled trial (RCT) of pre- licensure training in DeKalb in 1983. Our Ohio results and major safety advances since DeKalb (GDL, stronger national driver training standards, and online training to address novice driver errors) moti- vated our proposed RCT of training (the 1st RCT in 3 decades). We propose a Phase III 3-arm RCT involv- ing 1000 adolescent novice drivers balanced by ages 16-18 years. With usual care in PA (GDL) as control, we will test 2 training interventions: Arm 2, ACCEL, an online training in hazard anticipation/response and atten- tion maintenance and Arm 3, 8 hours of state-of-the-art BTW training. We will examine 3 outcomes: (1) Smartphone-monitored driving from start of intervention period through 6 months post-licensure, (2) PA license exam result; and (3) VDA performance at licensure. Participants will be recruited from 5 Philadelphia-area practice sites (2 urban, 2 suburban, 1 rural) as part of routine adolescent care. All participants will undergo baseline assessment of driving performance (VDA) and a neurocognitive and personality battery. Aim 1: De- termine the effect of ACCEL or BTW training versus usual care on driving crash risk (e.g., rates of hard brak- ing) during the first 6 months post-licensure. Hypotheses: (1) Both ACCEL and BTW will reduce early licensure crash risk. (2) ACCEL will produce greater reduction in crash risk than BTW training because ACCEL targets skills that reduce crash risk. Aim 2: Determine the effect of ACCEL or BTW training versus usual care on skill acquisition. Hypotheses: (1) Both ACCEL and BTW will improve skill acquisition. (2) ACCEL will produce fewer errors on the VDA measure of skills than BTW; however, BTW may produce better license exam performance (e.g., parallel parking). Aim 3: Identify age-related risk factors for crashes that are resistant to training. Hypoth- eses: ACCEL and BTW will mitigate cognitive skills but will be less successful for impulse/personality differ- ences related to risky driving practices. The expected R01 results will directly inform policy and provide guid- ance for future clinical practice.

NIH Research Projects · FY 2025 · 2023-09

Summary The temporal and spatial distribution of signaling proteins is dynamically regulated by post-translational modifications (PTMs). PTMs such as phosphorylation, ubiquitination, or lipid modification dictate protein activities and access to substrates, thereby cellular outcomes. The precise control of signaling pathways is critical to normal hematopoiesis and aberrant signaling leads to malignant transformation of hematopoietic stem and progenitor cells (HSPCs). This application is based on our novel finding that FLT3 (FMS-like tyrosine kinase 3) is palmitoylated and disrupting palmitoylation of oncogenic FLT3 mutants changes their subcellular localization, rewires downstream signaling, and promotes leukemic progression. Internal tandem duplication within FLT3 (FLT3-ITD) is one of the most frequent mutations in acute myeloid leukemia (AML) and correlates with poor prognosis. While wildtype FLT3 receptor tyrosine kinase is activated at the plasma membrane to transduce PI3K/AKT and RAS/MAPK signaling, FLT3-ITD resides in the endoplasmic reticulum (ER) and triggers constitutive STAT5 phosphorylation. Mechanisms underlying this aberrant FLT3-ITD subcellular localization or its impact on leukemogenesis remain poorly understood. We discovered that FLT3-ITD is S-palmitoylated by the ZDHHC6 acyltransferase. Disruption of palmitoylation redirects FLT3-ITD to the plasma membrane and rewires its downstream signaling by activating AKT and ERK pathways in addition to STAT5. Consequently, abrogation of FLT3-ITD palmitoylation via ZDHHC6 depletion promotes FLT3-ITD surface expression, signaling, and increased leukemic progression in xenotransplanted mouse models. Furthermore, we demonstrate that FLT3 proteins are palmitoylated in primary human AML cells. Stabilization of FLT3-ITD palmitoylation by pharmacological inhibition of depalmitoylation synergizes with FLT3 tyrosine kinase inhibitor (TKI) gilteritinib in abrogating the growth of primary FLT3-ITD+ AML cells. The central goal of this grant is to define the molecular basis underlying the regulation of oncogenic FLT3 signaling by palmitoylation and explore its physiological and functional significance in myeloid malignancies. We propose to define roles of ZDHHC6 in FLT3-ITD palmitoylation in vivo in mouse models of myeloproliferative neoplasm (MPN) and AML. We will also identify depalmitoylase(s) for FLT3-ITD that modify FLT3-ITD localization, and activity using combinatorial approaches of targeted and unbiased chemical biology, molecular biology, and genetics. Moreover, we will explore the therapeutic potential of targeting FLT3-ITD depalmitoylation in primary human FLT3-ITD+ AMLs. We will investigate if inhibition of FLT3-ITD depalmitoylase enhances responses to TKI using primary human AML cells as well as patient-derived xenotransplant (PDX) models. These findings provide novel insights into lipid- dependent compartmentalization of FLT3-ITD signaling and suggest targeting depalmitoylation as a new therapeutic strategy to treat FLT3-ITD+ leukemias.

NIH Research Projects · FY 2025 · 2023-09

Tobacco use remains the leading preventable cause of disease and death in the US, and 40% of children are regularly exposed to the harms of secondhand smoke (SHS), most often from a household member who smokes. Pediatricians are uniquely positioned to help families to address smoking and protect children from SHS exposure, but appropriate treatments are rarely delivered to parents who smoke. Emerging clinical decision support (CDS) systems within electronic health records (EHRs), including those developed by this team, help pediatricians screen for SHS exposure, motivate parent treatment engagement, and prescribe and/or connect caregivers to tobacco interventions. Office-based approaches, however, focus only on caregivers attending clinic visits with their children, failing to reach additional household members who smoke, leaving many adults without access to evidence-based treatments and children continually exposed to detrimental effects of SHS. Thus, a major barrier to protecting children from SHS exposure and extending tobacco use treatment to adults who smoke is identifying an efficient and scalable method to engage all household members who smoke, not just parents who present to the pediatric clinic with the child. This proposal uses an innovative, multi-disciplinary research approach incorporating both population health and clinical informatics implementation strategies to overcome this barrier and systematically expand the reach of tobacco use treatment through pediatric healthcare settings. EHR-based informatics tools can efficiently identify additional household members who smoke and proactively offer tobacco treatment. Using a rigorous, 2-arm pragmatic randomized control trial within a large pediatric network comprising practices with high rates of Medicaid-insured children, we will compare a novel intervention using population health and clinical informatics implementation strategies vs. usual care to increase the reach and effectiveness of tobacco use treatments. We will use a Type 2 hybrid effectiveness-implementation design, measuring the clinical intervention's impact on priority outcomes and testing an implementation strategy. The specific aims are: Aim 1) To compare the reach of Refer2Quit - a proactive, population health and clinical informatics implementation intervention on tobacco use treatment engagement for household members who smoke vs. usual care; Aim 2) To compare the effectiveness of the Refer2Quit intervention for increasing quit rates among household members who smoke vs. usual care; and Aim 3) To study household member and pediatric patient characteristics that are associated with reach and effectiveness of Refer2Quit. This addresses a significant practice gap in the utilization of evidence-based treatments for tobacco. Leveraging the pediatric setting can increase access and use of evidence-based tobacco treatments. This proposal will yield a scalable strategy to address the impacts of tobacco use and SHS in families.

NIH Research Projects · FY 2025 · 2023-09

Project Summary One in 10 critically ill children in the ICU requires tracheal intubation (TI). TIs are hazard-prone procedures given that critically ill children who require TI often have limited oxygen reserve, challenging anatomy, and life-threatening hemodynamic instability. They are at the highest risk for Adverse Airway Outcomes [AAO]: Tracheal Intubation Associated Events (TIAE) and/or severe oxygen desaturation. Since 2010, the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative led by our team has demonstrated that children with AAO had significantly longer mechanical ventilation duration, longer ICU stays, and higher mortality. Our pediatric ICU Airway Bundle with bedside checklist reduced the AAO. However, substantial room for improvement still exists. In 2019, across 54 NEAR4KIDS pediatric ICUs, 24% of critically ill children requiring TI still experienced AAOs. To substantially improve the safety of high-risk TI for critically ill children, it is essential to facilitate bedside team performance with optimal technology and a human factors approach. Our overarching goal is to transform the safety and quality of TI in critically ill children across diverse pediatric ICUs. We will achieve this goal by implementing a digitalized Smart Checklist that has three specific features: prompts based on patient characteristics, direct display of difficult airway status and airway information from the electronic health record, and high-risk warning based on predictive analytics. We will characterize the impact of the intervention on work processes and systems (i.e., flow disruptions, workflow integration, teamwork, team leader’s cognitive taskload) to determine explanatory factors for the clinical impact (i.e., to understand how and why). We will implement a digitalized Smart Checklist across 6 Pediatric ICUs within NEAR4KIDS using a cluster-randomized design. Smart Checklist upgrades will take place over 12 months and will include digital conversion, the introduction of prompts, full EHR-integrated airway history display, and risk calculation. Our team of investigators includes an experienced EHR clinical decision support programmer for multicenter use with a robust track record of success. We developed a clear implementation plan. We will test the hypothesis: Smart Checklist implementation will reduce the occurrence of AAO by 27% (relative risk reduction, 6% absolute). In Aim 2, we will determine how and why the Smart Checklist implementation reduces the AAO at each ICU using an established human factors approach. Our findings will be widely applicable in any procedural safety with various provider skill levels, especially when and where the procedural risk is high.

NIH Research Projects · FY 2025 · 2023-09

Modified Project Summary/Abstract The broad, long-term objectives of this proposal are two-fold: 1) to provide high-quality mentoring to contribute to the career development of trainees from varying backgrounds and 2) to advance the quality, rigor and breadth of health outcomes research in transplantation and pediatric nephrology. For decades, it has been recognized that some children are less likely to receive kidney transplantation compared with others, especially from a living donor. Most published studies examining transplant access and outcomes have been limited in how they have measured social determinants of health (SDOH) and the majority of studies are descriptive with few providing actionable findings to overcome barriers to access. Further, proposed interventions are often targeted at the individual patient rather than the healthcare systems that contribute to access barriers. Another challenge to improving transplant access for all children lies in the limits of national data. Currently, national surveillance registries capture patients when they begin renal replacement therapy (United States Renal Data System) and when they are waitlisted or transplanted (Scientific Registry of Transplant Recipients), but not what happens during the time in between when patients must undergo transplant referral and evaluation to be deemed transplant eligible. Given this context, the transplant community has asserted a call to action to achieve access and outcomes in transplantation by improving rigor, quality and transparency in transplant-related health outcomes research. Dr. Amaral’s research proposal seeks to move from describing differences in access to improving transplant access and outcomes through research that leverages diverse study designs and varied data sources to identify potentially modifiable healthcare system barriers to transplant access. Two current projects will support this award. The REACH-TRANSPLANT study (R01 DK120886) examines differences that arise during recipient and living donor (LD) evaluation, LD selection, and LD follow-up related to healthcare system practices. The study has three aims and applies both primary and secondary data collection, large electronic health records, research cohort data and survey data. The second project, The House Calls Project, focuses on identifying and addressing adverse social determinants of health (SDOH) that interfere with pediatric kidney transplant evaluation completion. This study will use interview and survey data. These studies provide robust training opportunities in health outcomes research for Dr. Amaral as a mentor and for mentees across many levels and background, making this proposal ideally aligned with the overarching goals of the K26 award mechanism.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY In the prior work we have extended our multimodal magnetoencephalography (MEG) and magnetic resonance imaging (MRI) approaches and have shown that it is possible to model, or predict, the latency of the auditory evoked neuromagnetic field component, the M50, occurring approximately 50-100ms post stimulus in children, but delayed in ASD, and measured by magnetoencephalography (MEG), by using diffusion magnetic resonance imaging (dMRI) to quantify the microstructure of the auditory pathway white matter (in particular the thalamocortical acoustic radiations). While this approach accounted for more than 50% of the variance in typically developing controls, it was confounded by heterogeneity in a cohort of ~100children with autism spectrum disorder (ASD). However, this actually allowed identification of a sub-population of children with ASD whose M50 responses appeared as “outliers” to the TD model (i.e. “unpredictably long M50’s); interestingly, these children showed significantly lower levels of gamma-aminobutyric acid (GABA) estimated by advance magnetic resonance spectroscopy (MRS) than their ASD peers whose latencies were consistent with the TD model. Identification of this group has significant implications for treatment/intervention by identifying a biological basis for stratification (sub-population definition) and thus a putative biological target for intervention (as well as a means of defining an inclusion criterion for selecting that therapy). The present proposal extends this work to the scientifically and societally critical group of children with ASD with severe language and cognitive impairments, who are under-included in imaging research, but whose vital participation is made possible by a combined behavioral and technical protocol we have recently developed, called MEG-PLAN, and its MRI analog: MRI-PLAN. To ascertain the clinical and behavioral implications of delayed M50 brain responses, we also recruit children with mixed etiology intellectual and developmental disability (IDD), but not autism, and seek to identify the relative associations of language impairment, cognitive impairment and ASD diagnosis to the M50 latency delay and to investigate the biophysical underpinnings of these association with multimodal MEG, MRI and MRS. We also extend beyond examination of auditory response timing to probes of auditory and language neuronal circuitry via. oscillatory responses also detected by MEG and examine their relation to GABA levels as well as to clinical language assessment. Taken together, this proposal focuses on several levels of stratification to combat the formidable heterogeneity observed in ASD and, critically, employs state of the art multimodal methodologies, made feasible by the MEG-PLAN and MRI-PLAN protocols, in severely-impaired children with ASD (conventionally not included in such research) to assess generalization of observations across the broad autism spectrum.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT Hypoplastic left heart syndrome (HLHS) is characterized by maldevelopment of the left heart and affects over 1000 live-born infants annually in the U.S. Neonates with HLHS undergo three staged open-chest reconstruction surgeries to create normal blood flood through the heart. However, twenty-five percent of HLHS Fontan patients (survivors who completed the three-staged surgeries) develop tricuspid regurgitation and are facing a significant risk of death and heart failure. Tricuspid valve intervention may treat valve leakage, but the surgical outcomes and long-term repair durability remain suboptimal due to the lack of mechanistic insights into the biomechanical and morphological factors that influence the tricuspid valve function. Prior work on image-derived atrioventricular valve finite element analysis has offered a sound computational framework for dissecting the relationship between valve structure and its biomechanical function. There is, however, a paucity of ex vivo and animal models of HLHS. As such, quantifying representative tricuspid valve tissue properties for patients in the HLHS population remains a challenge. This limits patient-specific clinical translation of finite element analysis and undermines the potential of computational analysis for guiding improved surgical decisions in HLHS. The objectives of this proposed project are to 1) discover representative tricuspid valve tissue properties in the HLHS population using physics-informed machine learning, and 2) to evaluate the relationship between tricuspid valve anatomic feature and the associated biomechanical indices (i.e., leaflet stress, strain, and coaptation height and gap area). We will identify the tricuspid valve leaflet tissue properties for a subset of HLHS tricuspid valves (n = 10 with trivial to mild regurgitation, n = 10 with moderate to severe regurgitation) and establish an empirical distribution of the tissue constants. This will inform the level of tissue heterogeneity within this subset of the HLHS population. We will also identify the association between anatomic features and biomechanical indices for this subset of the HLHS population using 3D echocardiography-derived finite element analysis. This will guide the design of customized valve repairs to improve surgical outcomes for individual patients. K25 Candidate Dr. Wu completed a Ph.D. in Structural Engineering at Cornell University. The proposed research and training plan will provide her with an initial exposure to biomedical research as she prepares for an independent research career in translational cardiovascular science. Further, this K25 will offer her the opportunity to cultivate a strong knowledge base in cardiovascular disease and treatment procedures, as well as expand her expertise in advanced computational modeling skills, within an immersive clinical environment. Dr. Wu’s exceptional mentoring team is uniquely positioned to guide her through her development toward becoming an independent investigator and leader in the multidisciplinary study of computational science engineering and cardiovascular science.

NIH Research Projects · FY 2025 · 2023-08

Abstract: Children with acute myeloid leukemia (AML) receive the maximum cumulative anthracycline exposure during frontline therapy (>440 mg/m2), an exposure that causes very well-described cardiac complications. The importance of acute, short-term cardiotoxicity in pediatric AML has been described recently by our group using Children’s Oncology Group (COG) clinical trial data. Specifically, nearly 40% of patients experienced left ventricular systolic dysfunction (LVSD) warranting chemotherapy modifications, and 21% suffered LVSD consistent with moderate to life-threatening cardiomyopathy or heart failure. Over 70% of LVSD was first documented during frontline therapy and was associated with a 13% absolute decrease in overall survival (OS). Notably, the decline in OS from early cardiotoxicity is larger than the improvement from any randomized intervention reported to date in pediatric AML cooperative group trials. Despite this clinical impact, there are no clinical prediction models for early chemotherapy associated cardiac toxicity. The cardiotoxicity prediction models developed to date focus exclusively on long-term childhood cancer survivors due to the absence of a sufficiently large and well-characterized de novo AML cohort. The variability in guidelines and clinical practice is fertile ground for disparities in echo monitoring and identification of cardiac outcomes, yet the well described disparities in survival outcomes by race/ethnicity in pediatric AML have not included analyses of echo adherence or cardiac dysfunction.With this application, we propose to develop a highly unique dataset including detailed demographic, clinical, genomic, treatment, and toxicity data, combined with longitudinal indices of LV size, diastolic, and systolic function from all clinical surveillance echocardiograms for patients enrolled on two COG AML trials, AAML0531 and AAML1031. With this unique data set, we will use novel, sophisticated analytic methods to develop models that: (1) continually update predictions of early cardiotoxicity risk during frontline therapy, (2) predict LV functional trajectories leading to persistent or worsening LVSD in the early/moderate time window after AML therapy, and (3) compare cancer treatment outcomes (EFS and OS) and detection of LVSD for three cardiotoxicity monitoring schedules with different echo frequencies in pediatric AML patients. The first model should enable personalized chemotherapy modifications and earlier initiation of cardiac-directed medications, thus improving survival outcomes. The second model should inform more personalized, evidence-based recommendations for off-treatment cardiotoxicity surveillance, potentially leading to improved adherence and reducing costs of unnecessary testing. The third analyses will provide a data driven guidance for on-therapy echocardiogram monitoring for pediatric patients with AML.

NIH Research Projects · FY 2024 · 2023-08

PROJECT SUMMARY/ABSTRACT Informed and in with consent/assent neurocognitive and diversity of support consent in human subject research is designe to espouse the moral principle of respect for persons is intended to provide information regardin the study purpose, procedures, risks/benefits, and voluntariness a comprehensible format. n youth, assent is recognized as a process that requires paren input and matures child development. In people with intellectual disabilities such as Down syndrome, participation n the process can be complicated by learning disabilities, communication differences, and decline. Unfortunately, l imited data are available to i nform an optimized consent/assent process, decision-making involvement has not been considered. This Administrative Supplement will expand the of the study team, stud sites, and participant population by extending our efforts to include University Miami and University of Texas Health Science Center-San Antonio which serve large Hispanic populations to ou patient-informed study of multi-media in the assent/consent process and decision-making d g I t i y r involvement. Our long-term objective is to address a methodologic gap in human subjects research, namely consent/assent in a diverse population of people with intellectual disabilities, to advance their decision making involvement, advocate for self-efficacy, and engage them in research. Additionally, we wish to expand the number and diversity of investigators pursuing research in Down syndrome and increase access to clinical research for people with Down syndrome. To this end, this administrative supplement proposes to include families with Down syndrome recruited through University of Miami and UTHSC-SA for:  initial feedback on the videos, interactive tool, and Spanish translation of materials  semi-structured in-person and virtual interviews with caregivers regarding engagement in research, e- education materials and social story, and questionnaires regarding shared decision-making.  testing of new materials Additionally, we will expand feedback from investigative teams in the practicality of using these materials.

NIH Research Projects · FY 2024 · 2023-08

PROJECT ABSTRACT Cardiovascular death is the number one cause of mortality for children with chronic kidney disease (CKD) once they reach adulthood. There is limited knowledge of the biochemical pathophysiology of left ventricular hypertrophy (LVH) and ventricular dysfunction (VD), prognostic markers of future adverse cardiac outcomes in pediatric CKD, and a dearth of targeted or preventive interventions. Metabolite associations with cardiac outcomes in children with CKD have been identified through plasma untargeted metabolomic profiling in the Chronic Kidney Disease in Children (CKiD) study. Multi-omics investigations can better elucidate pathomechanism and have to led to significant discoveries; however, studies in pediatric CKD have been limited. This proposal builds upon previous metabolomics work by integrating genotyping data to identify causal gene- metabolite axes with left LVH and VD in pediatric CKD. This work seeks to answer two specific aims, 1) if there is genetic variation associated with circulating metabolite levels that have been previously associated with pediatric CKD cardiovascular outcomes and 2) if circulating metabolite levels have causal effects on LVH and VD in pediatric CKD. Circulating metabolite levels' association with single nucleotide polymorphisms (SNPs) will be assessed through metabolomics-genome wide association studies (mGWAS) analyses. Metabolite causality on LVH and VD pathogenesis will be assessed with bidirectional Mendelian randomization, leverage genotype data as instrument variables. Elucidation of pathophysiology of LVH and VD in pediatric CKD may inform continued research investigations and development of therapeutic targets, aiding in the eventual prevention and treatment of cardiac risk factors in this underexamined population in clinical practice. In addition to the scientific pursuits of this career development award, Dr. Arthur Lee will make significant advances toward developing his career as an independent clinician investigator. Dr. Lee's career goals are to 1) extend the science of his R38 metabolomics work through the integration of genomics data, 2) gain skills in biostatistics by working with genomics data and multi-omics analyses, and 3) to continue receiving mentorship and formalized didactical training in large data-based clinical research. Dr. Lee will meet regularly with his primary mentor and two working groups, and will receive feedback from his mentoring committee quarterly. Dr. Lee will pursue a Masters of Science in Translational Research (MSTR), with a concentration in Bioinformatics, which advances future researchers through didactive coursework, a formal mentorship program, research training, professional skills development program, and guidance towards protocol and grant development. Completion of this K38 research will result in abstract submissions to national conferences and first-author manuscripts for each aim. Altogether, this proposal will serve as a bridge leading to a NIH early career funding proposal, analogous to how the R38 served as a pipeline to this K38 application.