Children'S Hosp Of Philadelphia

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY / ABSTRACT Despite increased use of insulin pumps (IP) and continuous glucose monitors (CGM) for pediatric type 1 diabetes (T1D) management and research studies showing benefits from the use of these devices, real-world glycemic control among youth with T1D has worsened in recent years. The lack of improvement in glycemic control despite increased use of these technologies indicates that youth receiving routine clinical T1D care are not realizing the full potential of IP and CGM. Although greater youth and parental diabetes knowledge is associated with better glycemic control, education alone is not sufficient to bring about the behavioral changes needed to improve outcomes in T1D. Psychoeducation recognizes the need to blend educational and behavioral approaches, including problem-solving and goal-setting, to support parents in developing optimal T1D management approaches. There are currently a lack of effective standardized tools to support patients and families in developing the knowledge and behavioral strategies needed to optimize the use of diabetes technologies. The development of innovative family-centered psychoeducational tools addressing both behavior and knowledge will help to realize the full potential of diabetes technologies to improve glycemic control and quality of life while ultimately preventing or delaying the development of both acute and long-term complications of T1D. The scientific goal of this proposal is to identify the unmet psychoeducational needs of parents of children 8-12 years of age using IP and CGM for pediatric T1D management and to leverage that information to develop an innovative psychoeducational intervention to optimize use of these technologies and improve T1D outcomes. In Aim 1, semantic content analysis of interviews involving children with T1D, their parents, and diabetes clinicians will be used to identify unmet educational and behavioral needs of parents and children using these technologies. We previously developed an app-delivered T1D technology education curriculum for clinicians and in Aim 2 will use instructional design and stakeholder input to adapt the existing curriculum to meet the specific needs of parents of school age children with T1D. Finally, in Aim 3, we will pilot this psychoeducational intervention. Parents will complete 4 months of the app-delivered psychoeducational curriculum and dyads will also meet with a diabetes educator trained in motivational interviewing to reinforce knowledge and problem solving skills learned in the curriculum by applying them to personal IP and CGM data. With the support of my mentors and advisory committee comprised of experts in T1D behavioral interventions, medical and family-facing education, and qualitative research, I will attain the career development goals of learning advanced techniques in qualitative and quantitative research, developing expertise in family-facing psychoeducational interventions, and cultivating the leadership skills needed to translate my findings into clinical practice. This mentored career development award will support my development as an independent investigator capable of harnessing the unmet potential of diabetes technologies. Outcomes will be used to power a randomized controlled trial for a future R01 submission.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY Tracheal Intubation (TI) is a common life-saving intervention for resuscitation of critically ill infants in Neonatal Intensive Care Units (NICUs). Through our NICHD-funded NICU multicenter registry (National Emergency Airway Registry for Neonates: NEAR4NEOS), we have identified that Adverse TI Associated Events (TIAEs) occur in 22% TIs, severe TIAES occur in 4% TIs, and multiple attempts occur in 23% TIs. Oxygen desaturations (captured separately from TIAEs) are frequent and pronounced, with a mean 28% decline in SpO2 during neonatal TI. Moreover, neonates who experienced adverse TIAEs were at higher risk of extubation failure and NICU mortality. We have identified key factors strongly associated with adverse TIAEs: 1) patient risk, 2) provider skill, 3) premedication with paralysis, and 4) video laryngoscopy. We have developed, refined, and tested a Personalized Intubation Safety (PINS) Bundle aimed at addressing these factors and prompting a prospective plan for TI management. The prototype Safety Bundle resulted in a sustained 66% reduction in severe TI adverse events in our pilot single center study. In this proposal, we will perform a pragmatic stepped wedge cluster randomized trial across 8 NEAR4NEOS NICUs to assess the impact of the Personalized Intubation Bundle on TI safety events. The timing of introducing the Bundle intervention will be randomized at the NICU site level. Our primary outcome is adverse TIAEs; secondary outcomes are severe TIAEs, multiple (>2) attempts, and magnitude of oxygen desaturation. We will test whether there is a significant variability in the treatment effect of the PINS Bundle based on the airway provider skill. This will provide important information about the impact of the Bundle intervention and its components for novice vs. experienced providers, which will help NICUs to contextualize study findings. Finally, we will explore the impact of the PINS Bundle intervention on relevant NICU patient outcomes, including extubation failure, duration of mechanical ventilation, intraventricular hemorrhage, and NICU mortality. Upon successful completion of this project, we will establish the effectiveness of a prospective Personalized Intubation Safety Bundle to reduce adverse events, multiple attempts and oxygen desaturation during neonatal TI. These results will generate a paradigm shift to improve neonatal intubation procedural safety.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY AND ABSTRACT The goal of this proposed five-year training program is to foster the development of the applicant's independent research career as a pediatric oncologist focused on exploiting inflammatory sensing pathways to improve immunotherapy in pediatric solid tumors. The candidate has completed a rigorous clinical training course and has a strong research foundation. In the short term, he will benefit from training to obtain research skills to study transcriptional regulation, work with immunocompetent mouse models of neuroblastoma, and analyze the tumor immune microenvironment. His mentors for this award are Dr. Chi Dang, an eminent cancer biologist with expertise in studying transcriptional regulation, and Dr. Michael Hogarty, a world-wide leader in neuroblastoma research. To add broad scientific expertise and provide additional career guidance, he has assembled a Mentoring Committee composed of scientists from diverse and complementary fields. Dr. Wolpaw will benefit from the rich resources and opportunities available at The Children's Hospital of Philadelphia, the University of Pennsylvania, and the Wistar Institute. The proposed research focuses on investigating the regulation of the inflammatory sensing cGAS-STING pathway in neuroblastoma to promote immune-targeting of mesenchymal state neuroblastoma (NBLMES). Neuroblastomas are composed of cells in an adrenergic (NBLADR) state that predominate at diagnosis and a NBLMES state that is initially a minor subpopulation but is a driver of relapse. Dr. Wolpaw's prior work shows that NBLMES cells have higher levels of inflammatory signaling at baseline in vitro and in vivo and are more responsive to some inflammatory stimuli, suggesting a unique immune vulnerability of this critical population. His current proposal capitalizes on these findings by focusing on the clinically relevant inflammatory sensing cGAS-STING pathway. This pathway responds to cytosolic DNA by broadly activating inflammatory signaling and is required for an immunogenic response to radiation therapy, including synergistic and systemic effects when local radiation is combined with immune checkpoint blockade. His preliminary data support the hypothesis that restoration of cGAS-STING will render NBLMES cells vulnerable to immuno-radiation therapy. To test this hypothesis, Dr. Wolpaw will purse two specific aims: 1) Elucidate the impact of NBLADR/NBLMES state on the transcriptional regulation of cGAS-STING and 2) Define the effect of restored cGAS expression on the response to radiation. Together, these aims will advance our understanding of how inflammatory sensors like cGAS-STING are regulated in neuroblastoma and how their manipulation can promote tumor-immune interactions. This will lay the foundation for improved immunotherapies in neuroblastoma and provide the training and experience needed to transition Dr. Wolpaw into an independent physician scientist.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY Antimicrobial drug resistance is an ongoing challenge for many serious diseases, including staphylococcal infections. Development of new antibiotics to combat methicillin-resistant Staphylococcus aureus—labeled a “serious threat” by the CDC—is a high priority. During drug development efforts, poor cellular penetration and drug-like features of compounds are a common roadblock. The studies in this proposal will advance a novel strategy to overcome this roadblock, by employing a prodrug approach, in which a bipartite molecule is activated intracellularly to release the active “warhead.” Central to our strategy is the determination of structure-activity relationships that define selective prodrug activation within S. aureus bacteria. We will advance this strategy by evaluating our preliminary prodrug SAR using two classes of inhibitors that are distinct in chemical structure and intracellular target. We will determine the enzymatic selectivity and evaluate how prodrugging alters biological properties of inhibitors, using in vitro and in vivo assays. In addition, we will use crystallographic approaches to delineate the structural features that define selective substrate recognition. Together, this project will establish and validate our approach for subsequent pre-clinical optimization of much-needed new antistaphylococcal therapies.

NIH Research Projects · FY 2025 · 2022-09

PROJECT SUMMARY The gut microbiome has a profound effect on human health by influencing the development of the immune system, producing bioactive metabolites and directly aiding in the processing of food. Changes in the composition and metabolism of the gut microbial community has been associated with a wide array of human diseases, including malnutrition, auto-immunity, and even neurological function. A central aspiration of gut microbiome research is to identify individuals with abnormalities in gut microbial composition in order to intervene therapeutically. However, a major limitation is that it is logistically challenging to evaluate gut microbial composition in a patient-care setting. The studies in this proposal will advance a novel strategy to overcome this roadblock. Based on powerful preliminary studies in germ-free mice and in humans, our central hypothesis is that the volatile composition of breath offers a dynamic representation of the composition and function of the gut microbiota. We will test this hypothesis by evaluating the association between breath, gut bacterial species, and microbial metabolic functions (Aim 1). In addition, we will use two unique clinical cohorts of infants to determine how the breath volatile profile changes dynamically with changes in gut microbial community composition (Aim 2). Together, our studies will not only advance our fundamental understanding of the spectrum of breath volatiles that arise from microbial metabolism, but will also be a critical first step in determining how “breathalyzer” diagnostics of gut health can be applied clinically.

NIH Research Projects · FY 2025 · 2022-08

ABSTRACT The United States Immunodeficiency Network (USIDNET) has been continuously funded as a resource for Clinical Immunologists since 1992, evolving from single diagnosis registries to a panel of research resources including a robust diverse patient registry with quality of life, laboratory, and clinical features; patient cell lines, and a variety of educational efforts. In 2017, the registry converted the data to SNOMED and LOINC terms, ushering in an era characterized by data standards and interoperability. The registry currently holds complex phenotype data on over 5000 patients with over 3000 discrete data fields. Genetic information is available on over 2000 patients. Under a new funding mechanism, USIDNET is poised to further enhance resources both incorporating and improving the state of genetic diagnostics for Inborn Errors of Immunity. Our central goal is to serve as a nexus of information on genotype and phenotype. The USIDNET registry will continue to serve a critical need by defining phenotypes and propelling improved outcomes research with enhanced longitudinal data. This evolution renders additional technical innovations possible in a manner that will serve community needs identified through discussion and a survey. This Program has six Aims which all derive from the central registry effort. The new registry will be anchored by a semi-automated data extraction from participating sites to maximize data standardization and longitudinal collection. Input of genetic data will be standardized and we will offer next generation sequencing to patients who otherwise cannot have sequencing, to improve the richness of genetic data in USIDNET and to nucleate a “matchmaking” effort. The six Aims are interwoven to support improved data and utilization. In Aim 1, we will improve the registry by developing a protocol for direct data extraction that can be shared across institutions and instituting a Single IRB to facilitate regulatory compliance. Aim 2 develops improved guidance for registry utilization, provides statistical support for end users, and spearheads studies of high impact, defined by the Steering Committee. Aim 3 proposes an innovative use of data to connect investigators who have similar patients through a specific matchmaking approach. In Aim 4, we will utilize USIDNET data to augment efforts to enrich immunology HPO terms and ClinGen entries. In Aim 5, we will galvanize successful dissemination efforts, develop a newsletter with structured features to improve clarity, and enhance material on our website. In Aim 6, we will formalize mentoring efforts to strengthen the research skills of the next generation and provide career mentoring. These resources will provide pivotal information for the Immunology community at a time when the wealth of new monogenic Inborn Errors of Immunity have made clinical decision making far more complex and uncertain. This new R24 builds on previous successes defining phenotypes in Inborn Errors of Immunity, improves data collection, and utilizes the data in new ways to support the community.

NIH Research Projects · FY 2026 · 2022-08

Multidrug-resistant organisms (MDRO) pose a significant risk to public health. Infections with MDRO are associated with high mortality rates and healthcare costs, particularly related to hospital-acquired pneumonia. Current approaches to control and prevent transmission of these pathogens focus primarily on clinical testing of infectious patient isolates. This is costly, labor-intensive, and fails to account for asymptomatic carriage. Wastewater testing can overcome many of the limitations posed by patient-based surveillance by enabling cost-effective population-level data acquisition, which can subsequently be used to model and forecast infectious outbreaks. To date, wastewater-based testing has been successfully used for surveillance of pathogenic viruses, but barriers remain in applying this approach to MDRO. While pathogenic bacteria and antibiotic resistance genes (ARGs) have been detected in wastewater treatment plants, several factors currently limit the utility and accuracy of wastewater as a marker for overall burden and diversity of antibiotic resistance. Here, we aim to better operationalize metagenomic wastewater-based epidemiology by understanding the dynamics of multidrug-resistant bacteria during wastewater flow, as well as the relationship between wastewater and clinical detection of MDRO. First, we will design wastewater MDRO model systems by constructing plug-flow reactors and testing the effects of flow parameters such as hydraulic retention time, pH, and temperature, as well as antibiotic pressure, on the prevalence and diversity of MDRO and ARG genotypes. This will account for dynamics in growth rates and potential ARG exchange across species along the wastewater flow, which could significantly affect the accuracy of wastewater-based surveillance models. These bioreactor model systems will enable future experiments testing conditions relevant to specific MDRO species or wastewater streams. In Aim 2, we will take advantage of our ongoing longitudinal wastewater sampling at a major hospital center and the surrounding community to correlate MDRO in wastewater with clinical MDRO and existing patient surveillance cohorts. Through chromatin-linked metagenomics and long- read sequencing we will elucidate phylogenetic links between MDRO in hospital and community wastewater with infectious patient isolates, and potential differences in evolutionary patterns of MDRO in patient versus wastewater collections. Lastly, in Aim 3 we will interrogate different approaches to wastewater-based epidemiological modeling to estimate MDRO burden in a given community. We will contrast linear and nonlinear additive regression models with dynamic mathematical modeling approaches. We will incorporate wastewater flow parameters and community sociodemographics as well as molecular biomarker data, as normalization factors to improve model accuracy. Risk assessment techniques will be applied to these wastewater models to inform development of future public health decision making tools. If successful, the results of this study would enable wastewater surveillance as a tool to inform targeted mitigation strategies to prevent the spread of antibiotic multidrug-resistance.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY Chronic musculoskeletal pain (CMP) affects as many as 4 in 10 children, mostly adolescents, and accounts for the majority of new referrals to pediatric rheumatology. Long-term physical and psychosocial outcomes for adolescents with CMP are poor with increased healthcare utilization and psychological co-morbidities. Additionally, current treatment regimens for CMP have limited accessibility. Resilience is a dynamic process of positive adaptation or development in the context of significant adversity, such as living with excessive chronic pain. Promoting Resilience in Stress Management (PRISM) is a successful resilience-training intervention for adolescents and young adults with serious illness. Preliminary data for this proposal demonstrate a moderate correlation between self-perceived resilience and symptom severity among adolescents as well as high feasibility and acceptability of PRISM delivery among youth with CMP. Qualitative feedback was universally positive with the consistent recommendation to add a patient group session to the intervention. With an added patient group session to the intervention, we now aim to ascertain the impact of the adapted intervention (Promoting Resilience in Stress Management (PRISM) for adolescent Chronic musculoskeletal pain [PRISM-C]) on pain-related clinical outcomes in a randomized controlled trial. The overall objectives of the proposed project are to (1) determine the efficacy of PRISM-C in a population of youth with CMP, (2) explore moderators of the intervention to identify youth most likely to benefit from resilience coaching, and (3) assess implementation outcomes and identify barriers and facilitators to engagement in PRISM-C. Findings from this work will further our understanding of psychosocial factors important in adolescent CMP in order to reduce disease burden and improve long-term outcomes. Study results will serve as preliminary data for an R01 application to perform a multicenter randomized controlled trial of PRISM-C for adolescents with CMP. The proposed Career Development Award addresses how to improve access to and efficacy of interdisciplinary treatments for CMP. The exceptional resources and institutional support at Children’s Hospital of Philadelphia and the University of Pennsylvania, outstanding multidisciplinary mentorship team, and proposed career development activities will allow the candidate to achieve her long-term goal of becoming an independent investigator and nationally recognized pediatric rheumatologist with expertise in pediatric chronic pain, resilience, and behavioral health interventions with the goal of improving the long-term physical and psychosocial outcomes for adolescents with CMP.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY - OVERALL The human heart presents remarkable anatomical, cellular and functional heterogeneity, with specialized cellular structures performing distinct yet essential physiological functions. A significant gap of knowledge is that different cells’ molecular signature, spatial distribution and interactions, and functional state remain little understood for the heart. We therefore propose the in-depth characterization of the heart which accounts for a large fraction of human disease burden. We will map molecular and cellular changes in heart tissues over the course of human lifespan using comprehensive multi-dimensional single-cell and imaging technologies. The final product will impact research of the heart in the following manner: 1) Organ Atlases: spatially resolved atlases will provide a highly user friendly, publicly available, searchable database of the most comprehensive multi-omic, single cell analysis of the heart. Molecular data will be richly annotated with additional clinical and epidemiological data. 2) Computational methods: in addition to the data, the critical computational tools and pipelines developed in this project will be available to the research community. These include methods and pipelines for processing multi-omics and imaging data, inference of cell-specific regulatory and signaling pathways, correlation of mesoscale imaging and molecular imaging features, as well as database algorithms for the query, exploration and visualization of highly complex data. 3) Access to biospecimens for follow-up studies: biospecimens collected in this project will be banked and made available to the biomedical research community. These include freshly frozen and fixed specimens and tissue sections. In summary, the proposed project will broadly impact the entire research community and jumpstart basic-science and medical discoveries based on a sophisticated understanding of the key molecular circuits underlying the development and aging of the heart.

NIH Research Projects · FY 2025 · 2022-08

PROJECT SUMMARY Dr. Pamela Weiss, with the support of this proposal, seeks to expand and improve her research program and her training, mentoring, and career development of greatly needed physician scientists pursuing patient- oriented research (POR) in pediatric rheumatology. Successful mentoring requires both an effective mentee and a skilled mentor, both of which are reflected in the training goals of this application and include building skills to 1) train junior faculty and peers to build and effectively manage their mentoring relationships, and 2) teach trainees how to effectively work with their mentoring team and navigate the research environment. The premise of this application is to leverage existing studies to improve the everyday clinical care of children with spondyloarthritis and to contribute to the design of studies of emerging targeted therapies. Three major obstacles block advancements in juvenile spondyloarthritis care. First, there is variability in the interpretation of diagnostic imaging studies because distinguishing immature structural bone from subchondral bone marrow edema at the sacroiliac joints in children is challenging. The apparent diffusion coefficient (ADC) from diffusion- weighted imaging (DWI) holds unique promise for the pediatric population as a tool to distinguish maturational changes from pathologic inflammation. Second, there are no pediatric diagnostic imaging criteria for sacroiliitis. Improved criteria is needed not only in the clinical setting to prevent overdiagnosis, but also in the research setting to accurately identify those who would benefit from clinical trials. Third, although there is a juvenile spondyloarthritis disease activity (JSpADA) index that is widely used in clinical research, the cut-off values for defining clinically important disease states are unknown. Since inactive disease remains unattainable for many with juvenile spondyloarthritis, there is a critical need to determine minimal clinically important improvement (MCII) and well-defined states of disease activity using the JSpADA index for use not only in clinical care but also studies of emerging therapies. The proposed research addresses these challenges and leverages existing studies conducted by the candidate at a world-renowned pediatric tertiary care center with expertise in spondyloarthritis and innovative imaging. Aim 1 will test ADC from DWI as a diagnostic biomarker for the presence of sacroiliitis in children. Aim 2 will determine candidate lesion-based criteria for defining a positive sacroiliac joint MRI. Aim 3 will determine the MCII and cut-off values for defining minimal disease activity and high disease activity for the JSpADA index. These aims will simultaneously provide significant added value to ongoing studies, aid the applicant to develop new research and mentoring skills, and offer a clinical research platform in which to mentor young physician scientists in POR and promote their transition to independence.

NIH Research Projects · FY 2025 · 2022-08

1 PROJECT SUMMARY/ABSTRACT 2 Obstructive sleep apnea (OSA) affects as much as 5% of children, and results in significant cardiovascular and 3 neurobehavioral morbidity if left untreated. The gold standard for evaluation of OSA in children is in-laboratory 4 polysomnography (PSG). However, PSG is resource-intensive, requiring caregivers to spend a night away 5 from home, and facilities are limited. Consequently, 90% of children who undergo adenotonsillectomy to treat 6 OSA never have the diagnosis made by PSG. Home sleep apnea testing (HSAT) is an alternative to PSG 7 where a patient has an unattended OSA assessment in their home. Clinical trials in adults showed no 8 difference in functional or treatment outcomes in those evaluated by HSAT compared to PSG, but similar 9 studies have not been conducted in children. The performance of HSAT compared to PSG in children is 10 unknown, and this has been a critical barrier to its clinical use as a diagnostic tool in the pediatric population. 11 HSAT has been shown to be feasible in children and our preliminary data have shown that HSAT may be 12 accurate compared to PSG and preferable to families. This milestone-driven comparative effectiveness trial will 13 compare HSAT to PSG for the evaluation of OSA in children through the following Aims: 14 1) Compare the diagnostic accuracy of HSAT with PSG for determining OSA status 15 2) Determine the agreement between HSAT and PSG results for therapeutic decision-making 16 3) Determine child/parent-reported acceptability of HSAT and preference of HSAT vs PSG. 17 To accomplish these aims, 317 children age 5-12 years old clinically referred for evaluation of OSA will 18 undergo HSAT and PSG within one week in random order and OSA classification between the two modalities 19 will be compared within subjects using receiver operating characteristics. Off-site investigators who are 20 pediatric sleep medicine physicians will provide a therapeutic decision based on clinical data and HSAT or 21 PSG result and agreement between therapeutic decision between the two tests will be assessed. Parent- and 22 child-reported questionnaires assessing preference and acceptability will be compared between HSAT and 23 PSG, and parent-reported feasibility of HSAT will be assessed. 24 The results of this comparative effectiveness trial will provide critical data directly comparing HSAT to the gold 25 standard in-lab PSG to determine its clinical utility. If shown to be diagnostically accurate and result in the 26 equivalent therapeutic decision as PSG, HSAT could provide a more patient-centered diagnostic alternative 27 that dramatically increase the capacity for OSA evaluation in children, reducing morbidity related to delayed 28 diagnosis and increasing objective testing prior to adenotonsillectomy.

NIH Research Projects · FY 2025 · 2022-08

Candidate: My long-term career goal is to reduce the cognitive, physical, and emotional morbidity following pe- diatric concussion by implementing early interventions to those at highest risk for persistent post-concussion symptoms (PPCS). With 75% of my time dedicated to patient-oriented research and career development, my short-term goals are to develop a predictive model to most accurately identify those patients at highest risk of developing PPCS, and to use a novel mobile health (mHealth) intervention to improve specialist access from the emergency department (ED) setting. This proposal builds on my prior work in researching objective mark- ers of dysfunction following concussion, and will position me to gain skills in advanced predictive modeling to facilitate early risk stratification, utilizing advanced mHealth-based interventions to facilitate care continuity and positioning such interventions for adoption and sustainability, and designing and leading clinical trials from the ED setting that utilize innovative methods to create the evidence base for mHealth intervention adoption. Environment: This proposal leverages the substantial resources available to me at Children’s Hospital of Phila- delphia, through the Division of Emergency Medicine, Center for Injury Research and Prevention, Innovation Ecosystem, and Sports Medicine and Performance Center; at The University of Pennsylvania, through the Center for Clinical Epidemiology and Biostatistics, The Penn Injury Science Center, and the Leonard Davis In- stitute of Health Economics; and through the Pediatric Emergency Care Applied Research Network. The men- tored research experience and formal didactic training, in addition to the clinical experience of practicing in a quaternary care pediatric ED, create an ideal environment for my ongoing career development. Research: Concussions are prevalent injuries in the pediatric population. While the majority of symptoms in concussed youth resolve within 1 month, a significant proportion (30%) experience symptoms lasting months to even years. Several observational studies have identified risk factors associated with PPCS, however the best current methods to risk stratify concussed youth do so with only moderate discrimination, and are heavily reliant on subjective symptoms. In addition, while traditionally, pediatric concussions were managed with pas- sive rest, more recently, active therapies have become the standard of care in the specialty setting. However, the traditional referral model presents several barriers to care continuity and specialist access for ED concus- sion patients. Novel mHealth interventions have the potential to improve care continuity, serving as a bridge between care settings for concussed youth. In order to facilitate improved care and ultimately reduce symptom burden to highest risk children, this proposal aims to: (1) Improve accuracy of concussion risk stratification from the ED using physiologic markers of injury; and (2) Assess the feasibility of a mHealth tool to facilitate specialist access and care continuity. Study results will allow me to develop a R01 proposal of a clinical trial evaluating the effectiveness of mHealth-facilitated targeted referral to reduce the incidence of PPCS.

NIH Research Projects · FY 2026 · 2022-07

PROJECT SUMMARY/ ABSTRACT The overarching objectives of this proposal are to investigate whether novel quantitative MRI and ultrasound imaging parameters can reliably detect kidney transplant injury that indicates risk of allograft failure in children. Children with end-stage kidney disease (ESKD) have a mortality rate 30 times higher than children without it. As kidney transplantation provides a significant survival advantage over dialysis, children with ESKD often require multiple kidney allografts over their lifespan. Each transplant increases surgical, immunological, and oncogenic risk. Kidney allograft injury results from inflammatory, infectious, vascular, and fibrotic changes that can ultimately result in allograft failure. A major limitation to promoting long-term allograft survival is the lack of non- invasive diagnostic and prognostic biomarkers to reliably detect early injury in the allograft. This proposal seeks to develop magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) biomarkers to measure inflammation of kidney transplant in children. Currently, kidney allograft biopsy is the gold standard to diagnose such changes, but is invasive and not free of complications, which limits its use. Identifying such markers will allow us to implement individualized interventions to improve allograft survival and decrease unnecessary biopsies. Aim 1 will determine advanced MRI and CEUS parameters that associate with histopathological total inflammation Banff score and Chronic Allograft Damage Index (CADI) score. Aim 2 will identify novel MRI and CEUS parameters that predict change of eGFR in pediatric kidney transplant recipients at 6-24 months post-transplantation. The results will inform the field of novel non-invasive imaging biomarkers in pediatric kidney transplantation. Complementary to this investigation I plan to acquire further training in 1) conventional and CEUS research imaging acquisition and analysis, 2) MRI research data acquisition and analysis, 3) design and implementation of biomedical imaging based patient-oriented research studies, and 4) acquire leadership skills through a professional development plan in the rigorous research environment of Children’s Hospital of Philadelphia and University of Pennsylvania. To accomplish these goals, I have assembled a multi-disciplinary mentoring/advisory team of experts in clinical nephrology patient-oriented research (Primary mentor, Susan Furth, MD, PhD), MRI clinical and translational research studies (Timothy Roberts, MD, PhD; Suraj Serai, PhD), CEUS (Chandra Seghal, PhD; Susan Back, MD; Anush Sridharan, PhD), pediatric kidney transplantation biomarkers (Sandra Amaral, MD, MHS), multinational collaborative networks (Gregory Tasian, MD, MSCE), kidney disease statistical methods (Jarcy Zee, PhD), and patient-oriented imaging research (Kassa Darge, MD, PhD; Erum Hartung, MD, MSTR; Hansel Otero, MD). The proposed research, along with the structured mentoring, coursework, and training that comprise my career development plan, will provide me with the skills and experience necessary to ensure my success as an independent investigator with a unique skill set in developing imaging biomarkers for kidney transplantation.

NIH Research Projects · FY 2025 · 2022-07

PROJECT SUMMARY/ABSTRACT A hallmark of adaptive immunity is mono-allelic expression (allelic exclusion) of B and T cell antigen receptor proteins, which is thought to allow highly-specific immune responses and inhibit autoimmunity. Allelic exclusion is achieved via mono-allelic initiation of RAG1/RAG2 (RAG) nuclease-mediated V gene segment recombination, followed by protein from a V(D)J rearrangement signaling permanent feedback inhibition of V recombination on the other allele. A shortcoming of this control is that it needs time for completion of recombination, expression and signaling of protein, and changes on the second allele. The applicant demonstrated that RAG DNA double strand breaks (DSBs) induced during Vk-to-Jk recombination in pre-B cells signal via the ATM kinase to inhibit Rag1/Rag2 expression, Jk accessibility, and RAG cleavage of the other allele until after the first allele is repaired. He showed that ATM deficiency in mice increases bi-allelic Igk IgH, or TCRb expression. While these data imply that ATM enforces allelic exclusion by signaling DSB feedback inhibition of V recombination, they neither prove this model nor rule out a role for ATM-stimulated DSB repair. The applicant shows new data that ATM enforces Igk allelic exclusion by signaling via the NFkB essential modulator (NEMO) protein, with inhibition of Rag1/Rag2 transcription likely key for inter-allelic control of Vk recombination. The applicant shows that RAG DSBs during IgH D-to-J recombination in pro-B cells or TCRb D-to-J, TCRg, and/or TCRd recombination in DN thymocytes do not require ATM to repress Rag1/Rag2 expression. However, these RAG TCR DSBs signal via ATM to repress expression of a Vb region anti-sense long non-coding RNA, which the applicant shows is expressed only in DN cells where Vb and Db-Jb segments interact and rearrange over vast genomic distances. Based on these data, the applicant hypothesizes that RAG DSBs feedback inhibit V(D)J recombination through complementary mechanisms, including cell type-specific signaling pathways that repress Rag1/Rag2 transcription and antigen receptor locus-specific alterations that suppress V rearrangements. He proposes two independent aims to test fundamental aspects of his model. Aim 1 proposes to elucidate how RAG DSBs induced during different types of rearrangements in different cell types signal repression of Rag1/Rag2 transcription to coordinate initiation of V-to-(D)J recombination between alleles and thereby enforce allelic exclusion. Aim 2 proposes to determine the role of V region anti-sense long non-coding RNAs in promoting long-range V-to-(D)J rearrangements and serving as a DSB-responsive switch to transiently inhibit these rearrangements and thereby orchestrate allelic exclusion. The proposed work will employ powerful mouse models to rigorously elucidate mechanisms by which RAG DSBs trigger transient feedback inhibition of V recombination to help enforce allelic exclusion. The project will provide novel mechanistic insights into one understudied and one completely novel line of research in the field, the latter relevant to the biology all cells. Beyond advancing understanding of a hallmark of adaptive immunity, the findings could identify mechanisms important for suppressing autoimmunity and/or lymphoid malignancies.

NIH Research Projects · FY 2025 · 2022-07

SUMMARY/ABSTRACT Stressors that significantly impact on the health and well-being of adults and children can be seen affecting many different systems including education, the economy, housing, and healthcare, widening known disparities. This is of particular importance for families with very young children considering the criticality of the peripartum period on early neurodevelopment. Recent findings suggest that early maternal symptomatology can have lasting, and negative effects on parent-child interactions, infant/child development, and mental health of both women and children. Overall, these findings take on further importance when contextualizing the disparate exposure of Black children and their families to the syndemic. Although there is increasing knowledge of the impact of environmental and neighborhood factors on child development beginning prenatally, mechanisms underpinning these transmissions are still being investigated. Identifying women disproportionately impacted by the syndemic during the peripartum period, provides an opportunity to understand the developing child’s environment, mother’s mental health, and parenting experience, with the long-term goal of improving infant/young child neurodevelopmental and mental health outcomes by ensuring appropriate, precise, personalized interventions. The proposed multi-methods project consists of three aims that will longitudinally examine child neurodevelopmental outcomes by early identification of racially/ethnically diverse mothers with mental health challenges. The first aim implements extensive screening of postpartum Black and non-Hispanic White (NHW) mothers using a battery of questionnaires and clinical psychiatric interviews to identify mothers currently experiencing distress and psychopathology, as well as determining resilience factors uncovering cross-cultural differences that may exist. Fathers/secondary caregivers will also complete similar questionnaires assessing levels of support. The second aim identifies maternal concern about their child’s development and mental health at two developmental time points (24 and 48-months) and assesses mother/child interactions on a series of dyadic tasks. The final aim consists of qualitative interviews with a sub-sample of Black women characterizing the impact of the syndemic on their mental health, parenting practices, perceptions of their child’s early development, and trust in the healthcare system. The overarching goal of this application is to deeply characterize the experiences of women and children impacted by the syndemic, filling the gap in the research by identifying specific maternal, environmental, and neighborhood factors and mechanisms that critically influence early child development and mental health and allowing for future intervention development.

NIH Research Projects · FY 2025 · 2022-07

Project Summary/Abstract This career development award details a 5-year training plan to facilitate the transition of Dr. Barbara H. Chaiyachati to an independent career as a physician-scientist studying predictors of mental and physical health of children after trauma with an objective to identify actionable targets of intervention. Experiences of child abuse and neglect place hundreds of thousands of children at risk for negative health outcomes every year in the U.S. Better understanding of proximate mental and physical health predictors after childhood traumatic stressful events (TSE), including predictive role of genetic susceptibility integrated with early biologic embedding by epigenetic age acceleration (EAA) and increased inflammation, may facilitate targeted interventions to ameliorate the spectrum of long-term health burdens. Thus, multimodal phenomic and genomic approaches are needed to elucidate the complex connections between maltreatment and health. The proposed project builds on the diverse clinical and research experiences of the candidate, with mentorship led by Dr. Raquel Gur, the Karl and Linda Rickels Professor of Psychiatry, Neurology and Radiology at the University of Pennsylvania and an expert in neurodevelopmental trajectories, and Dr. Hakon Hakonarson, Professor of Pediatrics at the Children’s Hospital of Philadelphia and an expert in translational genomics. A team of collaborators adds expertise in developmental psychology, basic and clinical immunology, psychiatric genetics, and behavioral epigenomics, with grounding in child abuse clinical care. The research leverages large, ancestry-diverse, adversity-exposed cohorts within established biorepositories to identify measurable, biologically-relevant health predictors after adversity in childhood. Dr. Chaiyachati will conduct phenomic (physical, mental health, systemic inflammation by cytokines) and genomic (whole genome and methylome) assessments. Specifically, Aim 1 is to determine the impact of TSEs and genetic stress sensitivity, as marked by genetic risk for PTSD, on mental and physical health in adolescence; Aim 2 will assess the impact of TSE on epigenetic aging per DNA methylation clocks; and Aim 3 will test for increased inflammation after experiences of maltreatment. Completion of the proposed studies will improve our understanding of mental and physical health trajectories after experiences of trauma. This proposal will also provide the candidate with experience studying phenomic and genomic data, writing grants and scientific papers, and allow her to gain skills requisite for supervision and leadership. Furthermore, this proposal will establish Dr. Chaiyachati’s intersectional research agenda and position her for independence as a physician-scientist.

NIH Research Projects · FY 2025 · 2022-07

PROJECT SUMMARY Although typical scRNA-seq or scATAC-seq data contain 5-25% of reads that map to the mitochondrial DNA (mtDNA) genome, such mtDNA mapped reads are often filtered out or ignored during downstream analysis. The mitochondria generate over 90% of the cellular energy and are central to health and disease. mtDNA mutations directly cause mitochondrial disease. In addition, random somatic mtDNA mutations accumulate with age and are associated with a broad range of aging-related diseases such as immune disorders, cardiovascular disease and neurodegeneration. However, little is understood about whether accumulation of specific mtDNA variants during aging occurs at the same rate across different cell types, organs, age, and sex. Such insights would substantially improve our understanding of how mtDNA mutations contribute to various human diseases. Accordingly, significant gaps of knowledge in the single-cell biology field include the lack of robust mtDNA analysis tools and how to utilize the rich mtDNA information often neglected in the everincreasing datasets to obtain new biological insights. We propose to address these knowledge gaps by: (1) develop robust mtDNA analysis workflows and tools integrated with the HuBMAP Portal; (2) comprehensively analyze mtDNA from single-cell datasets generated by HuBMAP and other resources; (3) determine whether and how prevalent human mtDNA variants impact mitochondrial and cellular function.

NIH Research Projects · FY 2026 · 2022-07

PROJECT SUMMARY/ABSTRACT Candidate: I am a headache specialist at the Children’s Hospital of Philadelphia (CHOP). I have a PhD in visual systems neuroscience that focused on studying properties of neuronal adaptation in the visual cortex. More recently, I have begun clinical research related to pediatric headache disorders and the study of photophobia in migraine. My long-term goal is to elucidate the pathophysiology of concussion and headache, identify relevant biomarkers, and improve the treatment of these conditions in young people. This grant will enable me to build skills in concussion biomarker development to become an independent, translational neuroscientist dedicated to improving the care of concussion and headache in children. Research: Concussion is a major health concern, affecting 20% of youth in the United States. Headache is the most common symptom following concussion and is associated with longer recovery times and greater disability. However, there are no accepted guidelines on how or when to treat post-traumatic headache (PTH), and there are no early biomarkers to identify youth at risk for prolonged PTH. PTH and migraine share many clinical features and may have overlapping pathophysiology. The goal of this proposal is to determine if pathophysiologic substrates of migraine are present early in PTH. I will examine electrophysiologic and blood candidate biomarkers associated with trigeminovascular pathway sensitization (central to migraine pathogenesis) at multiple time points in youth with PTH lasting longer than 1 month. These measures will be compared to youth with symptom resolution. Environment and Career Development: CHOP and University of Pennsylvania (Penn) offer a rich environment for me to develop as an independent investigator. My mentorship team has diverse expertise and will provide me with a unique set of skills to support biomarker development in pediatric concussion. My primary mentor, Dr. Geoffrey K Aguirre, is an accomplished vision neuroscientist with expertise in the visual system in migraine. He will provide the mentorship needed to develop advanced techniques in signal processing for electrophysiologic biomarkers. My co-mentor, Dr. Ramon Diaz-Arrastia, is a leader in traumatic brain injury biomarker research. He will provide guidance and support on study design for blood biomarker development including the use of biomarkers in clinical trials. My second co-mentor, Dr. Christina Master, is an expert in pediatric concussion who has built the Frontier Minds Matter concussion program at CHOP. This program provides an extensive and well-integrated clinical and research infrastructure for longitudinal concussion studies in youth, which will provide crucial support to the proposed studies.

NIH Research Projects · FY 2025 · 2022-07

ABSTRACT Adoptive transfer of hematopoietic stem and progenitor cells (HSPC) can provide effective treatment for non- malignant disorders in the form of allogeneic hematopoietic stem cell transplantation (HSCT) or as a platform for autologous gene therapy. Bone marrow (BM) niches are the operationally-defined core units that sustain hematopoietic function, where signals from non-hematopoietic support cells adapt HSPC output to organismal demand. HSPC occupancy in the BM, however, is a competitive process, and HSCT patients typically require conditioning to eliminate endogenous hematopoiesis and “create space”, thereby promoting homing and engraftment in highly vascularized niches. Secretory activity is a fundamental HSPC property, but the impact of signals that emerge from HSPC, and their cellular targets in the niche are not well understood. The gap in knowledge regarding the crosstalk between HSPC and vascular niche endothelial cells specifically, may hold important biological insight and opportunities to improve competitive HSPC niche fitness, and a potentially novel strategy to offset the toxicity and long-term side effects from HSCT conditioning treatments. The secretion of nanometer sized extracellular vesicles (EVs) that traffic protein and RNA cargo is a constitutive cellular function. Intriguingly, mobilized CD34+ HSPC -which provide known advantages to engraftment after HSCT- have been shown to release EVs (EVCD34) that are highly abundant in microRNA-126, an “angiomiR” that regulates Akt/mTOR signaling, which in turn is central to EC hematopoiesis support. Others showed that adoptively transferred EVCD34, rich in miR-126, enhance EC proliferation and function. Our principal hypothesis is that EVHSPC trafficking of miR-126 actively shapes EC function in the vascular BM niche to enhance occupancy and improve repopulation. Three aims will test our hypothesis. In Aim 1 we will determine the cell-autonomous impact of EVHSPC secretion on self-renewal and repopulation potency under conditions of homeostasis and stress. Aim 2 will test the role of endothelial cells as predominant cellular targets for EV trafficking in the BM niche. Aim 3 will dissect the specific role of miR-126 and in regulating BM endothelial cell fates and the involved signaling pathways. As a proof of principle study, this proposal places an experimental and mechanistic focus on EVHSPC, but insight into the biologic role of the HSPC secretome in the BM niche will be broad. Translationally, our long-term goal is the development of new, non-toxic approaches to improve outcomes after allogeneic HSCT and autologous gene therapy.

NIH Research Projects · FY 2025 · 2022-07

SUMMARY/ABSTRACT Shorter sleep duration has been consistently associated with childhood obesity, and the American Academy of Pediatrics recommends that pediatricians promote sleep as part of their obesity prevention efforts. The pediatric primary care setting has enormous potential to promote sleep, but a lack of time at the point of care is a key barrier, and insufficient sleep and childhood obesity are not equally distributed across sociodemographic groups. To overcome these barriers, mobile health platforms need to be developed to deliver behavioral sleep promotion remotely in the home setting, with tailoring to individual and contextual factors to help ensure equitable effectiveness across sociodemographic groups. Multi-component sleep promotion interventions have been developed, and initial findings suggest that behavioral sleep interventions are effective. However, these interventions have not been designed for remote delivery in the pediatric primary care context. Furthermore, the individual components have not yet been optimized, meaning some components may be ineffective or counter- effective. The study team’s objective is to engineer a mobile health platform for the pediatric care setting to promote longer sleep duration for childhood obesity prevention. Their central hypothesis is that they will identify an optimal set of intervention components to increase sleep duration and prevent excess weight gain, with equitable effectiveness across sociodemographic backgrounds. This hypothesis will be tested by pursuing three specific aims and will be guided by the Multiphase Optimization Strategy (MOST) framework. Under aim 1, an optimization trial will be conducted using an innovative experimental design to determine optimal component settings for sleep promotion. A total of four candidate components will be experimentally tested: 1) a sleep goal component, 2) a digital messaging component, 3) a parent-directed incentive component, and 4) a personalized feedback component. An advisory board (family, youth, and clinicians) will provide feedback throughout to ensure acceptability of the component content. Under aim 2, the investigative team will determine if optimal settings for sleep promotion lead to lesser gains in fat mass index. They will also measure total energy intake and the timing and composition of meals to gain mechanistic insights. Under aim 3, the investigators will determine if optimal settings for sleep promotion are comparable across individual- and neighborhood-level sociodemographic factors. This innovative research shifts attention from the problem of insufficient sleep to a solution for insufficient sleep, and represents the first application of the MOST framework to engineer a mobile health platform to promote sleep for obesity prevention that will be equitable across sociodemographic groups. The proposed research will greatly advance the field of behavioral sleep medicine and reimagine how insufficient sleep duration and obesity are prevented in pediatric healthcare.

NIH Research Projects · FY 2025 · 2022-07

The goals of the T32 Multidisciplinary Training Program in Pediatric Lung Diseases at Children’s Hospital of Philadelphia are: (1) To provide a mechanism for training by which postdoctoral fellows can pursue and develop successful academic careers in clinical, translational, or basic research dedicated to improving child lung health; (2) To advance pediatric lung research through training physician scientists and PhD scientists in the areas of (a) genetic and rare lung diseases, including interstitial lung disease (ILD), cystic fibrosis (CF), bronchopulmonary dysplasia (BPD), and pulmonary vascular disease, (b) lung injury, repair, and development, (c) asthma and inflammatory lung diseases, and (d) respiratory physiology; and (3) To create collaboration among trainees and established investigators to promote a spectrum of patient-oriented and basic investigation, resulting in rigorous and high impact advances in respiratory health in children. The proposed training program will provide 2-3 years of training in pediatric lung-related research at the postdoctoral level for qualified candidates with an MD, MD/PhD, or DO degree and 1-3 years of training for those with a PhD degree. We are requesting support for 4 post-doctoral fellows/year. This training program is the result of a robust collaboration between research faculty members with multiple areas of expertise. These faculty offer mentored training in patient-oriented or basic research within the four thematic areas noted above. The mentor-mentee relationship between research preceptor and trainee will be central to the training experience, which will be supplemented by formal training in clinical and laboratory investigation, preparation of grant applications, participation in a responsible conduct of research curriculum and program-wide conferences, presentation of original research at national scientific meetings, and publication of original research in peer-reviewed journals. Drs. Lisa Young and Sharon McGrath-Morrow are the Program Directors and will have overall responsibility for coordination of the program, including its scientific, educational, and administrative aspects. To support excellence in the research training of this T32 program, the Program Directors will receive consultation from an Internal Steering Committee and an External Advisory Board. The Children’s Hospital of Philadelphia has one of the largest and strongest pediatric pulmonary fellowship programs in the country and is the oldest children’s hospital in the United States. The Program Directors have trained many leaders in the field for Pediatric Pulmonology and are uniquely positioned to facilitate success among postdoctoral trainees who will become physician scientists and researchers in pediatric lung-related research.

NIH Research Projects · FY 2026 · 2022-06

PROJECT SUMMARY/ABSTRACT There are no approved therapies for the autosomal-recessive neuro- and cardio-degenerative disorder Friedreich ataxia (FA). FA is caused by hypomorphic mutations in the gene encoding the protein frataxin. Frataxin localizes to the mitochondrial matrix and functions in the biogenesis of iron-sulfur-clusters (ISCs), which are important prosthetic groups for both intra- and extra-mitochondrial enzymes. We found that the p38 MAP kinase stress- response pathway is constitutively hyperactivated in FA cells, likely as a result of ongoing oxidative stress and/or an ongoing DNA damage response (DDR). Our working hypothesis is that chronic hyperactivation of the p38 pathway, which modulates a key protein in the ISC biogenesis complex, is part of a maladaptive feedback loop that further suppresses ISC biogenesis in FA cells; hence, inhibition of the p38 pathway, or of its activation, counteracts the deleterious effects of decreased frataxin function. Our preliminary studies have implicated lipid peroxidation and telomere damage in FA pathogenesis, both of which activate p38, and both of which are consequences of ISC deficiency. We hypothesize that ISC biogenesis in FA cells will be increased, and FA- associated defects ameliorated, by (i) inhibition of p38 and/or MK2, which links p38 to ISC biogenesis; or (ii) a reduction in p38 activation, either through a decrease in oxidative stress (particularly lipid peroxidation) or a decrease in the DDR (particularly secondary to critical telomere shortening). Complemented by genetic approaches, we will test compounds that are known to target these pathways, allowing us to elucidate the roles of these pathways in FA pathogenesis while simultaneously advancing our overall goal of identifying and prioritizing compounds for potential clinical development. Our Specific Aims are: Aim 1. To use fibroblast models to interrogate the interrelated roles of the p38-MAPK pathway, oxidative stress, and DNA damage in the pathogenesis of FA, and to test relevant drugs and drug targets for amelioration of FA-associated defects. We will test our hypothesis that constitutive hyperactivation of the p38 pathway in FA cells represents a maladaptive feedback loop, and that inhibiting this pathway counteracts the deleterious effects of decreased frataxin function, thereby ameliorating FA-associated defects. Using a combination of genetic and small-molecule approaches, we will test the effects of antioxidants, anti-DDR agents, and p38/MK2 inhibition on p38 activation, ISC biogenesis, and FA-associated defects. Aims 2 and 3. To use FA iPSC- derived cardiomyocytes and sensory neurons (Aim 2), and FA zebrafish (Aim 3), to test our hypotheses in affected cell types in vitro and in vivo. Using a combination of genetic and small-molecule approaches, we will test the effects of antioxidants, anti-DDR agents, and p38/MK2 inhibition on p38 activation, ISC biogenesis, and FA-associated defects validated in these models. We anticipate a significant positive impact: our preliminary studies already link these pathways to FA pathophysiology, and compounds targeting these pathways have been developed and, in some cases, are already in clinical trials for other disorders.

NIH Research Projects · FY 2026 · 2022-06

PROJECT SUMMARY/ABSTRACT The purpose of this Mentored Clinical Scientist Research Career Development Award (K08) is to prepare Heidi M. Herrick, MD MSCE, Clinical Instructor and Attending Physician at the Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania for her long-term goal of becoming an independent health services research scientist with expertise in Human Factors (HF) and its application to neonatal resuscitation. Her long-term career objective is to apply HF methodology to neonatal resuscitation to improve provider resuscitation performance and neonatal outcomes. Her immediate goal is to acquire the mentorship, training, and research experience needed to successfully compete for R01 grants aimed at optimizing neonatal resuscitation to decrease variation in DR practices and outcomes. To achieve these goals and transition to independence, Dr. Herrick and her mentors have developed a comprehensive career development plan based on the following: (1) intensive mentorship from a team with whom she has a proven track record of collaboration and scholarship; (2) advanced training in HF in complex systems, quality metric development, and qualitative methodology; (3) mentored leadership positions, and (4) an innovative research plan to use a HF framework to define and validate DR quality metrics and to develop comprehensive DR models to evaluate factors that impact quality. Prematurity is a major clinical problem with enormous societal burden and cost, affecting one in ten deliveries in the US. DR resuscitation is paramount to the survival of extremely premature neonates. Unfortunately, significant variation in DR practices and outcomes exist within the US. This variation emphasizes the need for improved and consistent care. Unfortunately, there are no comprehensive approaches to assess DR care, and no validated DR quality metrics exist to help explain and rectify this variation. Leveraging HF methodology in a multicenter study, Dr. Herrick’s research proposal will fill this knowledge gap by (1) performing and in-depth works systems analysis of DR resuscitation to identify systematic factors that impact process and outcome variation, (2) identifying and refining DR quality metrics using a modified Delphi Process, and (3) testing reliability and validity of consensus quality metrics. Dr. Herrick’s K08 studies will address the critical gap of lack of DR quality metrics. The findings from these studies will directly inform future R01 proposals aimed at decreasing variation to optimize neonatal resuscitation. Her career development plan outlines a clear path to gain the knowledge, skills, and experience needed to gain independence as a health services research scientist and to become a leader in the application of human factors to neonatal resuscitation.

NIH Research Projects · FY 2026 · 2022-05

PROJECT SUMMARY Growth plates are highly specialized cartilage structures that ensure skeletal growth and endochondral ossification during fetal and postnatal development. They are formed and maintained by chondrocytes, as these cells follow a spatially and temporally tightly controlled multi-step differentiation program. The present project focuses on transcription factors that have pivotal roles in effecting this program, but whose modes of actions remain incompletely deciphered. It will test the paradigm-shifting hypothesis that SOX9, its cofactors SOX5 and SOX6, and RUNX2 and RUNX3 fulfill many of their main functions in a cooperative manner. This hypothesis is based on a solid scientific premise that includes co-expression of the factors in growth plate chondrocytes, the presence of RUNT-domain motifs in many chondrocyte-specific enhancers bound by SOX9, and preliminary evidence that the SOX and RUNX proteins have synergistic activities in enhancer activation. Specific Aim 1 is to determine whether SOX5/6, SOX9 and RUNX2/3 genetically interact during growth plate formation in mouse fetuses and in the maintenance of active growth plates in juvenile mice. Specific Aim 2 is to profile the whole genetic targetomes of SOX5/6, SOX9 and RUNX2/3 in growth plate chondrocytes, and to assess and validate their overlap. Specific Aim 3 is to identify mechanisms underlying SOX5/6, SOX9 and RUNX2/3 cooperativity. The proteins will be tested for roles in inducing chromatin accessibility and three- dimensional connectivity, and for cooperativity in DNA binding and recruitment of functional partners. New findings should have a significant impact on current understanding of fundamental mechanisms governing the formation and maintenance of growth plates and other cartilage types. They should thereby help uncover the molecular basis of many types of pathologies, including chondrodysplasias, tumors and joint degenerative diseases, and also suggest novel, innovative and efficient treatments for these still unsatisfactorily treatable diseases.

NIH Research Projects · FY 2026 · 2022-05

PROJECT SUMMARY Intellectual disabilities (ID) are lifelong conditions caused by neurodevelopmental errors. We recently identified gain and loss of function (GOF and LOF) mutations in the chromatin modifier Enhancer of Zeste Homologue 1 (EZH1) as the cause a previously undiagnosed intellectual disability syndrome in ten children. EZH1 is one of the two Histone H3 Lysine 27 (H3K27) methyltransferases of the Polycomb Repressive Complex 2 (PRC2). The other one, EZH2, has long been considered the main responsible for H3K27 di and trimethylation (H3K27me2/3) and PRC2 mediated transcriptional repression, in part owing to a weaker catalytic activity of EZH1. EZH2 is highly expressed in dividing cells, and its dysfunction leads to defects in neural progenitor proliferation and fate specification, and neurodevelopmental disease. Despite evidence indicating that EZH1 is also expressed in the developing and adult nervous system, its relevance and function in neural development and homeostasis remain unknown. In preliminary work, we found that EZH1 is expressed constantly across human cerebral cortex development and becomes the predominant paralogue by the late neurogenesis period owing to a rapid decline of EZH2 expression. Using human embryonic stem cells (hESC) carrying EZH1 LOF and GOF mutations, and their differentiation to cortical neurons in monolayer and organoid cultures, we found signs of delayed neuronal differentiation in EZH1 LOF and premature differentiation in EZH1 GOF. However, amounts of H3K27me3 measured by WB, showed similar levels across all the mutant and control cell lines. Thus, we hypothesize that EZH1 regulates cortical neurogenesis timing through a non EZH2 redundant mechanism that becomes dominant as neurogenesis progresses and EZH2 expression declines. To test this hypothesis in Aim 1 we will determine differentiation stage specific molecular functions of EZH1 during neurogenesis by defining the genomic binding profile of EZH1 (SubAim1.1), its effects on H3K27 methylation and transcriptional regulation (SubAim1.2), and the composition of PRC2-EZH1 subcomplexes (SubAim1.3) over time during neuronal differentiation. In Aim 2 we will dissect the effect of EZH1 mutations in cortical neurogenesis timing and the ability of EZH1/2 inhibitors to them we will dissect the origin and consequences of EZH1 mutation driven dysregulated neurogenesis timing by extending our organoid analysis to 30, 40, 60 and 100 days (SubAim2.1), by unbiased quantification of the composition and cell type specific differential gene expression using scRNAseq of the organoids (SubAim2.2), and assessing the potential of EZH1/2 inhibitors on restoring the cellular and molecular alterations caused by EZH1LOF and GOF mutations (SubAim2.3). These studies will uncover a currently disregarded role of EZH1 in the regulation of cortical neurogenesis and neurodevelopmental diseases and may provide new therapeutic targets for IDs.