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2018 ACTRI Pilot Project Recipients

Clinical Research | Life Course Research | Academic-Community Pilot Project | Dissemination and Implementation Research Pilot Project

UC San Diego Altman Clinical and Translational Research Institute (ACTRI) announces the selection of 14 Pilot Project grant awardees for 2018. Pilot Project grants are one-year competitive cash awards for researchers to obtain preliminary data. Recipients were awarded in the categories of clinical and translational research and, for the first time, two were selected in the category of life course research. Funding priority is given to junior faculty members. Below are the 2018 projects.

Funding Period is April 1, 2018 through March 31, 2019 [pending IRB approval].

Clinical and Translational Research Pilot Projects

Andrew Barleben, MD, MPH Andrew Barleben, MD, MPH
UC San Diego Department of Surgery

Title: Combined Computational-Experimental Approach to Evaluation of Abdominal Aortic Aneurysms following Stent Graft Placement to Mitigate Endoleak and Late Graft Failure

The prevalence of abdominal aortic aneurysm (AAA) is up to 9 percent in developed countries with nearly 15,000 rupture-related deaths per year in the U.S. alone. This mortality rate is declining due to the administration of screening tests combined with the use of minimally invasive endovascular aneurysm repair (EVAR). In the U.S., approximately 30,000 aortic EVAR interventions are performed annually, with the majority of interventions performed in elective situations. However, large randomized, controlled trials have recently shown a higher risk of aneurysm-related mortality following EVAR compared to open surgical repair. This demonstrated increase in mortality rates following EVARs is often associated with the late development of endoleaks (ELs), a persistent leak of blood into the space between the vascular wall and the graft material that, over time, continually pressurizes and enlarges the aneurysmal sac. In spite of multiple studies targeting ELs, strategies to prevent these leaks remain elusive, pointing to an immediate need to improve the current understanding of the mechanisms responsible for their formation.

In order to develop the optimal patient-specific strategy to prevent the formation of ELs after EVAR, the vascular surgery division and engineering department propose to conduct a study of the complex AAA vascular network before and after EVAR using two different models. We will first reconstruct the AAA and its branches from high resolution CT scans (fine cut 1-2 mm) in 3D silicone flow models. This patient-specific information will then be investigated in two parallel models: 1) 3D-printed molds for precise silicone models for in vitro flow experiments following stent graft deployments, and 2) CFD simulations derived from these live models. Our combined computational-experimental approach will enable us to systematically explore the optimal strategy to minimize the onset of ELs and to maximize the efficacy of EL treatment should it occur. Our approach will also enable us to vary all relevant hemodynamic parameters in the abdominal aorta as well as in the branch vessels for each AAA geometry and endovascular graft position. Most importantly, our two-pronged approach will allow us to evaluate interventions leading to the cessation of pressure and flow outside of the EVAR in the aneurysmal sac optimizing its long-term outcomes. This will allow for several publications evaluating and validating the model and providing funding for future models and ultimately clinical application.

The main goal of this project is to develop a dual computational and experimental methodology that will guide the planning of AAA intervention. With the current advances in CFD simulations and high-resolution 3D printing, we expect that the proposed pre-intervention study could be conducted in just a few days. Additionally, our approach will allow for the optimization of other patient-specific pathology and interventions including thoraco-abdominal aneurysms and arterio-venous malformations. This dual methodology has the potential to improve the outcomes of thousands of people internationally and to minimize the future need of surveillance following repair of life-threatening disease.

Rafael Bejar, MD, PhD Rafael Bejar, MD, PhD
UC San Diego Department of Medicine

Title: Pilot study of age-associated cellular and molecular markers in patients with MDS

Older age is associated with increased risk of many cancer types, implicating age-related cellular processes in the transformation and growth of malignant cells. Progressive changes in telomere length, altered DNA methylation, clonal hematopoiesis, and increases in reactive oxygen species (ROS) and other inflammation associated molecules have been linked to age, systemic inflammation, and oncogenesis. Interactions among these changes and their amenability to therapeutic intervention has not been well explored. Thus, we propose to conduct correlative studies of age-related cellular processes in samples from a UC San Diego randomized, placebo-controlled clinical trial, Reach for Health (RfH), which was completed in 2016. This 2 by 2 designed trial explored the impact of 6 months of exercise and/or metformin treatment on endocrine and inflammatory biomarkers in 330 breast cancer survivors. Blood samples were collected before and after the 6 months of intervention and are available for correlative studies. To strengthen a future NCI/NIA proposal, this pilot study will provide preliminary results, feasibility data, and evidence of interaction between our experimental groups.

Leslie Crews, PhD Leslie Crews, PhD
UC San Diego Department of Medicine

Title: Targeting Interferon-responsive Transcripts to Prevent Malignant Regeneration in Multiple Myeloma

The overall goal of this pilot translational research study is to elucidate the inflammation-responsive molecular mechanisms that promote malignant stem cell generation in multiple myeloma, a fatal plasma cell neoplasm that represents the second most common blood cancer in the U.S. To achieve this goal, this project combines a hypothesis-driven investigation of the relationship between interferon-response factor (IRF) transcriptional activation and stem cell regulatory gene expression with pre-clinical evaluation of a novel antisense oligonucleotide therapeutic strategy targeting IRF4 transcripts. This is a collaborative effort utilizing pre-clinical reagents developed by Ionis Pharmaceuticals (Carlsbad, CA) in our novel primary-patient derived xenograft (PDX) models of high-risk multiple myeloma. By uniting hematology clinical experts at the Moores Cancer Center with drug development industry collaborators, along with my stem cell biology and cancer research expertise, this multidisciplinary project will yield new insights into the pathogenesis of multiple myeloma with a focus on preventing malignant regeneration leading to drug resistance. Comprehensive mechanistic and functional studies will validate the potential impact of IRF4 gene modulation on myeloma-initiating cell survival and self-renewal. The aims of this proposal will 1) investigate whether IRF pathways activate pro-survival and self-renewal genes in multiple myeloma samples or in vitro drug resistance models and 2) evaluate the therapeutic efficacy of IRF4 antisense oligonucleotide treatment in humanized animal models. We will utilize frozen as well as fresh primary patient samples collected through an ongoing collaboration with Dr. Caitlin Costello at Moores Cancer Center. Mechanistic studies to validate the contribution of IRF4 to stem cell gene expression will involve sensitive single-cell profiling strategies correlating endogenous or lentivirally-enforced IRF4 expression with stem cell gene expression. Functional stem cell assays will include serial transplantation in vivo studies – the gold standard for evaluating cancer stem cell self-renewal –in PDX models that represent the most faithful pre-clinical models of human plasma cell neoplasms to date. Together, these unique disease models will facilitate generation of informative data on the potential therapeutic efficacy of IRF4 inhibition. These studies have the potential to bring about breakthroughs in the understanding of multiple myeloma progression and drug resistance, and identify a novel RNA-targeted treatment modality for multiple myeloma. By leveraging the expertise of a team of collaborators who are highly experienced in the development of novel therapeutics for cancer, this pilot project will help advance the rapid translation of IRF4 inhibitor therapy for myeloma. Implementation of multiple myeloma cancer stem cell-targeted trials will be accelerated with the support of stem cell clinical trials infrastructure established through the Moores Cancer Center and the California Institute for Regenerative Medicine (CIRM) Alpha Clinic at UCSD (Director, C. Jamieson).

Soumita Das, PhD Soumita Das, PhD
UC San Diego Department of Pathology

 Title: Targeting the Gut Barrier to Cure Inflammatory Bowel Diseases

In the U.S. approximately 1.3 million people suffer from Inflammatory Bowel Disease (IBD; consists of Crohn’s Disease and Ulcerative Colitis). IBD is characterized by inflammation that compromises the integrity of the epithelial barrier. The intestinal barrier separates diverse stressors (microbes, toxins) on one side from the immune system on the other. Harmful microbes cause infections that lead to chronic inflammation/IBD while dietary components and probiotics, (lactobacilli, E. coli Nissle) can maintain the health of intestinal epithelial cells [IECs] and the tight junctions (TJs). Despite the growth in this area of research and discovery of plausible targets, our knowledge about the protective components that reinforce the gut barrier during stress is incomplete and we need targeted therapy in IBD other than the anti-cytokine treatment. We propose to understand a specialized signaling initiated by the AMP-activated kinase (AMPK), called the stress-polarity pathway, which tightens the TJs. The PI’s collaborator Dr. Ghosh had recently discovered that GIV/Girdin is an essential downstream effector of AMPK at the TJs. Single site phosphorylation of GIV by AMPK is important to strengthen TJs in cultured epithelial monolayers. Using human gut-derived enteroid monolayers (Ems), AMPK→GIV stress-polarity pathway will be tested to know the protecting effect of the gut-barrier against a variety of stressors (e.g., pathogenic strains of E coli, LPS or ROS). We hypothesize that vitamins, probiotics (kefir/yogurt), all of which are known to activate AMPK, protect the gut-barrier via the AMPK→GIV stress-polarity pathway, and thereby, promote healthy state that will be tested in the following aims: 1) Determine the effect of pathogenic microbes on the stress-polarity pathway in the healthy colon vs IBD; and 2) Determine the effect of natural products, micronutrients and probiotics on the stress-polarity pathway in the healthy colon vs IBD. In both the aims, TJ integrity will be monitored by measuring transepithelial electrical resistance, permeation of fluorescent dextran, confocal imaging of junctional markers. The expected outcomes include unraveling a new strategy to treat IBD, uncover any dietary components as adjuvant therapy, and also, developing a method for rapid screening of food products and probiotics for their barrier-protective/destroying effects in the gut.

Adam DeConde, MD Adam DeConde, MD
UC San Diego Department of Surgery

 Title: Investigation of the Lipomics of Aspirin-exacerbated Respiratory Disease

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease present in up to 15% of the U.S. population with an estimated annual cost of $22 billion. Despite an optimized multidisciplinary approach to CRS, the progression of the disease process results in revision surgery within 5 years in the majority of CRS patients with nasal polyposis (CRSwNP). A subset (15%) of patients with CRSwNP are afflicted by a particularly recalcitrant form that is marked by respiratory tract reactions to aspirin (ASA), nasal polyposis, and moderate-to-severe asthma. The mechanism underlying this disorder, known as ASA-exacerbated respiratory disease (AERD), is not fully understood, but is marked by aberrant metabolism of arachidonic acid resulting in rapid eicosanoid formation and robust eosinophilic tissue infiltration. Aspirin-induced acetylation and inhibition of human cyclooxygenase-2 (COX-2) eventually leads to accumulation of PGD2 as well as 15-HETE that then yields lipoxin A and B, which are potent anti-inflammatory mediators. The PGD2 receptor CRTH2 has a known role for chemotaxis of eosinophils and T helper type 2 cells (Th2) and our group and others have shown that PGD2 also induces chemotaxis of innate lymphoid type 2 cells (ILC2s) via CRTH2. Our group was also the first to report that ILC2s are recruited to nasal mucosa of AERD patients after COX-1 inhibition. In addition to chemotaxis, PGD2 induces Th2 cytokine production from purified ILC2s suggesting that the PGD2/ILC2 axis could promote AERD features. Overall, levels of PGD-2, 15-HETE, lipoxins A&B, and ILC2s are likely critical in the regulation of AERD pathogenesis. Through a collaboration with the UC San Diego Lipidomics Core we will use liquid chromatography and mass spectrometry to analyze 160 eicosanoids associated with AERD CRS. Our approach addresses two questions: 1) How do levels of novel eicosanoid mediators change pre and post COX inhibition in AERD patients?; and 2) How do novel eicosanoid mediators regulate innate lymphoid type 2 cells (ILC2s) in AERD? For the first, we hypothesize that patients that have previously undergone successful aspirin-desensitization will have maintained higher levels of 15-HETE relative to baseline levels of those who did not respond to desensitization. Using the biobank of serum and urine specimens we have collected from patients undergoing aspirin challenges and long-term desensitization (>6-months), we will perform a complete lipidomics analysis. We expect to find elevation of 15-HETE and lipoxins A&B after successful desensitization as well as discover novel lipid mediators that may contribute to AERD.

For the second, we hypothesize that anti-inflammatory eicosanoids 15-HETE and lipoxins will be increased in patients with reduced levels of tissue ILC2s and that anti-inflammatory lipids will directly reduce ILC2 activity in vitro. We will correlate changes in eicosanoid mediators with changes in ILC2 and eosinophil levels in blood and nasal samples. Further, we will sort peripheral blood ILC2s from patients and culture with lipid mediators to assess chemotaxis and Th2 cytokine production after stimulation with PGD2 and CysLTs. We expect that 15-HETE as well as lipoxins A&B will be increased in patients with reduced tissue ILC2s and may directly reduce ILC2 chemotaxis and activation in vitro.

Paul Kim, MD, FACC Paul Kim, MD, FACC
UC San Diego, Division of Cardiology

Title: Identifying an Immune-mediated Mechanism in Non-specific Allograft Dysfunction of Heart-Transplant Patients

Heart-transplantation saves the lives of approximately 5,000 end-stage heart failure patients worldwide annually. However, heart-transplantation is not a cure and its longevity is typically limited to 10 years due to graft dysfunction. The major known causes of graft dysfunction are acute cellular rejection, antibody-mediated rejection and cardiac allograft vasculopathy (CAV). Despite improved recognition and understanding of rejection, a significant percentage of heart-transplant patients with graft dysfunction still do not have an identified cause. These patients are categorized as having nonspecific graft dysfunction (NGD) and represent up to 36 percent of patients with graft. NGD is the leading cause of death in years 1 through 10 after heart transplantation and is one of the top three indications for retransplantation. Without understanding the cause for graft dysfunction, heart-transplant physicians do not know how to best care for NGD patients and improve their survival. Our objective is to identify the underlying cause of NGD in heart-transplant patients, with an aim to identify the immune-mediated mechanism for NGD. Our hypothesis is that NGD is primarily due to microvascular CAV as a result of chronic inflammation mediated by T-cells. Cardiac MRI has shown potential to be much more sensitive in diagnosis of both macro- and microvascular CAV than the current standard of coronary angiography. The PI previously conducted a study of 18 patients at Stanford University demonstrating significantly decreased myocardial perfusion reserve in NGD patients compared to heart-transplant patients with normal graft function, consistent with microvascular CAV. Given the essential role for T cells in regulating immunologic tolerance and multiple pathways for contributing to acute allograft rejection, we hypothesize that alloreactive T cell responses are also the central element regulating chronic rejection that leads to persistent inflammation of the intima seen in CAV. Population-level analysis of T cells have demonstrated that alloreactive T cell responses are oligoclonal, with identifiable TCR𝛽 clonotypes associated with either rejection or immunologic tolerance. We will use blood samples from the prior study and from heart-transplant patients here at UC San Diego. We will separate peripheral blood mononuclear cells and subsequently sort individual T cells. We will perform single-cell T cell receptor (TCR) sequencing and key effector gene expression analysis to identify significantly increased TCR clonotypes and their associated functional phenotype in NGD patients compared to patients with normal graft function and previously diagnosed macrovascular CAV. Dr. Morris has successfully adapted a barcoded nested PCR strategy for identification of TCR𝛂 and TCR𝛽 transcripts, as well as evaluation of expression of key transcription factors. Additionally, immunophenotyping of peripheral blood mononuclear cells by CyTOF at the La Jolla Institute will be performed to identify other increased immune cell subsets. The prepared and banked samples from the previous study are ready to be run as the first batch. We hypothesize that a particular T cell clonotype and its associated phenotype will be significantly increased in NGD patients. Such a finding would be the crucial first step in the development of life-saving treatments for heart-transplant patients with NGD and macrovascular CAV.

Kevin King, MD, PhD Kevin King, MD, PhD (Daniel T. O’Connor Award Recipient)
UC San Diego, Division of Cardiology, and Department of Bioengineering

Title: Clinical Pilot of Single Cell Analysis during Human Cardiac Ischemia and Infarction

Ischemic heart disease, which spans myocardial infarction (MI), fatal arrhythmias, and heart failure, is the most common cause of death in the world. When heart cells die, they release molecular danger signals that overlap with features sensed by our immune system to recognize pathogens. Consequently, MI elicits a strong innate immune response by recruiting inflammatory cells to the heart, first from the blood, but later from emergency hematopoietic reservoirs in the bone marrow. Deep phenotyping of post-MI trafficking cells can provide a window into the biology that orchestrates cardiac healing, repair, and remodeling. The goal of this pilot is to use single cell RNA-Seq of circulating cells to perform comprehensive transcriptional profiling of all genes expressed by all trafficking immune cells after MI in humans.

In mice, the signaling molecules that dominate post-MI inflammation were thought to be toll like receptors (TLRs), NFkB-dependent cytokines such as TNFa and IL1b, and the inflammasome. We recently discovered that a parallel arm of the immune system known as the anti-viral response plays an equally critical role in post-MI biology. We found that the DNA sensor cGAS, the transcription factor IRF3, and type I interferon-induced chemokines and cytokines are strongly activated in cardiac macrophage subsets after MI. Genetically or pharmacologically inhibiting this response reduced inflammation, improved ventricular remodeling, and led to improved survival after MI (NIH NHLBI K99/R00) (manuscript in final revision at Nature Medicine). Discovery of this new pathway was made possible by genome-wide profiling post-MI immune and non-immune cell responses using single cell RNA-Seq. In this pilot project, we will adapt these methods to study the response to myocardial injury in humans. In humans, the relationship between inflammation to ischemic heart disease is increasingly evident. Early observational studies found that patients with greater monocytosis had worse outcomes after MI. More recently, patients with clonal hematopoiesis of indeterminate potential (CHIP) were found to have a four-fold increased risk of MI, demonstrating that immune cell reservoirs are unexpected determinants of ischemic heart disease. Finally, in July 2017, CANTOS, a Phase 3 clinical trial of anti-IL1b monoclonal antibody therapy for secondary prevention of MI, reported that its primary endpoint was met, providing the first human evidence that therapeutically targeting inflammation is beneficial for ischemic heart disease. A comprehensive and molecularly unbiased investigation of the overlapping immune responses to MI will provide a powerful foundation for rational development of new post-MI therapies. We will collect whole blood and clinical data from patients presenting with MI (NSTEMI/ STEMI). After removing erythrocytes and sorting live cells, we will perform Split-Seq, a new method that requires minimal instrumentation and is highly compatible with clinical environments. We anticipate barcoding >5,000 single cells from each of five patients in the pilot.

Olivia Osborn, PhD Olivia Osborn, PhD
UC San Diego, Department of Medicine

Title: Metabolomic Signatures Associated with Antipsychotic-induced Food Intake

Antipsychotic medications (AP) are prescribed to manage a range of illnesses including schizophrenia, depression, post traumatic stress disorder and general anxiety. However, AP medications induce rapid weight gain driving subsequent development of cardiovascular disease and type 2 diabetes. With the current worldwide obesity epidemic it is particularly important to mitigate the weight gain side effects of medications that could further exacerbate this obesity crisis. The polypharmacological nature of APs has made it extremely difficult to separate therapeutic efficacy from unwanted side effects and thus the exact mechanisms by which they induce increased food intake (hypeprhagia) are still unclear. We made the surprising discovery that APs also induced a hyperphagic response in the basic organism C. elegans. We then conducted an in vivo food intake screen in C. elegans to identify potential adjuvant therapies that would abrogate the hyperphagia and weight gain effects. We screened FDA-approved drugs to reduce the risk of toxicity and other unwanted side-effects and provide the fasted potential route to identification of an adjuvant treatment that could be used in the clinic. We identified that minocycline potently suppressed olanzapine-induced hyperphagia and extensive testing in mice shows that this effect is conserved in mammals. Co-treatment with minocycline completely blocks olanzapine-induced hyperphagia and weight gain in both short-term and chronic studies. Importantly, treatment of minocycline alone had no effect on body weight or feeding behavior suggesting that AP-induced hyperphagia is distinct from normal mechanisms involved in feeding. We will conduct metabolomic studies, in collaboration with Dr, Mohit Jain (Dept. of Medicine), to determine putative biomarkers and underlying pathways involved in AP-induced hyperphagia. We plan to perform untargeted metabolomics analysis to determine the metabolite profile in mouse plasma from the four treatment groups, olanzapine, vehicle, minocycline and co-treatment with olanzapine and minocycline (n=8 per group). This study will identify biomarkers and underlying pathways involved in AP-induced hyperphagia that can then be directly tested in human patients in future human clinical trials.

Bryan Sun, MD, PhD Bryan Sun, MD, PhD
UC San Diego, Department of Dermatology

Title: Impact of Beckers Nevus-Associated ACTB Mutations on Hedgehog Signaling

Beckers nevus (BN) is a cutaneous hamartoma that classically appears in childhood as a unilateral tan-to-brown patch that increases in thickness, pigmentation, and hair growth during puberty. It affects approximately 1 in 200 males. Histologically, BN is characterized by epidermal acanthosis, increased terminal hair follicles, and irregularly dispersed ectopic smooth muscle bundles. In rare instances, BN can be associated with underlying musculoskeletal abnormalities, mental retardation, developmental delay, and/or cardiomyopathy. These syndromic cases are termed Beckers nevus syndrome (OMIM 604909). On the skin, conditions that appear in a segmental, regional, or linear distribution often result from somatic mutations that are present only the affected portion of the skin, which we and others have demonstrated in skin conditions such as sebaceous and epidermal nevi (Sun et al. 2013, PMID 23096709). Recently, we identified beta-actin (ACTB) missense mutations that are present in most cases of Beckers nevi but absent in adjacent normal skin, implicating this mutation as the underlying cause (Cai et al. 2017, PMID 28347698). Expression of BN-associated ACTB mutant proteins in a myoblast cell line resulted in increased expression of Gli-1, a key transcription factor of the Sonic Hedgehog (Shh) signaling pathway. The Shh pathway contributes to muscle, hair follicle, and epidermal development, suggesting a potential mechanism linking these ACTB mutations to their phenotype. The goal of this proposal is to determine if aberrant Shh signaling drives the pathogenesis of Beckers nevi.

Cytoskeletal proteins such as actins, collagens, and keratins are often envisioned as primarily structural molecules. However, there is growing appreciation that these classes of proteins also play critical roles in cell signaling, immune reactions, tissue homeostasis, and predisposition to cancer. We aim to study the pathogenesis of a mosaic skin condition to better understand the broader biological role of cytoskeletal mutations and cell signaling on tissue development, cell-cell communication, and disease. Histologically, BN demonstrate overgrowth of multiple cell lineages, including epidermal keratinocytes, hair follicles, and smooth muscle. Our first aim will be to evaluate Shh pathway activity in constituent cell types of BN and control skin tissue samples by immunohistochemistry. Our second aim will be to investigate the biological mechanism by which BN-associated ACTB mutations lead to the overgrowth phenotype. We will use CRISPR-Cas9 editing to engineer the causative mutations in keratinocytes, fibroblasts, and myocytes. We will perform whole transcriptome studies to determine which cellular pathways are altered by these ACTB mutations.

Niels Vande Casteele, PhD Niels Vande Casteele, PhD
UC San Diego, Department of Medicine

Title: Quantification of Denatured and Degraded Drug in Intestinal Tissue Samples from Inflammatory Bowel Disease Patients Treated with Vedolizumab

To understand the pharmacokinetics of biologics used in inflammatory bowel disease (IBD) in relation to safety and efficacy, it’s important to investigate intestinal tissue drug concentrations. Confirmation of drug exposure at the target site (bowel mucosa) is of high interest for systemically administered biologics to confirm local target engagement and mechanism of action (MOA). Furthermore, quantification of biologics in intestinal tissue along with disease activity measures (histology) is critical, since the disease state can modulate the penetration of biologics into the affected tissue. The antibody vedolizumab, an integrin antagonist targeting α4β7, showed to be effective in inducing and maintaining clinical remission in IBD (Sandborn 2013; Feagan 2013). Vedolizumab inhibits leukocyte migration to the gut through blockage of the interaction between α4β7 integrin on memory T- and B-cells and mucosal addressin cell adhesion molecule-1 expressed on the vascular endothelium of the gut. Even though in vitro studies showed 95 percent receptor occupancy at vedolizumab concentrations of 1 ug/mL (Rosario 2015), there may be a benefit for targeting higher serum vedolizumab concentrations in patients as higher vedolizumab serum concentrations were associated with better outcomes to therapy, which cannot be explained by receptor saturation alone (Sandborn 2013; Feagan 2013). This leads to the possibility that penetration of drug into the tissue may be important for the MOA of vedolizmab. Quantitative analysis of biologic drug tissue concentrations will enable a better understanding of parameters influencing drug disposition and target engagement at site of action. The goal is to develop and validate a generic method to quantify denatured and degraded vedolizumab in intestinal tissue biopsies. The method, however, would allow for the quantification of vedolizumab in blood and stool samples as well. Although vedolizumab is approved for the treatment of IBD, there is currently no data regarding tissue concentrations in relation to serum concentrations or clinical, biomarker or endoscopic outcomes. There are no commercial assays to quantitatively measure vedolizumab in tissue and stool samples. The specific aims of this project are to 1) Develop a multiple reaction monitoring-mass spectrometry (MRM-MS) technique for the detection and quantification of vedolizumab in freshly frozen tissue biopsy samples and 2) Validate the MRM-MS technique by analyzing biobanked intestinal tissue biopsy samples from well-characterized IBD patients that received vedolizumab and to correlate this with concentrations of drug found in serum and stool.

This project will be a collaboration between the UC San Diego Division of Gastroenterology and the Biomolecular and Proteomics Mass Spectrometry Facility, and requires a multidisciplinary approach combining know-how and expertise from the field of molecular biology, pharmacology, immunology and medicine and will lead to pioneering translational research.

Amir Zarrinpar, MD, PhD Amir Zarrinpar, MD, PhD
UC San Diego, Department of Medicine

Title: Serum Bile Acid Pool of Patients with Hepatic Encephalopathy

Hepatic encephalopathy (HE), a potentially reversible and manageable complication of liver failure, is manifested by abnormal behavior, cognitive impairment, and, in severe cases, coma. Although the first neuropathological description of HE occurred seven decades ago, our understanding of its pathogenesis is incomplete. The prevailing theory has been that the cognitive impairment and cerebral edema is the result of shunting of ammonia from the portal into the systemic circulation. However, studies over the last two decades have both cast doubt on the central role of this mechanism and introduced other etiologies for this disease, including alteration in the bile acid (BA) pool size and composition. For example, deoxycholic acid can affect the permeability of the blood brain barrier, whereas ursodeoxycholic acid can reverse neuroinflammation. In addition, HE is associated with an increase in the size of the serum BA pool, making direct administration of beneficial BAs an ineffective therapy. Of note, the composition of the serum BA pool is shaped by the gut microbiome which supply many of the secondary BAs. BA sequestrants have been effective in treating HE in animal models. Current treatments for HE attempt to decrease serum ammonia by altering the composition of the gut microbiome, either with lactulose (a non-absorbable sugar) or rifaximin (antibiotic). Interestingly, these treatments can also potentially affect the size and composition of the BA pool by changing the gut microbiome. Hence, the central hypothesis of our proposal is that serum BA pool plays an important role in the etiopathology of HE.

This project aims to determine whether the transjugular intrahepatic portosystemic shunt (TIPS) procedure alters systemic BA pool and composition. Patients who receive TIPS procedures for complications of chronic liver disease are particularly at risk for development of HE. The risk of overt HE after TIPS is approximately 35 percent. We will acquire blood immediately before (when portal and systemic circulation are separated) and immediately after (when there is a shunt between portal and systemic circulations) the TIPS procedure. We will attain an additional blood sample if the patient is hospitalized for HE. Comparing serum BA pool before and after the procedure, along with tracking the participant’s cognitive/HE status, will help us determine whether BA changes are associated with HE.

This project will be done collaboratively with Dr. Irine Vodkin (hepatology), Dr. Hamed Aryafar (interventional radiology), and Dr. Alan Hofmann (bile acid expert, mentor). The results from this study will also help determine whether affecting the BA pool is a plausible strategy for the treatment of HE.

Life Course Research

Eileen Moore, PhD Eileen Moore, PhD
San Diego State University, Department of Psychology

Title: Pharmacological Treatment to Improve White Matter Plasticity in FASD

Prenatal alcohol exposure can cause a range of birth defects, growth retardation, dysmorphology, and neurobehavioral deficits. Collectively, these are referred to as fetal alcohol spectrum disorders (FASD). The brain is vulnerable to alcohol teratogenesis, and the impact of prenatal alcohol exposure on brain structure and function has been well documented. Individuals with prenatal alcohol exposure suffer behavioral and cognitive deficits that have a profound impact on their quality of life. Children and adolescents with FASD display deficits in attention, visuospatial processing, memory, and executive functions, among others. They also have increased rates of psychiatric disorders such as depression and anxiety, have difficulties socially and academically, and are over represented in the juvenile justice system. Adults with FASD continue to display cognitive deficits, have high rates of psychiatric and personality disorders, have difficulty living independently and maintaining employment, and are more likely to have trouble with the law or develop a substance abuse problem. Efforts to increase public awareness of the devastating consequences of prenatal alcohol exposure are ongoing in an attempt to prevent alcohol-exposed pregnancies. Despite prevention efforts, current estimates indicate that as many as 5 percent of children in the U.S. are living with an FASD, highlighting the crucial need to identify efficacious treatments to assist these individuals.

Magnetic resonance imaging (MRI) research has shown that the brain’s white matter is a target of alcohol teratogenesis. For example, the corpus callosum of individuals with FASD is smaller, malformed, and displays microstructural abnormalities as compared to individuals without prenatal alcohol exposure. However, longitudinal studies show that for children with FASD, increases in white matter volume over time are associated with cognitive gains. This suggests that interventions that improve white matter integrity or plasticity could be beneficial for those with FASD. This translational research plan uses a model of FASD to evaluate pharmacological compounds that have the potential to promote white matter development. The pilot will evaluate TRO 19622 (Olexoxime), a drug that is commercially available and has been shown to promote myelin formation and alleviation of spatial learning and memory deficits in a rat model of demyelination. Mice that have been exposed to alcohol prenatally will be treated with Olexoxime or vehicle during the juvenile and adolescent period, and subsequently will be tested to determine if this drug can ameliorate alcohol-related spatial learning and memory deficits in these mice. Subsequently, T2-weighted MRI and diffusion tensor imaging (DTI) will be utilized to determine if changes in white matter can be observed following Olexoxime treatment. Lastly, histological and immunohistochemical methods will be utilized to verify Olexoxime treatment produces changes in white matter. This project utilizes a pre-clinical model of prenatal alcohol exposure to aid in developing a novel potential pharmacological treatment that would be administered to alleviate deficits seen in childhood and adolescence.

Academic-Community Pilot Project

Inna Fishman, PhD Mikaela Kinnear, PhD Inna Fishman, PhD
Department of Psychology
San Diego State University

Mikaela Kinnear, PhD
Department of Psychology
San Diego State University

Community Partner:
Richie Ploesch, MA, BCBA
National Comedy Theatre
Unscripted Learning

Title: Evaluating Clinical Outcomes of Improv Theater Intervention for Teens with Autism

The high prevalence of autism spectrum disorders (ASDs) presents a growing public health challenge. Difficulties with social interactions, a hallmark characteristic of ASDs, have cascading deleterious effects on the ability to productively participate in society, with profound consequences for health, economic and social outcomes throughout the lifespan. Although a number of evidence-based interventions have shown promise in reducing social symptoms in younger children with ASDs, improving social functioning in adolescents with ASDs remains a persistent challenge. This community-university partnership project will investigate the promise of a novel intervention rooted in Improvisational theater and comedy to improve social skills in adolescents with ASDs. Unscripted Learning (UL) is a non-profit organization affiliated with the National Comedy Theater in San Diego, CA, utilizing Improvisational Comedy Theater to address social anxiety, cognitive flexibility, and verbal and non-verbal communication skills. UL's existing program, Connections, uses Improv theater techniques to teach creative thinking, listening and social awareness to help teens with ASDs develop social and communication skills in a fun and safe environment. We will assess whether this intervention can bring a measurable change in anxiety, social competence, empathy, cognitive flexibility, and overall quality of life for teens participating in the UL’s Connections Program.

To achieve the project’s aims, students enrolled in the upcoming UL Connections sessions will be asked to participate in the program evaluation to determine its efficacy as a social skills intervention. Those who agree to participate will receive a packet of the assessment measures. Measures of ASD symptoms, anxiety, social competence, empathy, executive function, and overall quality of life will be administered at three time points: prior to the start of the program (baseline), at the completion of the program (posttest), and 6 months following the program completion (follow up). This study design will allow us to assess differences in anxiety and other associated symptoms resulting from the intervention, as well as test for persistence of change following the program. It is anticipated that approximately 30 adolescents with ASDs between the ages of 13-17 years will participate in the upcoming UL Connections (over the course of 2018) and agree to take part in the study. Given the nature of comedy improvisation – it requires creative thinking, listening and social awareness – we anticipate significant improvements on measures of social competence and empathy, as well as a decrease in symptoms of anxiety.

In summary, this project will forge a new collaboration between the UL’s Connections Program and San Diego State University (SDSU), allowing acquisition of pilot data, which can strengthen a future application for external funding addressing the translational aspects of this research for people with ASDs. Given the dramatic rise in the numbers of children diagnosed with autism, a disorder that severely compromises the ability to participate productively in society, this project will have a substantial impact on the ASD community (independent on the anticipated results) through providing additional funds for the Connections program to support additional programming, and to further serve as a resource for parents and teens with ASDs.

Dissemination and Implementation Research Pilot Project

Sheila Mody, MD, MPH
Department of Reproductive Medicine
UC San Diego

Title: Exploring the Layers of Logistics of Adoption: Utilizing the PRISM Framework-informed Implementation Intervention for Direct Provision of Emergency Contraception by Pharmacists

UC San Diego is conducting a research study to assess pharmacists’ practices and attitudes on prescribing emergency contraception. We are inviting registered pharmacists working in the community to complete the survey. The information learned in this study will assist in dissemination and implementation of pharmacist services.

This study promotes the use of emergency contraception that has the potential public health impact of reducing the rate of unintended pregnancy. Nearly half (45%) of all pregnancies are unintended in the United States. The final opportunity to prevent an unintended pregnancy is to use emergency contraception. Most women access emergency contraception from pharmacies. In June 2013, levonorgestrel (Plan B) became available over-the-counter for consumers of all ages. Prior to this, levonorgestrel emergency contraception was available over-the-counter for consumers ages 17 and up or 18 and up, as well as from pharmacist prescribers in selected states including California. In 2010, ulipristal acetate (Ella), an anti-progestin, was approved by the United States’ Food and Drug Administration (FDA) for emergency contraception but is available by prescription only.

Pharmacist knowledge and local pharmacy availability of all oral emergency contraception options will enhance patient access and proper use. Ella, unlike Plan B, is available by prescription only. In seven states including California, pharmacists can prescribe Ella. Little is known about system and individual barriers and facilitators of emergency contraception counseling by pharmacists that includes Ella. Most of the studies focused on pharmacists being barriers rather than facilitators of emergency contraception. No study has investigated an intervention to support pharmacists with the implementation of emergency contraceptive provision that includes Ella.

In Phase 1 of this study, we will conduct up to 20 interviews with various stakeholders. The interviews will explore barriers and facilitators to pharmacist counseling and provision of emergency contraception including Ella. We will also conduct a survey of up to 1,000 pharmacists utilizing social media and e-mail list-serves for recruitment across California. In Phase 2 we will pilot test the academic detailing intervention in a cluster randomized trial comparing the effectiveness of the academic detailing intervention with no training. We will include a total of eight pharmacies, randomly assigning four to the academic detailing intervention and four to no intervention.