David J. Margolis, Ph.D. - US grants

Venous leg ulcers account for 40 to 70% of all chronic wounds, afflict 1 million Americans per year, and standard treatment for these patients is estimated to cost more than l billion dollars per year. The current standard therapy for these wounds is a limb compression bandage, which at best has a success rate of 70 to 80%. Very little information exists that can be used to predict who will have a successful outcome. The hypothesis of this proposal is that there are identifiable risk factors that can be used to predict which individuals will have a successful outcome. A statistically powerful prediction model will be created using logistic regression analysis based on a dataset derived from the candidate's clinical practice and the control inns of industry sponsored trials. This model will be validated using a split sample technique, and by a prospective study in Penn's Cutaneous Ulcer Center. It will provide information that will guide the design of studies to evaluate new therapies, establish relationships between risk factor and wound healing which will lead to properly controlled hypothesis driven research, and may demonstrate two clinically distinct subsets of patients with venous led ulcers.

DESCRIPTION: (Adapted from Investigator's Abstract) In the elderly, 2% to 5% are afflicted with chronic wounds. Chronic wounds account for more than 1 billion dollars of health care cost per year in the U.S. and seven billion dollars per year world wide. The two most common chronic wounds in the elderly population are pressure ulcers and venous leg ulcers. Patients with these wounds have a diminished quality of life, more frequent visits with health care providers, and increased morbidity and mortality. Treatments for these wounds are often unsuccessful, so prevention is important. However, there is very limited clinical information based or good scientific study on how to prevent the occurrence of these wounds. The hypothesis of this application is that individuals with pressure ulcers or venous leg ulcers have identifiable medical profiles that can be used in clinically useful models to determine who is at risk for a venous leg ulcer or pressure ulcer. The incidence rates of venous leg ulcers and pressure ulcers will be determined in cohorts established using data from U.S. Medicaid and the U.K. based General Practice Research Database (GPRD). Both of these databases have been extensively analyzed and used in peer reviewed publications. They differ in that the U.S. Medicaid database is a claims based database and the GPRD is a patient record database. The population of these databases represents only those who are seeking medical care. These are the individuals who are most seriously afflicted with a venous leg ulcer or pressure ulcer, the most likely to suffer morbidity and mortality from the conditions and, since they have contact with health care providers, exactly those who can be evaluated for prevention. A case-cohort study design will be used to examine risk factors for nonspecific chronic wounds and risk factors specific to venous leg ulcers and pressure ulcers, from among those that have been suggested by expert opinion, case reports, non-experimental studies and experimental studies. Fully adjusted explanatory models will be developed utilizing a modified Cox proportional hazards method. Prediction models will then be developed for U.S. Medicaid data, using a modified Cox proportional hazard method, and subsequently validated using the GPRD data.

This is a dual phase 1 set of studies on venous leg ulcer therapy, the goals of which are to (1) determine the maximum tolerated dose of an adenovirus vector based gene transfer of PDGF/B into chronic wounds, and (2) determine the feasibility and safety of this approach for the treatment of venous stasis leg ulcers over a 24 week course. The investigators will evaluate the safety and feasibility of this approach in the trial and the ancillary studies will investigate the persistence of the transferred genetic material in the patient, critical for advancing the use of the therapy.

DESCRIPTION (adapted from the application) Lower extremity ulcers are a serious complication of diabetes mellitus. More than 16 million people in the US have diabetes mellitus and 15% of them can expect to develop a foot ulcer at some point in their life. Annually more than 50% of all non-traumatic amputations occur in patients with diabetes, thereby making diabetes the leading cause of lower extremity non-traumatic amputation. Lower extremity chronic wounds precede more than 85% of these amputations. In diabetics, the etiologies of these wounds are believed to be lower-limb arterial insufficiency, neuropathy, or a combination of both. The patients with diabetic neuropathy are often managed medically while those with arterial insufficiency are treated by vascular surgical intervention. Previous studies have shown that both poor lower-limb arterial blood flow and diabetic neuropathy are associated with the risk of developing a foot ulcer and eventually an amputation. However, very little has been published on the risk factors or prognostic factors associated with the failure of a patient with a diabetic neuropathic foot ulcer to heal. This is problematic, since new medical treatments recently approved by the FDA were specifically labeled for the treatment of diabetic neuropathic foot ulcers. Without knowledge of risk and prognostic factors, it is difficult for health care practitioners to make informed decisions with respect to whom they should treat with standard care and it is very difficult for a clinical investigator to plan well designed clinical trials. Using the largest wound care specific database and multivariable regression techniques, we will conduct a series of cohort studies to create explanatory and prognostic models. The explanatory models will be used to estimate the association of a risk factor on the likelihood that a wound will heal (or require an amputation) by the 20th week of standard therapy. The prognostic models will be used to estimate the probability that an individual with a neuropathic foot ulcer will heal with standard therapy. Ultimately, parsimonious clinically friendly models will be developed from complex models, so that a healthcare provider can discriminate between those wounds that will heal (or require an amputation) with standard care and those wounds that will not heal (or require an amputation). These models will not only be useful to health care providers, but they will also be useful to clinical investigators trying to design clinical trials on patients that might maximally benefit from a new treatment.

DESCRIPTION (Taken from the applicant's abstract): David J. Margolis, M.D. MSCE is currently Associate Professor of Dermatology, an Associate Professor of Epidemiology in the Department of Biostatistics and Epidemiology, and Senior Scholar (core faculty member) in the Center for Clinical Epidemiology and Biostatistics of the University of Pennsylvania. He is a patient-oriented researcher with a track record of research. His research has been focused on the prevention and treatment of chronic wounds. He has applied a variety of epidemlologic tools and patient-oriented research methods to address research issues. His immediate and long-term career goals center on his desire and intention to continue to evolve and mature as a patient-oriented researcher, teacher, and mentor. Resources available to him, on and around the Penn campus, include biostatistical support, data management support, and research/clinical laboratory services. The proposed patient-oriented NAIMS-funded research project is in its first of five years. Most patients with chronic wounds of the lower extremity fail to heal in a reasonable period of time. In fact, despite considerable advances in elucidating the molecular basis of wound repair, attempts at developing new therapies have been disappointing. Current methods of applying cytokines to chronic wounds are inadequate. The PI hypothesize that a growth factor associated with wound healing PDGF-BB, when produced in large quantities within the wound bed due to adenovirus-mediated gene overexpression by the cells of the wound bed, will dramatically enhance wound healing. This study will use a gene therapy approach, adenovirus-Ad5 and the PDGF-B gene, to insure delivery of a cytokine growth factor to a non-healing wound. The aim of the research study is to assess local and systemic toxicity, and the biologic feasibility of using the maximum tolerated dose of H5.020CMVPDGF-B associated with in vivo PDGF-BB gene transduction via an intra-ulcer injection of H5.020CMVPDGF-B in patients with chronic venous leg ulcers. This study is a collaborative effort between investigators from the University of Pennsylvania Medical Center (Dermatology and Institute for Human Gene Therapy), the Wistar Institute, and the Children's Hospital of Philadelphia.

DESCRIPTION (provided by applicant): Acne vulgaris is an illness that afflicts adolescents and young adults. About 20% of those with acne, who seek medical care, are severe enough to require systemic therapy. Those on antibiotics receive about 9.7 million prescriptions for oral antibiotics and about 8.2 million for the topical antibiotics. Therapy frequently continues for more than 6 months. Simply stated, very large quantities of antibiotics are used for an extended period of time by this sector of the population. The burden of both acne and acne therapies, as with all skin diseases, on society and the patient has not been well described as discussed at a recent NIAMS conference. We have recently demonstrated that antibiotic therapy for ache when given topical and/or orally to young adults may profoundly affect an individual's likelihood of being colonized with group A streptococcus (GAS), the main bacterial cause of pharyngitis. Upper respiratory tract infections, including pharyngitis, are extraordinarily common acute medical problems that are primarily of viral origin, are self-limited acute condition, and are generally mild but have huge public health implications due to the shear magnitude of numbers of individuals afflicted. In fact, the US economic cost is estimated to be more than 25 billion dollars per year. There are very few natural models of truly long-term human antibiotic use. Acne is a model of a disease for which long-term antibiotic use is standard and appropriate therapy. In this proposal, we will explore possible mechanisms that may be responsible for the increase in oro-pharyngeal colonization of GAS that we have noted in individuals who use antibiotics (oral and/or topical) for acne. We believe that the antimicrobial effect is through the elimination of competing normal bacterial flora. In fact, GAS in the oro-pharynx has been shown to be "regulated" by another organism, like S. Salivarius. Epidemiologically, very little is known about the association of changes in the normal flora of the throat and how this may impact the acquisition and chronic carriage of GAS, or whether these changes are associated with an infectious illness (i.e., pharyngitis). Persistent colonization, potentially does not only put the patient at risk but increases the risk of spread of GAS to close contacts. Persistent colonization of GAS also increases the likelihood of GAS acquiring resistance directly and horizontally from related species. Finally, with respect to bioterrorism post-exposure prophylaxis with antibiotics such as the tetracyclines, which are used to treat acne, will need to be maintained for prolonged periods of time (6 to 8 months). There is currently very limited data on the long-term consequences of tetracycline use. With respect to all of these issues, acne patients represent a great model to study regarding both the long-term toxicity of antibiotics and the risks of increasing resistance among bacterial pathogens exposed to drugs during treatment. We hypothesize that the use of long-term antibiotics for acne can result in oropharyngeal colonization with GAS and that this colonization can result in morbidity. To that end, we describe studies to help us understand who is at risk for colonization with GAS, the likelihood that these individuals will be persistently colonized, and the likelihood that individuals on antibiotics will develop pharyngitis.

DESCRIPTION (provided by applicant): Atopic dermatitis (AD) is a highly pruritic chronic inflammatory skin disease that predominantly presents during infancy but may also present during childhood or adulthood. AD is a common skin disease characterized by recurrent episodes of itching and a chronic, relapsing course. The lifetime prevalence of AD is about 5-20 percent. Many with AD will also suffer with asthma and allergic rhinitis. The simple act of reliably identifying affected patients with AD and prognosticating on the natural history of their illness has been difficult. Clues on the severity of atopic dermatitis should center on a better understanding of the pathogenesis of this disorder. Many have assumed that the pathogenesis is based on genetic and environmental factors and that these factors influenced the clinical phenotype of the disorder. Most investigations on the pathogenesis of AD have centered on immunologic mechanisms and evaluations. However, starting in 2006 several seminal studies were published that may potentially revolutionize our understanding of the pathophysiology of AD. These studies described a defect in the skin barrier that is strongly associated with AD. This defect was due to a loss- of-function mutation for the production of a protein called filaggrin (FLG). The gene is located on chromosome 1q21. This gene encodes for profilaggrin, which is the principal constituent of the keratohyalin granule found in keratinocytes and the precursor for filaggrin. Based on studies using the first two sequenced FLG loss-of- function variants, the odds ratio of association among those with AD as compared to those without AD was between 8 and 14. However, the type of FLG loss-of-function mutations varies by cohort studied with the majority of those currently studied being of European ancestry. No large studies have been conducted on the heterogenous US population and very few have evaluated the prognosis of those who have AD and a FLG loss-of-function mutation. The Pediatric Eczema Elective Registry (PEER) is an ongoing prospective 10-year observational registry that is part of a post-marketing commitment by Novartis to the FDA and the European Drug Agency. The nearly 4,000 US children currently enrolled in the registry represent a unique opportunity to evaluate the natural history of AD in a group of children with a physician-confirmed diagnosis of AD. To that end we plan to establish a US national biobank of individuals with physician confirmed atopic dermatitis; to fully explore, sequence and identified FLG loss-of-function mutations (gene 1q21.3) unique to our ethnically diverse cohort; and to determine the association of the FLG loss-of-function mutations with respect to the natural history of AD in the PEER cohort. Atopic dermatitis is a chronic itchy rash of childhood and is estimated to cost these country 1.6 billion dollars per year. Over a lifetime, between 5 and 20 percent of the population will suffer from this disorder. Very recent work has shown that many with this disorder will have a genetic defect that alters how their skin protects them from the outside world. The goal of this study is to see how this defect may affect the diverse US population and whether the prognosis is different for those with this defect as compared to those who do not have this defect.

DESCRIPTION (provided by applicant): Management of lower extremity neuropathic ulcers in diabetic patients has changed little in the past decade. The healing rate is poor, risk of amputations relatively high, and there is a paucity of objective methods for choosing treatments. We will carry out a multi-center clinical cohort study of circulating and wound margin vasculogenic stem/progenitor cells (SPCs) in diabetic patients undergoing treatment for lower extremity neuropathic ulcers. The goal is to develop simple, quantitative methods that provide guidance on effective treatment choices. Our hypothesis is that an analysis of SPCs number and their biochemical characteristics can predict whether diabetic foot ulcers will heal. The experimental approach is built on the very productive framework used in our preliminary R21 project and recent publication. The four specific aims center on SPCs and their association with traditional methods for assessing diabetic control and wound characteristics. Aims are as follows: (1) Determine whether SPCs mobilization/wound recruitment and hypoxia inducible factor-related processes are associated with wound repair, (2) Assess if wound care practices are associated with SPCs mobilization and SPCs homing to wounds, (3) Determine if variations in SPCs are associated with healing, and (4) Assess whether SPCs differences observed between a healing acute biopsy wound versus the foot ulcer are related to clinical issues such as metabolic status. We will evaluate whether SPCs number and content of several intracellular proteins correlate with wound and disease-related factors and whether these measurements can be used to predict diabetic wound healing.

The major goal of Resource Core C, the Study Design and Data Analysis Core, is to facilitate basic and translational research in cutaneous biology and disease by providing assistance to investigators on the planning, design, and analysis (both statistical and informatics) of studies of the skin. Core C directors will apply classical and innovative approaches from clinical epidemiology, biostatistics, and bioinformatics to enhance the efficiency, reproducibility, and validity of cutaneous research. A proper study design and statistical analysis plan is fundamental to providing a solid foundation for statistical inferences in both basic and clinical investigations. By the very nature of the services provided by Core C, the Core will be highly collaborative and will add value to the other cores of the SBDRC. Core C directors will encourage investigators interested in cutaneous research to work with Core faculty and staff at every stage of design and analysis, thus promoting a team science approach from hypothesis inception, to study execution, analysis, and interpretation. This level of collaboration will help ensure that study designs are efficient and that analyses are accurate and correct. Core C faculty and staff have extensive experience with the design and analysis of basic and clinical investigations of cutaneous biology and skin disease. Core C will provide SBDRC investigators with the following services: (1) Advise on appropriate study design methodologies necessary to design and implement rigorous experimental and clinical investigations; (2) Provide statistical analyses of investigators' experimental data to determine whether study results are significant; (3) Interpret research data to make scientifically and statistically appropriate statements; (4) Advise on appropriate translational and Phase 1 clinical trial study designs for translation of bench findings to human research; (5) Bioinformatics analyses of large datasets from Next Generation sequencing studies, including from ChIP-Seq, exome-seq, 16S RNA-seq, and phage display experiments. Core C will significantly add to the overall success of the SBDRC because a critical barrier to progress in cutaneous biology and skin disease research is the lack of integration of biostatistical, epidemiological, and bioinformatics approaches in basic and clinical investigations. Implementing such approaches from inception through project completion will improve the reproducibility and validity of research findings. Cores A and B will be able to leverage the expertise of Core C faculty and staff to enhance the efficiency, reproducibility, and validity of research promoted by the SBDRC. Core C will also develop innovative approaches to analyze population stratification in genetic and genomic studies and for the analysis of cutaneous microbiome data when existing methodologies are insufficient.

SUMMARY Response inhibition, the ability to inhibit actions in the appropriate contexts, is important for the cognitive control of behavior and its dysfunction has been implicated in numerous neurological disorders. This proposal aims to understand corticostriatal signaling underlying response inhibition in mice during performance and learning of a whisker-based tactile discrimination task. A major goal is to address the gap in knowledge that exists for the role of primary somatosensory cortex (S1) in response inhibition. Based on its prominent projections to striatum and increasingly appreciated sensorimotor functionality, S1 is an overlooked candidate for brain stimulation in behavioral control that could have therapeutic advantages compared to frontal brain areas. The proposed experiments first aim to establish a causal relationship between cortical input from S1 and behavioral task performance. The hypothesis is that signaling from S1 to dorsal striatum (DStr), via its massive axonal projection, is necessary and sufficient to drive behavioral responses and response inhibition in the appropriate behavioral context. We will test this hypothesis by expressing optogenetic actuators and silencers (ChR2, ArchT) in S1 and manipulating axonal activity in DStr during task performance. The results will establish the causal influence of S1 on sensory-guided behavior. The next series of experiments will investigate the cellular basis of task-related activity in S1 using chronic in vivo two-photon imaging and electrophysiology. Chronic imaging of genetically encoded calcium indicators will allow for imaging of deep layer striatal projection neurons in S1 to determine the behavioral selectivity of S1-DStr populations. The hypothesis is that subpopulations of S1-DStr neurons encode response activation and inhibition, respectively. The timing of behavior-related neuronal activity will be resolved using targeted electrophysiological recordings. The final series of experiments will determine the emergence of cellular behavioral selectivity by tracking activity changes in S1 using chronic two-photon imaging. Experiments will be performed both through initial learning and stimulus reversal to dissociate stimulus and response. Our experimental approach will provide critical information about the capacity of S1-DStr projections for eliciting response inhibition, which will have implications for improved treatment of neurological disorders involving deficits in cognitive/behavioral control.

? DESCRIPTION (provided by applicant): Atopic dermatitis (AD) is a highly pruritic chronic episodic inflammatory skin disease that often presents between 3 and 6 months of age but may also present during later childhood or in adulthood. In the US, AD affects roughly 10-20% of all children of all races and ethnic groups. The highest prevalence of AD in the US is among African-Americans. The prevalence of AD is increasing worldwide and it is a major public health burden. The majority of children with AD will also develop asthma and seasonal allergies. From the recent Global Burden of Disease study, AD was among the top 50 most prevalent diseases worldwide and it had the second highest disability rank of all non-malignant skin diseases. Recent studies have established a strong association between loss-of-function mutations in filaggrin (FLG), a gene coding for a protein responsible for maintaining an intact skin barrier and AD. We have already demonstrated that these mutations are also associated with more persistent AD. However, these mutations are rarely noted in children of African ancestry. As a result, there is a gap in our knowledge with respect to the basic biology of AD in African-Americans. We recently found that mutations in filaggrin-2 (FLG2) are associated with persistence of AD in African-American children. We have also shown that genetic variation of the gene that codes thymic stromal lymphopoietin appears to modify the association of FLG with AD. The goals of this proposal are to comprehensively explore the association of FLG2 with AD in African-Americans, to better understand the association of thymic stromal lymphopoietin with the persistence of AD, and to explore how TSLP/FLG2 interact to create the phenotype of persistent AD. We will continue to focus on loss-of- function mutations in skin barrier genes using FLG as a model, a concept that was recently justified by a report that LOF may be a preferred pathway for adaptation to environmental stimuli. We plan to focus our studies on African-Americans. This proposal has two goals. The first goal is to better understand FLG2 loss-of-function mutations in African Americans. The second goal is to better understand TSLP variation and ultimately the interaction between TSLP and barrier dysfunction.

1605646 - Najafizadeh

The brain is a highly complex dynamic system in which neural functional connections are continuously changing at multiple time scales. These changes can occur at very short scales, for example due to learning a simple task, or at relatively longer scales, due to wide range of reasons, such as learning complex concepts, brain-related diseases (e.g. Alzheimer's and depression), and going through rehabilitation. Currently, our understanding of how the neural functional interactions form and change with time has been very limited because of lack of 1) quantitative measures that can reliably characterize these changes at different time scales, and 2) the ability to continuously monitor and record brain activities at different time scales, from millisecond to days and weeks. This project aims to address these limitations by taking a combined theoretical-experimental approach to establish a data-driven computational framework with new quantitative measures that can characterize the temporal evolution of dynamics of brain functional networks, across short-and long time scales. To further broaden the capabilities of the framework, this project will take a step further to consider scenarios where the brain network structure has been manipulated, and will computationally and experimentally investigate how brain networks reorganize and change with time in response to transient, localized manipulations of the network structure. The outcome of this project will have a transformative impact in the field of neuroscience by introducing a powerful computational framework for quantifying the dynamics of brain networks that have been evaluated experimentally under various conditions. The project will also provide a unique opportunity for the graduate and undergraduate students to obtain multidisciplinary expertise at the intersection of signal processing, statistics, neurobiology and imaging, thus providing an ideal platform for the training of the next generation engineers and neuroscientists.


One of the fundamental problems in the field of neuroscience and brain mapping is the lack of a generalized computational framework with reliable quantitative measures for characterizing the changes that occur in the functional interactions among brain networks at multiple temporal scales. The focus of this three-year project is to establish a comprehensive data-driven quantitative framework, which will enable studying and quantitatively characterizing the dynamic properties of brain functional networks at multiple temporal scales. With a focus on somatosensory learning, this research will use the proposed framework along with chronic imaging in GCaMP6f reporter mice, to quantitatively examine 1) how the interactions among functional brain networks are modified by task performance (short term changes), 2) how such interactions differ over days when mice finally becomes expert in performing the task (long term changes), and 3) how manipulating different nodes in the network, will change dynamics of brain functional interactions. This project, via combined theoretical-experimental studies, will introduce innovative approaches at three frontends. First, a systematic data-driven approach for quantitatively analyzing the temporal evolution of dynamics of brain functional networks at different temporal scales will be established. The aim is to represent the functionality of the brain networks with a multi-layer network, in which layers are labeled by time. Second, using state-of-the-art chronic imaging in GCaMP6f reporter mice, the project will monitor network activities at several temporal scales, from fast millisecond to those that occur on a slower time scale of days to weeks. The joining of quantitative analysis with in vivo imaging brings a powerful approach to the understanding of behavior-related dynamic changes in the cortical network. Third, to strengthen the capabilities of the framework, quantitatively and experimentally (using simulations as well as inactivation methods during imaging), the project investigates how the functional network is altered by transient, localized manipulations of network structure. The outcomes will be particularly important for advancing understanding of the dynamics of functional reorganization of the brain networks after stroke or injuries. The success of this project, by including the temporal dimension into the analysis, will have a transformative impact in the field of neuroscience. The new comprehensive framework will enable quantitative assessment of studying short-term and long-term network changes to advance our understanding of the dynamics of functional reorganization of the brain. The unique rich data set that will be generated through the state-of-art imaging system in this project along with the framework will provide important information on how cortical network activity changes across fast and slow time scales as related to learning. The outcomes of this research will have a significant impact in the clinical domain, helping the development of the next generation of personalized rehabilitation technology. In addition, the proposed research work is multidisciplinary as it covers topics from signal processing, statistics and engineering to neurobiology, imaging and neuroscience, thus providing a unique opportunity for the graduate and undergraduate students involved in the project to gain new learning experiences.

? DESCRIPTION: Chronic wounds are an enormously costly worldwide health concern that causes nearly 80,000 lower leg amputations annually in the U.S. alone and is associated with an increased likelihood of death. Strategies to encourage improved repair would impact both quality of life and mortality rates, yet myriad cellular and pathophysiological abnormalities continue to produce severely limited healing incidences with standard therapies. Promising therapeutic alternatives include the application of cellular scaffolds, topical growth factors (GF), or combination wound dressings. However, the incidence of complete closure remains strikingly low and GF delivery strategies largely fail to provide a sufficient quantity of GF to stimulate robust cellular responses. Additional concerns include the need for high GF doses as well as construct escape/off- target effects. New strategies to stimulate efficient and localized production of GFs in situ, by cells involved in active tissue repair, would offer a provocative approach to overcome these difficulties. Thus, we detail an innovative strategy to improve control over the dynamics and location of GF delivery by harnessing ECM remodeling to stimulate GF gene release and expression. In particular, we will exploit our expertise in designing collagen-mimetic peptide (CMP) nanostructures to engineer DNA polyplex-modified collagen scaffolds that induce localized, high efficiency GF expression coordinated with tissue repair kinetics. Our prior studies show that CMP linkage retains polyplexes for over a month in collagen and preserves gene activity in serum. In vivo model gene transfer was significantly enhanced by the CMP modification, and the duration of expression could be easily tuned for periods of a few days to multiple weeks. Moreover, CMP/polyplex/collagens only released polyplexes during collagen turnover, and the freed polyplexes were linked to collagen fragments that appeared to hijack natural endocytic collagen processing pathways. The ability to maintain stable gene depots should provide key reductions in dosing and limit construct escape in slow-healing chronic wounds. Meanwhile, on-demand release and expression is ideally suited to the uncoordinated repair processes that are a hallmark of the chronic wound environment. We will produce CMP/polyplex-modified collagens and will determine whether CMP linkage enhances retention within wound sites and stimulates the simultaneous processing of polyplexes with bioactive ECM fragments. We will elucidate key design parameters controlling polyplex retention, CMP/polyplex/collagen processing, and gene transfer, and will clearly link enhanced gene transfer efficacy to improved activity of GFs such as PDGF. Finally, we will use murine and rabbit wound repair models to test the ability of the PDGF gene product to enhance granulation tissue formation and increase the speed and efficacy of wound repair. These approaches will ultimately be useful as a versatile biomaterials platform able to stimulate improved healing in chronic wounds and a variety of other regenerative medicine applications.

Project Summary/Abstract Atopic dermatitis (AD) is a highly pruritic chronic episodic inflammatory skin disease that often presents between 3 and 6 months of age but may also present during later childhood or in adulthood. In the US, AD affects roughly 10-20% of all children of all races and ethnic groups. The prevalence of AD is increasing worldwide and it is a major public health burden. The majority of children with AD will also develop asthma and seasonal allergies. From the recent Global Burden of Disease study, AD was among the top 50 most prevalent diseases worldwide and it had the second highest disability rank of all non -malignant skin diseases. Many genes have been associated with the onset of AD. These genes are mostly associated with skin barrier changes (e.g. FLG) or immune dysregulation. Antigen-presenting cells (APC) are known to be involved in the initiation of the skin immune response. APC presentation of antigen to the immune system is guided by human leukocyte antigen (HLA) molecules, which are encoded within the major histocompatibility complex (MHC) located on chromosome 6. Six large population genetic studies of children with AD have been published and three of these studies demonstrated an association between the 6p21.3 cytoband (i.e. the MHC) region and AD. In a preliminary study, we have shown, for the first time, that specific variation of the HLA II DRB1 allele results in amino acid variations at position 9 (pocket 4), position 26 (pocket 4), and position 78 (pocket 4) that were marginally associated with the prevalence of AD and markedly associated with the persistence of AD. Importantly, unlike many other associations between HLA alleles and diseases (e.g., diabetes), the pathogenesis of AD is known to be associated with cutaneous inflammation and HLA II is known to be expressed on APCs that have an effect on the inflammatory cascade. We plan to focus on the HLA region of the genome using new technology to better understand the genetics of AD and the interplay between skin barrier dysfunction and immune dysregulation. This proposal has two goals. The first goal is to define HLA variation associated with the onset and persistence of AD. The second goal is to demonstrate that HLA variation is associated with immune dysregulation in those with AD.

Project Summary/Abstract Diabetes mellitus has reached epidemic proportions. A significant complication of diabetes is impaired healing which results in diabetic foot ulcer (DFU) and lower extremity amputation (LEA). About 20% of those with diabetes will develop a DFU. The annual incidence of LEA in Medicare beneficiaries with diabetes is about 4 per thousand, but rates of LEA can vary up to two- to threefold by race/ethnicity, geographic location, and gender. Individuals with diabetes develop DFU and LEA for many reasons that probably include interactions or alterations in intrinsic pathways responsible for wound repair, the presence of infection, changes to immune regulation, neuropathy, peripheral vascular disease, changes in anatomic function of the foot, and local trauma. DFUs are chronic wounds, which are by definition are wounds that have failed to follow an orderly and timely sequence resulting in healing and have impaired healing. Those that develop chronic wounds that result in LEA have wounds that heal slowly or not at all. Why a wound becomes chronic is not well understood. In the past 5 years, we have developed preliminary evidence showing that genetic variation in NOS1AP, which codes for a protein called capon, is associated with impaired healing of DFU, an increased risk of LEA, and decrease in the number or circulating endothelial precursors cells, which have been shown to be associated with individuals with a DFU that are less likely to heal. Our project focuses on producing further evidence to confirm the association of NOS1AP variation with impaired healing and to discern the functional basis of NOS1AP genetic variation on capon and ultimately capon?s influence on wound repair. To that end, the goal of our present study is to explore the possibility that common genetic variants of NOS1AP in those who have diabetes are associated with alterations in wound repair.

Project Summary/Abstract Acne is one of the most common diseases worldwide, affecting 85% of adolescents and often persisting into adulthood. Acne is responsible for a greater global burden of disease than psoriasis, cellulitis, and melanoma. While mild acne can usually be managed with topical medications, moderate to severe acne often requires treatment with systemic agents such as oral antibiotics, hormonal therapies, and isotretinoin. Remarkably, while these agents are a standard part of care, there are very few randomized clinical trials showing efficacy and none that show comparative effectiveness between these commonly used agents; the Institute of Medicine has identified this area as one of the top priorities for comparative effectiveness research. Previous work by our group has shown oral antibiotics are the most common systemic agent used in the treatment of acne and patients frequently use them for more than one year. In fact, dermatologists prescribe more antibiotics per capita than any other specialty. However, prolonged antibiotic use may be associated with a variety of adverse outcomes including bacterial antibiotic resistance, pharyngitis, collagen vascular illnesses, inflammatory bowel disease, and breast and colon cancer. As a result, there is growing international interest and attention specifically from the Centers for Disease Control regarding improving antibiotic stewardship in the outpatient setting and multiple clinical guidelines for acne have recommended reducing the use of antibiotics through the use of non-antimicrobial therapies and by limiting the duration of therapy. For women with moderate to severe acne, spironolactone may represent an effective, well-tolerated alternative to oral antibiotics. Developed as a potassium-sparing diuretic, for many years it has also been used off-label for acne due to its impact on hormonal pathogenesis of this disease. However, despite expert opinion supporting the use of spironolactone in the treatment of acne, its use remains relatively uncommon and clinical evidence demonstrating the effectiveness of spironolactone is limited to small, often retrospective studies. Trials comparing the effectiveness of spironolactone to that of other agents such as oral antibiotics are lacking. Our ultimate goal is to complete the necessary planning and preparation to conduct a novel, prospective, randomized clinical trial evaluating the comparative effectiveness of spironolactone and oral tetracycline-class antibiotics in the treatment of acne in adult women. No such study has previously been conducted. The results of this study would have substantial implications for the treatment of acne and antibiotic stewardship. In addition, this study may allow us to monitor for the timing of the development of antibiotic resistance in a healthy population of patients treated with extended courses of antibiotics and to evaluate the impact of prolonged exposure to oral antibiotics on the microbiome. Our proposed study could significantly influence healthcare practice with respect to the treatment of moderate to severe acne in women and inform policy regarding more appropriate use of antibiotics throughout medicine.

The overarching goal of this well-established training program is to maintain and accelerate long term research progess and innovation in cutaneous biology, skin diseases, and dermatoepidemiology, leading to novel treatments for skin disease and improvements in overall human health. We aim to achieve this by identifying and training the next generation of leaders in this area. Our specific goals are to: (i) recruit diverse trainees at early stages in their careers by exposure to the excitement and impact of dermatology research; (ii) support the research and training of young scientists with established interests in the skin and its diseases; and (iii) provide cross-disciplinary training in skin biology and diverse fields such as genomics, epidemiology or bioengineering. To these ends we request support for: 4 long-term (1 year or more) predoctoral fellowships to support the thesis research of MD PhD students, PhD students engaging in innovative, interdisciplinary work relevant to cutaneous biology and skin disease, or students pursuing dual MD and Masters in Clinical Epidemiology (MSCE) degrees; and 4 postdoctoral fellowships for MD, PhD and MD PhD scientists committed to careers in cutaneous biology and skin disease. Our program involves 41 highly qualified trainers drawn from the Department of Dermatology, from other departments within the Perelman School of Medicine, and from other Schools at University of Pennsylvania including the School of Veterinary Medicine, the School of Engineering and Applied Sciences, and the School of Dental Medicine. To promote cutting-edge and interdisciplinary research, our trainers have expertise ranging from clinical epidemiology, genomics, bioinformatics, microbiology, immunology, to developmental biology, stem cells, and regeneration. A particular emphasis of our training program is to encourage and train physician scientists in Dermatology. In addition to training MD and MD PhD students in skin-related research, we established a four-year clinical/research dermatology residency program in which trainees pursue T32-supported postdoctoral research fellowships that provide a basis for obtaining independent funding. This program has already been extremely successful, attracting exceptionally qualified, diverse, and enthusiastic trainees, several of whom are now established as NIH-funded independent physician-scientists. Our training program includes opportunities for lab-based research, translational research, clinical trials, and epidemiology. In parallel with ?hands on? research training, our trainees attend seminars, journal clubs and technical and skills workshops both within and outside Dermatology. We provide networking lunches and research retreats for trainees, and trainees invite two seminar speakers per year to present their research in the Dermatology Seminar Series, followed by lunch with the speaker. Trainees receive formal instruction in the Responsible Conduct of Research, and extensive mentoring, career counseling, and assistance in identifying suitable positions in academia, industry, or for further training in clinical or research areas from the Co- Directors of the training program as well as from their mentors and, in the case of MD PhD and PhD thesis students, their home Graduate Programs.

Project Summary/Abstract Acne is one of the most common diseases worldwide, affecting 85% of adolescents and often persisting into adulthood. Acne is responsible for a greater global burden of disease than psoriasis, cellulitis, and melanoma. Although mild acne can usually be managed with topical medications, moderate to severe acne often requires treatment with systemic medications such as oral antibiotics, spironolactone, and isotretinoin. While these medications are a standard part of care, there are very few randomized clinical trials showing efficacy and none that show comparative effectiveness between these commonly used treatment options. The Institute of Medicine has identified this area as one of the top priorities for comparative effectiveness research. In addition, little is known about the effects of these different treatments on the microbiome. Previous work by our group has shown oral antibiotics are the most common systemic medication used in the treatment of acne and patients frequently use them for more than one year. In fact, dermatologists prescribe more antibiotics per capita than any other specialty. However, prolonged antibiotic use may be associated with a variety of adverse outcomes including bacterial antibiotic resistance, pharyngitis, collagen vascular illnesses, inflammatory bowel disease, and breast and colon cancer. As a result, there is growing international interest and attention specifically from the Centers for Disease Control regarding improving antibiotic stewardship in the outpatient setting and multiple clinical guidelines for acne have recommended reducing the use of antibiotics through the use of non-antimicrobial therapies and by limiting the duration of therapy. For women with moderate to severe acne, spironolactone may represent an effective, well-tolerated therapeutic alternative to oral antibiotics. Originally developed as a potassium-sparing diuretic, for many years it has also been used off-label for acne due to its potential impact on hormonal pathogenesis of this disease. However, despite expert opinion supporting the use of spironolactone in the treatment of acne, its use remains relatively uncommon and clinical evidence demonstrating the effectiveness of spironolactone is limited to small, often retrospective studies. Trials comparing the effectiveness of spironolactone to that of other medications such as oral antibiotics are lacking. In Specific Aim 1, we will conduct a double-blind randomized controlled non-inferiority comparative effectiveness study of spironolactone versus doxycycline for women with acne. Since oral tetracycline-class antibiotics like doxycycline are currently the most common systemic medication prescribed for acne, the results of this trial will have substantial implications for the treatment of acne. In Specific Aim 2, we will evaluate the impact of spironolactone versus doxycycline treatment on the microbiome, which will provide valuable insights regarding the relative effects of antibiotic (doxycycline) versus non-antibiotic (spironolactone) acne treatments on the microbiome. This trial will significantly influence healthcare practice with respect to the treatment of moderate to severe acne in women and inform policy regarding more appropriate use of antibiotics throughout medicine.

PROJECT SUMMARY ? Diabetic foot ulcers (DFU) are an enormously costly worldwide health concern. They cause nearly 80,000 lower leg amputations annually in the U.S. alone and are associated with significantly increased likelihood of death. Strategies to improve their healing have been a subject of intense study for decades, yet myriad cellular and pathophysiological abnormalities continue to severely limit efficacy of standard therapies. Promising therapeutic alternatives include the application of cellular scaffolds, topical growth factors (especially platelet-derived growth factor), or combination wound dressings. However, the incidence of complete closure remains strikingly low and growth factor delivery strategies largely fail owing to their instability in the inflammatory, MMP-rich environment of the chronic wound. New strategies that can normalize this proteolytic and inflammatory environment, by stimulating local production of therapeutic proteins by fibroblasts and macrophages, would thus offer a provocative approach to improve clinical outcomes. We have recently demonstrated that protease activity in the wound bed can be harnessed to stimulate localized growth factor gene delivery and provide tailorable expression of growth factors over multiweek timeframes. We introduce collagen mimetic peptide (CMP) and therapeutic gene-modified collagens (COATs) as a platform for (i) robust retention of growth factor-encoding polyplexes in collagen- containing wound dressings and (ii) localized, cell-initiated gene delivery during collagen remodeling. Because COATs integrate DNA polyplexes directly into collagen fibrils, our approaches have been shown to significantly improve in vivo wound repair at concentrations of growth factors orders of magnitude lower than those in currently employed topical therapies. These outcomes, coupled with recent advances in the translation of other gene therapies, suggests the high potential for clinical impact of the COATs platform. In the proposed R01 program, we will apply COATs in experimental DFUs and cell-based assays to understand three important aspects of orchestrating wound repair, in the following three Aims. In Aim 1, we will probe variations in CMP modifications that optimize the extended delivery of genes (initially for platelet-derived growth factor (PDGF)) in a murine diabetic wound environment. In Aim 2, we will complement these studies with cell-based investigations that elucidate the role of MMPs (soluble and membrane-bound) in regulating PDGF gene delivery by COATs and PDGF protein lifetime. In Aim 3, we will test how COATs-mediated, sequential delivery of genes for immunomodulatory cytokines (IL4 and IL10) modulates MMP activity in DFUs. These approaches will provide both mechanistic insights for resolving the chronicity of DFUs, and also a new platform that could be integrated into existing wound-care strategies to dramatically improve clinical outcomes.

PROJECT SUMMARY The major focus of Core C, the Data Science and Informatics (DSI) core, is to facilitate human discovery through basic and translational research in cutaneous biology and disease by providing assistance to investigators on the planning, design, and analysis (both statistical and informatics) of studies of the skin. The DSI interacts directly with the other Resource Cores and the overall theme of the SBDRC in that bench and human translational research needs to be well designed, properly conducted, and correctly analyzed in order to maintain high standards of rigor and reproducibility. DSI achieves these goals by a combination of epidemiologic, statistical and informatics approaches. By its very nature, DSI will continue to be highly collaborative and will add value to the other cores. DSI Core directors will encourage investigators interested in cutaneous research to work with Core faculty and staff at every stage of design and analysis, thus promoting a team science approach from hypothesis inception to study execution, analysis, and interpretation. DSI?s functions are represented by two Aims that leverage expertise of Core faculty and staff in the following areas: Aim 1: To provide study design and biostatistical services to SBDRC Core users, including: 1) Study design methodologies necessary to design and implement rigorous experimental and clinical investigations; 2) Statistical methodologies critical for the evaluation of each project?s research hypotheses including consideration of sex as a biologic variable; 3) Interpretation of research data to make scientifically and statistically appropriate statements; 4) Translation of bench findings to human research using translational and clinical trial designs. Aim 2: To provide biomedical informatics & computational dermatology services to SBDRC Core users, including: 1) Bioinformatics approaches to allow for the analysis and conceptualization of large genomic and metagenomic datasets; 2) Artificial intelligence-guided approaches to quantify patterns and textures in microscopy images; 3) Medical informatics approaches to query medical records databases from UPHS and extramural sources. A critical barrier to progress in cutaneous biology and skin disease research is the lack of integration of biostatistical, epidemiological (both quantitative and qualitative), and informatics approaches to basic and clinical investigation. DSI will significantly add to the overall success of the SBDRC by addressing this barrier and the specific need for these approaches in human translational research. Implementing such approaches from inception through project completion will improve the reproducibility, rigor, and validity of research findings. The other SBDRC Resource Cores and the Administrative Core will be able to leverage the expertise of DSI faculty and staff to enhance the efficiency, reproducibility, and validity of research promoted by the SBDRC.